Free and Public

Access to medicines in Malawi: a battle for all, even presidents

A nurse handing over antibiotics to a patient in a  Hospital in Lilongwe, Malawi. Source: Oxfam photosMost presidents in Africa do not die in their own hospitals. They die in Europe or in posh private hospitals in South Africa.

In Malawi, for the past three years accessing basic medicines has been a challenge for poor people. Going to hospitals is a big decision as people do not expect to find medicines most of the time. Half the time most of the shelves at public hospitals are empty and even the most basic drugs for treating malaria and other common diseases are scarce.

But who would have thought that this would also be an issue for a president? Nobody until President Bingu wa Mutharika the late president of Malawi died of a cardiac arrest after being taken to the main hospital in the capital city Lilongwe. The story is that the doctors could not get him basic adrenaline for him to be revived before being flown to South Africa.

One wonders how many poor people suffer the challenge of not only failure to access medicines, but failure to access their basic right to health services.

For most poor men and women, dying at the front gates of hospitals due to lack of medicines is nothing new. Malawi is one of the poorest countries in the world, with more than half its population living on less than a dollar a day.  There has been a campaign to make access to essential medicines a reality for all. In 2004, the Malawi government introduced an Essential Healthcare Package (EHP), to ensure that people had a cost-effective package of essential health services covering 11 common diseases, including malaria and HIV and AIDS. Medicines were supposed to be free at the point of delivery in public hospitals and clinics. However, for this to be possible one needed strong government funding and strong civil society programmes to track budgets for medicines.
 
In rural areas improving access to basic health services for poor and vulnerable groups is a crucial step to overcoming poverty. However, despite the government’s recognition of the importance of this issue, drug shortages and long periods when no medicines are available (known as drug ‘stock-outs’) are still being experienced in Malawi on a regular basis in rural clinics. And, as has been shown recently, even in major public hospitals.

The lack of free essential medicines in government clinics and hospitals is due to a combination of poor investment in personnel and infrastructure, inadequate resources, and corruption and mismanagement. These issues need to be examined and acted upon by those responsible, including the Ministry of Health (MoH), the Central Medical Stores (CMS, the national pharmacy of the MoH), and district health officers. 

The case of the dead president re-ignites the importance of civil society engagement in order to ensure that the government’s budget has adequate provision for essential medicines and that people in rural clinics can question if these medicines are not available.

Donors can also play a part too – to support countries like Malawi realise their MDGs on health, so that medicines can be found in local clinics and in major public hospitals too – for free!

Dr. Joshua, from Dowa District Hospital reports: ‘Medicines are a big challenge. We have a lot of gaps. When you come to treat patients it’s frustrating when you find that what you were supposed to prescribe is unavailable.’

It’s even more frustrating for the patients themselves, for whom the journey to and from hospital will have incurred great costs in terms of out of pocket expenditure and loss of income. If the required medicine is not available then these costs will have been incurred in vain.

Grounding active grassroots involvement and building active citizenship are still challenges in Malawi as most ordinary Malawians are still not sure of their rights. In addition, in districts where hospitals have never been challenged regarding their use of resources, it is very difficult to work with the community and the hospitals to promote change. There needs to be some degree of openness on the part of hospitals, willingness by local people to engage, and a degree of capability among community members in order to initiate an effective campaign. But since health is a human right and is key to achieving MDGs, international support is needed to ensure ordinary people can access medicines in Malawi (and other poor countries). This is also where international organizations should continue working with people on the ground – to build their capacities to demand their rights and to push their governments for good policies, coupled with a demand for accountability on how resources poured into the health sector are used.

For Malawi, the battle by civil society for poor people to access medicines has to continue or be resuscitated at all levels.

Shenard Mazengera is an Essential Services Adviser at Oxfam-GB

This article was originally posted on the Oxfam Policy and Practice website (posted on 18/06/2012).  It has been adapted and reproduced here with permission from the author. 

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Campaign averts savage cuts to health budget in Armenia but out-of-pocket payments still dangerously high

A patient receiving treatment in a health post in Khachik village in ArmeniaIn 2012, in the midst of difficult economic conditions, the government of Armenia proposed to cut health spending by 5.4% in its draft budget. Although an Oxfam-led campaign has helped to avert these cuts, questions remain as to whether the government should be spending a lot more on health and reducing harmful out of pocket expenditure. 
     
Armenia has one of the worst mortality rates in Europe. 29 out of every 100,000 women die during pregnancy and childbirth; and for every 1000 births, 22 children die before their fifth birthday.  This contrasts strikingly with other European countries where average maternal mortality rate is 21 deaths per 100,000 births and under-5 mortality rate is 13 deaths per every 100 live births.  The problem of poor health outcomes in Armenia are in large part a result of high out-of-pocket (OOP) payments, poor utilisation rates, and poor quality of care. These problems are in turn largely explained by low government spending on health over the years.

In 2008, the total expenditure on health was only 3.8% of the country’s total economic output (GDP).  This was half the health expenditure of Georgia and a quarter of Argentina’s (both in the same income group as Armenia). As a proportion of total government expenditure, health spending has also been low – just 7% in 2010. 

The lack of public spending on health means people are left with no choice but to make substantial out-of-pocket payments to meet their healthcare needs, or go without. Such out-of-pocket payments constrain access and squeeze poor people into deeper levels of poverty. In Armenia, OOPs are as high as 52% of total health spending. It is estimated that between 16% – 26% of households face catastrophic health expenditure as a result.

As a result of low government expenditure, unofficial patient charges are also a significant problem. Health workers are poorly remunerated and health facilities run on minimal budgets. It is estimated that an average medical staff earns US$ 134 per month (before tax and social security deduction), compared to a national living wage of US$67 per month.  Consequently, health workers often resort to unofficial charges to supplement their wages and pay for services and medicines.  Such charges add to the already high official fees to make healthcare unaffordable. It is estimated that only 30% of people with injuries or illness are actually able to seek care.

Quality of care has also suffered massively under the current funding shortfalls. Health facilities often have barely enough resources to operate effectively.  An Oxfam study in 2011 found severe shortages in medical equipment in health facilities, as well as insufficient and poor quality medicines, all of which are undermining effective treatment.
 
In the midst of this low expenditure, the Armenian government proposed in late 2011 to cut spending on health by 5.4% in 2012.  Oxfam-Armenia led a campaign of civil society organisations to avert the cuts using a combination of evidence from the ground, persistent lobby and media work including radio and internet adverts, TV interviews andfacebook discussions on the proposed budget cuts. Consequently, the government has rescinded its decision on the cuts, and the 2012 budget for primary healthcare will remain equivalent to the 2011 budget (US$60.2 million). 

Although the proposed cuts have been dropped, which the government must be commended for, current funding levels are still woefully inadequate. Government needs to find ways to significantly increase its spending on health. A good way to do this could be for government to re-prioritise its agenda and increase the allocation of the national budget to health. Government can also increase its revenue, and for that matter its contribution to health,   through effective tax collection, as well as levying new taxes on the rich and hypothecating these to the health sector.

Kristine Hovhannisyan is a media and advocacy officer at Oxfam-Armenia

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.