This blog is made of short scenes because the woman’ story at the end is worth a thousand studies, statements, national or international policies.
Scene one 1986 DC
Economists do a lot of studies and extensive thinking on the critical issue of how to finance health care. They tell the world that governments cannot afford to pay for health care and that free care encourages overuse and therefore people must pay fee for services.
Scene two: October 2012 DC
Over the years mounting evidence demonstrates how user fees excludes poor people especially women from access to essential healthcare. Hundreds of NGOs send a letter to Jim Kim the president of the World Bank requesting the bank to support countries removing user fees.
Scene 3: Dec 2013 Tokyo
Jim Kim the president of the World bank says: “Even tiny out-of-pocket charges can drastically reduce [poor people’s] use of needed services. This is both unjust and un-necessary “
Scene 4: March 2016 Cameroon
Newspaper published a horrific story of a pregnant women dying at the hospital door in Cameron simply because she could not afford user fees. Her niece tried to deliver the twins but both died.
Scene 5: still to come
Governments abolish user fees. Donors including the World Bank work with the governments to fully finance essential health care for all that are free at the point of use. In Cameroon women deliver attended by trained health workers without paying for the service.
Lesotho has a new hospital – built and operated under the first public-private partnership (PPP) of its kind in any low-income country. The IFC advice and promise was that it would cost the same as the public hospital it replaced. Instead the PPP hospital is costing the government 51% of their total health budget while providing 25% returns to the private partner and a success fee of $723,000 for the IFC.
In a report released today, ‘A Dangerous Diversion’, Oxfam and the Consumer Protection Association (Lesotho) explain how the Lesotho health PPP was developed under the advice of the International Finance Corporation (IFC – the private sector investment arm of the World Bank) and now costs the government $67 million per year, or at least three times the cost of the old public hospital. The hospital is reported by the IFC to be delivering better outcomes in some areas. But the biggest concern is that as costs escalate for the PPP hospital in the capital, fewer and fewer resources will be available to tackle serious and increasing health problems in rural areas where three quarters of the population live.
A consortium called Tsepong Ltd – among whose shareholders are South African healthcare giant Netcare – won an 18-year contract to build and run the new 425-bed hospital. Its return on investment is 25%. The PPP is the first of its kind in a low-income country and more ambitious and complex than the majority of PPPs attempted in high-income contexts. Not only is the private consortium responsible for designing, building, maintaining and partly financing the hospital, it also provides all clinical services for the contract period.
Since well before the PPP contract was even signed (in 2009) the IFC was busy marketing it a major success, proposing it as a model for other countries to replicate. In 2007, Bernard Sheahan, the IFC‘s Director of Advisory Services, said:
‘This project provides a new model for governments and the private sector in providing health services for sub-Saharan Africa and other regions. The PPP structure enables the government to offer high-quality services more efficiently and within budget, while the private sector is presented with a new and robust market opportunity in health services.’
And despite a significant body of evidence highlighting the high risks and costs associated with health PPPs in rich and poor countries alike, similar IFC-supported health PPPs are now well advanced in Nigeria, and in the pipeline in Benin. The IFC’s health PPP advisory facility has financial backing from the governments of the UK, the Netherlands, South Africa and Japan.
So why is the PPP so expensive? There are multiple and wide-ranging reasons outlined in the new report and in a previous blog authored by Dr John Lister on this site. Some of these seem inherent to health PPPs and raise serious questions about why the model was pursued in a low-income, low-capacity context. Other cost increases appear to be a result of bad advice given by the IFC.
It is accepted that borrowing capital via the private sector will always be more expensive than governments borrowing on their own account. The theoretical cost saving and value for money potential of PPP financing and delivery therefore lies in effective risk transfer to the private sector and, in turn, the effective management of that risk by the private sector in the form of improved performance and greater cost efficiency in its operations. In the case of Lesotho, this potential benefit has not been realised, and the costs are already escalating to unsustainable levels. As savings on clinical services have not been delivered, it is even more important to raise serious questions about why cheaper public financing options were not pursued.
The biggest losers of the Lesotho health PPP are the majority of Basotho people who live below the poverty line in poor rural areas, who have little or no access to decent healthcare and where mortality rates are high and rising. Amongst the most severe challenges facing the health system is the shortage of health workers. Yet while the budget line covering the health PPP will see a 116% rise in the next 3 years, the health worker budget will see below inflation annual increases of just 4.7%.
As the country‘s health financing crisis escalates, the option of reintroducing and increasing user fees at primary and secondary level facilities has already been tabled for debate. Such a devastating and retrograde move in Lesotho would further exacerbate inequality and increase rather than reduce access to healthcare for the majority of the population. World Bank President, Jim Yong Kim, recently stated that user fees for healthcare are both unjust and unnecessary. In an interview just last week in the UK’s Guardian newspaper Kim said:
“There’s now just overwhelming evidence that those user fees actually worsened health outcomes. There’s no question about it. So did the bank get it wrong before? Yeah. I think the bank was ideological.”
To ensure ideology rather than evidence is not driving the IFC’s continuing promotion of health PPPs in poor countries, our report calls for a fully independent review using peer reviewed evidence to question the appropriateness, cost-effectiveness and equity impact of this model. Oxfam and the Consumer Protection Association (Lesotho) also say that the IFC’s role in exposing Lesotho to such a high-risk, high-cost long-term contract should be investigated and, until then, the World Bank should stop all IFC advisory work in support of health PPPs.
Anna Marriott is the author of ‘A Dangerous Diversion’ and editor of Global Health Check.
Low investment in the public health sector over the years has left India with a fractured and weak health system, unable to meet the needs of the majority of its citizens. Despite efforts in recent years to strengthen public health system – most notably through the National Rural Health Mission – India has one of the lowest levels of government investment in health in the world, with just four countries (Afghanistan, Chad, Guinea, and Myanmar) allocating a smaller share of their overall budget to health. In 2010 government expenditure on health was just 1% of GDP.
The gap left by the public health system combined with a government policy of proactively promoting the private sector has led to the proliferation of private health providers which are unregulated, unaccountable, and out of control. From initially providing 8% of healthcare facilities in 1949, the private sector now accounts for 93% of the hospitals and 85% of doctors. The number of first class private hospitals in India has ballooned in recent years and health tourism has become big business. But such first class service comes with a high price tag and is out of reach for the vast majority of Indians. Instead, poor people become dependent on unqualified drug peddlers, fake doctors (quacks), and unlicensed shops that are largely unregulated. Up to a million unregistered providers are practicing in India today. When the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their governments to account and to seek justice.Scandals of corruption, unethical practice and human rights violations frequently break out in national newspapers.
War on women: private clinics exploiting poor women for a profit in Rajasthan, Bihar and Chhattisgarh
Under-privileged women from poor communities in India are being left with crippling debts and poor health after being incorrectly advised by private clinics to have unnecessary hysterectomies. These procedures come with huge price tags and high medical risks. In the case of Bihar, Chhattisgarh, and Rajasthan, the government and the private hospitals in some districts have violated the fundamental rights of women and girls in their failures to provide adequate healthcare.
In the last few years NGOs and citizens legal networks have attempted to investigate the practices carried out by private clinics. Local NGOs, have filed a series of Right to Information (RTI) petitions which shed light on the high number of hysterectomies being conducted.
In Dausa, a district in the rural interior of Rajasthan, thousands of women have been subjected to hysterectomies by doctors looking to make a profit at their expense. Women from the most discriminated low castes and poor economic backgrounds are being targeted because access to free government healthcare is very limited and illiteracy rates are high. In April 2012, it came to light that four private hospitals in the state’s Dausa district removed the uterus of 226 women last year and earned about Rs 14,000 (around $220) from each patient. One of the women who underwent the surgery explained, “I had a constant stomach ache and they removed by uterus, but the pain did not go. Then I went to Jaipur for treatment and it was found that I was wrongly operated upon.”
Kaushalya, a farm labourer was told she must have a hysterectomy when she visited the clinic with stomach pains. She was charged 30,000 rupees for the operation (around $540). “I went to get medication and have a check up. Because the government hospitals are far away I went to a private clinic. They didn’t check me, they didn’t give me any medication. But they gave me an injection and performed an operation. Even though I only had a tummy ache, they took my uterus out. I still have the same stomach pain I had before. I can’t work, I can’t lift heavy things. Being a poor farmer I don’t have any money, so I had to borrow money. So far I have not even been able to pay just the interest.”
Durga Prasad Saini, an advocate for a local NGO, Akhil Bhartiya Grahak Panchayat, said: “women go to doctors with some sort of abdominal pains and are then advised to undergo a hysterectomy with little diagnosis of the problem. The doctors force them to undergo surgery even though it is not necessary and scare the women in their greed for money.” The NGO filed an RTI (right to information) case to try to get to the bottom of the problem. Only 3 of the 5 clinics provided the information but the results were shocking. Nearly 70 per cent of the women investigated had had their uterus taken out – a large number of the women were under the age of 29, with the youngest being just 18 years old. Despite the fact that complaints have been made to the police and local government, no action has been taken. A special committee, which included leading gynaecologists, public health experts and government officials from Jaipur, was set up over a year ago but to date none of the affected women have been visited by committee members or had their testimonies heard.
Dr Gupta, a medical expert and head of NGO Prayas –who work with Oxfam in India, states in his report that most of the women he interviewed in Rajasthan should not have undergone a hysterectomy, and could have been cured with other treatments. Moreover, he explains that a sonography alone is insufficient to determine a need for hysterectomy, and alternative treatments should always be attempted before this invasive surgery is performed. Dr Gupta adds “Subjecting women to unethical, unreasonable and unnecessary hysterectomies or caesarean sections for financial gain is a violation of human rights and most awful form of gender based violence. The mass hysterectomies by private hospitals in Dausa are a wicked act, but such malpractices are happening in other areas as well. Prayas is initiating an intensive investigation against such unethical practices.” Similarly news stories and investigation reports in Chattisgargh and Bihar indicate that unnecessary hysterectomies are common phenomena in rural areas. Recent reports in the Indian Express exposed that many of the women who seek hysterectomies are not informed about the possible side effects, and think of a hysterectomy as an easy cure to stop menstrual problems. Prayas also found that the doctors are not obtaining informed consent for the hysterectomies.
In Bihar, Prayas found that several women had undergone hysterectomies at private hospitals on the same day as their initial hospital consultations. The women had only had sonographies – no additional tests were performed. As Dr. Gupta makes clear in his report, women should undergo several tests and be offered alternative treatments before a hysterectomy is performed. Many of the women interviewed in Bihar, Chhattisgarh, and Rajasthan were misled into believing that there was an emergency and that the surgery was urgent or made to believe they might get cancer if they did not comply with the doctors’ advice. In most cases the women received no paperwork regarding the surgeries, and many of the BPL (Below Poverty Line) women paid out-of-pocket for the operation. The fact-finding team also found that there is illicit recruiting in the villages, involving “middlemen” who convince women to go to private hospitals. Fraud committed by the private hospitals has also come to light, with physical examinations of former patients revealing that some of the surgeries never took place.
NGOs investigating this case have decided to go the Supreme Court to seek justice for these women and bring the unregulated and unaccountable private providers of healthcare to account.
Action for change: Implementing Universal health coverage
These cases are not ‘stand-alone’ cases of poor health care provision they are in fact symptoms of a failing and weak health care system that needs urgent rectification. Private health care providers need to be regulated and controlled and public health care provision needs to be scaled up and improved.
In line with the recommendations of a recent High Level Expert Group report, Oxfam along with its partners is calling for the government to prioritise strengthening and scaling up of government health care which is available to all citizens.
Oxfam wants immediate action to regulate private providers and cease further promotion and funding of PPPs until regulation is enforced and quality and equity performance standards are shown to have improved. Private hospitals, nursing homes and other clinical establishments must be properly standardised to improve rationality of care, regulation of fees, and to uphold patient’s rights.
Oxfam calls on international donors to support evidence-based strategies to expand government provision of health care and not promote scaling-up of private-sector health service delivery in low- and middle-income countries. The private sector’s role needs to be clearly defined and regulated and donors should work with governments to strengthen their capacity to regulate existing private health-care providers.
This story has recently featured on BBC News Online – click here for more information
Araddhya Mehtta is an Essential Services Global Campaigner for Oxfam GB
In March this year, the Nigerien government organised a conference to discuss the impact and challenges of its free healthcare initiative for women and children. The conference brought to the fore the remarkable health gains that the initiative has achieved since it was introduced in 2005, but also highlighted the acute funding challenges that are threatening the sustainability of the scheme.
Niger has one of the worst maternal and child mortality rates in the world. According to the World Health Organisation (WHO), one in every 23 Nigerien women will die during pregnancy or child birth (compared to 1 in 42 for the Africa Region), only a fifth of births are attended by skilled health workers, and only 46% of pregnant women will benefit from antenatal care. What is more, one in every seven children risks dying before their 5th birthday.
In light of such startling statistics, it is laudable that the government of Niger introduced a free healthcare policy to alleviate the financial burden of accessing health care for women and children. Under this initiative, women are entitled to free contraceptive services, antenatal care, deliveries including caesarean sections, and free treatment for breast and uterus cancers. Children under-5 are entitled to receive a wide range of health services free of charge, including consultations, surgery, medicines, and laboratory tests.
The March 2012 conference coincided with the release of findings of an evaluation (1) of the free healthcare programme, which showed impressive health achievements. In just 5 years, uptake of antenatal services has more than doubled from just under 38% in 2004 to 90% in 2009. Use of modern contraceptive methods also increased from 5% in 2006 to 16% in 2010, while the number of C-sections also increased from 0.8% to 2.8% during the same period. The evaluation revealed that as financial barriers were lifted, uptake of health services by women and children rose and there was a drastic reduction in self medication and use of traditional medicine.
In spite of the progress made so far, the free healthcare initiative is threatened by acute funding shortfalls creating fears that it may be scaled back. Between 2007 and 2011, the average annual budget allocated to the initiative was 4 billion CFA francs (US$7.8 million) (see Figure 1), which is only about half of what was needed to fully implement the programme. Although government allocations for the initiative improved slightly in 2011, the funding shortfalls of the previous years have created huge unpaid healthcare bills (amounting to around US$41.4 million as of March 2012), which has affected the ability of health service providers to deliver services to beneficiaries. Many healthcare providers that operate under the programme experience frequent stock-outs of medicine and medical consumables which compromise effective utilisaiton of care by beneficiaries.
Figure 1: Ministry of Health (Niger) budget allocations for the free healthcare initiative and funds required for full implemention of the programme (2)
The funding challenges are partly due to the failure of policy makers to properly assess the financial requirements of the initiative and to put measures in place to fund it. Also, donor support has been disappointingly low, including from agencies that encouraged the government to adopt the free health care policy in the first place. So far, only the French Development Agency has proposed to reimburse a fifth of the cost of the initiative as well as UNICEF who occasionally provide some financial support. Improved donor support, both technical and financial, will be crucial to enable the government to scale up the initiative and assure its sustainability.
A further challenge has been the lack of accountability and transparency in the management of funds, with cases of inaccurate invoicing and double payments widely reported. Health workers have also complained of increased workload without adequate compensation. And although the majority of health providers support the free health care initiative, they are worried it is not properly implemented leaving them to pick up the pieces.
The evaluation also notes that while the initiative has brought benefits to women and children, healthcare user fees for the rest of the population are still very high. The WHO estimates that out-of-pocket payments account for 41% of total health expenditure in Niger – more than twice the recommended rate of 15 – 20%. Given that around 70% of Nigeriens live on less than US$1 a day it is clear that low levels of financial protection will be affecting millions of people, driving the poorest households into deeper levels of poverty and denying them access to essential health care.
The recommendations that came out of the conference were clear and it is important for government to take these seriously. In particular the government should look to increase its allocations for the health sector, especially to the free health care initiative, and for the Ministry of Health to settle the arrears that are owed to health service providers. In order to increase revenue, government should consider using innovative financial measures such as raising VAT on luxury products, and taxing the telecommunication, alcohol and tobacco sectors. In the immediate term donor agencies should step up their support to the government of Niger so that funding shortfalls do not undermine the significant progress made so far.
(1) The evaluation is not available online yet. The information presented here is based on the author’s notes from a presentation given by the General Secretary of Ministry of Health (Niger) during a national conference on the Niger free healthcare.
(2) This chart is based on the author’s notes from a presentation given by the Ministry of Health (Niger) during a national conference on the Niger free healthcare initiative.
Hassane Boukar is a Project Officer for Budget Transparency at Alternative Espaces Citoyens in Niger
South Sudan has some of the worst rates of maternal and child mortality in the world. One in ten babies in South Sudan will not see their fifth birthday; and maternal mortality is 2,000 per 100,000. Today, for every woman liable to die in childbirth in Europe, 250 young mothers will die in South Sudan.
Such deaths can be avoided through relatively modest investments – so long as those investments are made in the right way. In October last year, I travelled to South Sudan to carry out a study, commissioned by World Vision, to identify key features of the problem, and the practical means by which they might be addressed. While the moral case for reducing maternal and child deaths hardly needs to be made, it is worth noting that such reductions actively support better levels of economic growth – something South Sudan desperately needs right now.
South Sudan is still a country in conflict. It requires both humanitarian relief and investment in dealing with the aftermath and security responses to the violence. But at the same time, the majority of the population are also struggling with the fundamental threats to life and livelihood of poverty and disease. To ignore this is to ignore the potential for popular dissatisfaction to re-create conditions for violence, conflict and crime. Better health is a fundamental part of human security.
So what is to be done? A good starting point would be to understand what drives maternal and newborn death rates in South Sudan. The study that I conducted in collaboration with World Vision (UK, Australia, Juba and Warrap State) arrived at some core challenges which, if properly addressed, could contribute to saving lives and improving the living conditions of communities across a country in which the dividends of peace have yet to materialise.
The first challenge is to stop blaming families and communities themselves. A common view among policy-makers and practitioners is that mothers and children die – in substantial part – because they prefer traditional, and dangerous, methods of obstetric, intrapartum and neonatal care to ‘modern’ treatment provided by the healthcare system.
Talking to women in villages, children at school, and community leaders, a very different picture emerges. The girls at Liet Nong primary school, in Warrap State to the north of the country, were remarkably well-informed, happily vocal, and clear about what they wanted. They wanted clinics and medicines and care, but they wanted them nearer to where they live. Certainly, they said, we can use medicines from the forest, but we only do that now because we can’t get help from a health centre that we can actually reach. A group of elderly women in Magai Village, some of them traditional birth attendants (TBAs), told stories of traumatic births and local rituals. But when it came to asking where they saw a solution, they asked where were the laboratories, where were the doctors, and where were the ‘microscopes’. These were not frivolous comments – rather they were a clear-eyed recognition of what was required and valued, but which was so far inaccessible.
In truth, many families do not, currently, use the local health facility (the Primary Health Care Unit – PHCU) in South Sudan – perhaps 20-40% of pregnancies, at the most. But this is not surprising, and should not be interpreted as a lack of demand. While PHCUs remain the poor cousin of national health spending (they receive around 6% of the total annual health budget), this critical part of the health infrastructure – close enough to people’s homes to make clinic attendance possible – will continue to under-perform. For now, more investment flows to the higher level Primary Health Care Centres (PHCC). Indeed the national health strategy is predicated on pregnant women being referred to PHCCs. The average distance from village to PHCC in South Sudan is 120km. With rained-out roads, limited transport options, and cash-poor families, travel to the nearest PHCC can take days. Post-partum haemorrhage – one of the principal causes of maternal mortality – can kill in less than two hours.
While the most accessible part of the healthcare system remains the least invested, rational villagers will continue to doubt their value, and continue to express this doubt by reverting to traditional practices over which they have, at least, some control. ‘Tradition’ and ‘culture’ are too often pointed to as the explanation for poor community health. The reality, often, is that tradition and culture are all that remain to people whose lives are circumscribed by poverty, exclusion, and a lack of access to the services they know they need and clearly want.
The remaining challenges flow more or less logically from this first observation. Although national health policies in South Sudan, including a constitutional commitment to free care, are fantastic on paper, most emphasis goes to investment in urban, secondary and tertiary care. The major focus right now, should be the Primary Health Care Unit, and in innovative ways to staff the PHCUs with qualified, credible health care workers. PHCUs should be able to provide time-critical obstetric and neonatal care in clean, safe and dignified conditions. This will address the real killers in childbirth: haemorrhage, infection, asphyxia. Preventive and health awareness services (for control of diseases like malaria, and to improve prevalent sexual health, for example) could be provided at the village by a corps of community health workers (possibly including rehabilitated TBAs) coordinated, trained and supervised from the PHCU.
This – as ever – means more money. Donors have done well in harmonising their aid investments. But they have been, up to now, too focused on the central level, and on various forms of administrative capacity-building, with much less emphasis on aid channelled to, and guided by, epidemiological evidence of priority problems and corresponding evidence of positive results on the ground. Reduction in maternal and neonatal deaths must be at the top of the list of the new ‘Health Pooled Fund’s’ goals, and in the first row of measures by which effectiveness of aid to South Sudan is assessed. The Republic of South Sudan should be asked to match international investments in health, by shifting some of its national budget – notwithstanding current austerity as a result of the suspension of oil exports – from security and veteran’s affairs to basic social welfare.
The issue of the current austerity budget, cutting national expenditure by more than half, requires some collective strategising among donors, Government of South Sudan (GOSS) and existing partners in the delivery of services including health. It is to be hoped that the suspension of oil production and its revenue stream will not last long. But whatever the outcome, this (partly endogenous) economic shock points to three key elements in financing for health in South Sudan. First, donors need to recognise that this is not the time to draw down or operationalise exit strategies (consistent with their own domestic austerity drives). New donor contributions should not be driven by day-to-day humanitarian concerns alone, but should be organised as investment in longer-term change in the structural conditions for well-being and growth across the country – education, health, infrastructure. Second, international NGOs may need to re-assess their current activities in South Sudan. They may ask donors for more resources, and GOSS for better access, but the quid pro quo is that they need to start generating better evidence that their programmes are building lasting benefit beyond the short-term. Third, GOSS needs to start thinking seriously about a long-run economic strategy to diversify away from its overweening dependence on oil. Diversification of this kind can attract the latest in entrepreneurial fads. A more grounded strategy – literally – is one that re-energises investment in the agricultural sector.
For the present, the key is not to advocate for health spending as an alternative to other fiscal requirements, in particular security. Rather, it is to argue that spending on fundamental public ‘goods’ (health, education, training, capacity, opportunity) is an investment in security – and a more sustainable and, ultimately less costly one than the conventional flow of funds into armed forces, military hardware, police services and penal systems. Whatever the international inputs and national strategy determined in the coming months to support the peace, providing humanitarian care to refugees on one hand, and preparing the way for longer-term economic recovery and diversification on the other, a focus on the problem of maternal and child health – transparently negotiated between donors and government, and consistent with prevailing humanitarian norms and development goals – should be central to the vision of, and plan for security in South Sudan’s future.
Dr. Sebastian Taylor is a Senior Consultant at the IDL Group