Free and Public

When wealth buys health, Niramaya may be the answer by Pallavi Gupta, Health Programme Coordinator, Oxfam India

I grew up learning that “Health is Wealth”. But today it seems that it is the other way round: one needs a substantial amount of Wealth to buy Health.

Article 14 of the Indian Constitution grants all Indians the Right to Life. Yet that right cannot become a reality when a quarter of the country’s population does not seek medical treatment because they cannot afford it and 65% do not have access to the medicines they need. India has one of the highest private out-of-pocket expenditures on healthcare at almost 70%[1]. Two-thirds of the out-of-pocket expenditure is on medicines alone[2]. Therefore, providing free medicines in public facilities can have a great impact on people’s healthcare costs and health outcomes.

Historically government hospitals were supposed to provide free medicines along with free consultation. Yet over the years buying medicines from private pharmacies has become almost a norm. Availability of medicines in public hospitals has been very limited over the last couple of decades[3]. To fix this problem, many state governments have announced their own free medicines scheme and set up state owned corporations to operationalise it. Tamil Nadu set up its corporation in 1995 to ensure availability of all essential medicines in the government medical institutions throughout the State.

Other states like Kerala, Andhra Pradesh, Bihar, Madhya Pradesh, Chhattisgarh followed suit. Rajasthan was the first of the Empowered Action Group of states[4] to roll it out successfully, thus inspiring other states in similar fiscal health. Evidence from Rajasthan illustrates that the availability of free medicines at public health facilities increases their utilization and is an important step towards strengthening the public health system.

In this pursuit, Government of Odisha increased its budget allocation for medicines to more than USD 15 million in 2012-13 and set up its state corporation for the purpose. Going a step further the government announced a specific free medicines scheme in the state called the “Niramaya Yojana” in April 2015 and increased the budget allocation to USD 32 million for the year 2014-15[5]. The increase is comparable to Rajasthan’s spending of around USD 48 million to provide more than 400 medicines.

In November 2015, I visited the Bhubaneswar public hospital, a multi-speciality 547- bed flagship hospital of Government of Odisha as part of Oxfam India’s campaign on free medicines (“#HAQBANTAHAI:Muft Dawa, Haq Hamara”). The hospital caters to over a million people. The hospital has 5 Drug Distribution Centres (DDCs) under the Niramaya Scheme, of which only two were functional at the time of my visit because of shortage of staff. One of the two DDCs operates 24 hours all days of the week while the other is open only during the day time. Out of the 570 medicines in the state’s essential drug list, the DDCs at the Hospital had only 236 medicines as the government is still in the process of procuring and providing more medicines.

According to the Central Medicines Store officer, “free medicines have always been available at government hospitals. It is just that now they are being provided under the name of a scheme”. He felt that the main problem with any scheme is the lack of “follow-up” after it is launched. The Central Medicines Store which manages the supply of medicines within the hospital regularly updates doctors on the availability of medicines to guide their prescriptions.

Staff at the DDC which functions 24×7 said that they serve nearly 1000 patients daily. In order to ensure continuous supply of medicines, they only dispense 3 to 7 days’ supply, even if patients came from far and had a chronic illness like diabetes or hypertension. As a result, the patients either discontinue the medicines or buy them from private pharmacies at higher costs or make additional trips to get the supply which for poor people is an additional financial burden.

Despite these limitations, I was very heartened to see the well-functioning DDC where patients trust the quality of its medicines. The DDC was clean and well-kept with medicines stored in racks in an organized manner. The room was well-equipped and staff were dispensing medicines very efficiently. In fact, the DDC could well pass off as one in any big private hospital.

The example of DDCs in Bhubaneswar clearly demonstrates that people use public facilities when they are available and well equipped. However, for continued success, the scheme must be “followed-up” as the officer mentioned above: the remaining 3 DDCs are opened, the stock of medicines is increased from the current 236 to the 570 on the essential drug list; and the doctors prescribe medicines available at the DDC. The success of the scheme would add to the evidence that public facilities do function!

References

[1]Global Health Observatory data repository, Health expenditure ratios, by country, 1995-2013, WHO

[2]Selvaraj S. and Mehta A., Access to Medicines, Medical Devices and Vaccines in India, India Infrastructure Report 2013-14

[3]Universal Access to Medicines in India: A Baseline Evaluation of the Rajasthan Free Medicines Scheme, WHO 2014

[4]Term used for socio-economically underdeveloped states in India.

[5]http://www.orissadiary.com/CurrentNews.asp?id=59020; Demand for Grants and Budget at a glance, government of Odisha http://www.odisha.gov.in/finance/Budgets/2015-16/Annual_Budget/DEMAND_FOR_GRANTS.pdf

 

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Ebola’s lessons for Universal Health Coverage  by Mohga Kamal-Yanni, Senior health policy advisor, Oxfam

This Saturday  is world Universal Health Coverage (UHC) Day. The UHC day comes after a year of the international community being busy in producing numerous reports on learning from the Ebola crisis. Most of the learning from these documents has focused on mechanisms for effective global response to outbreaks.

However, more attention should be directed to learning from the role of local institutions in tackling the Ebola outbreak including how critically needed advances towards UHC can be achieved. Two key ingredients for effective epidemic prevention and response require particular focus:  community engagement and health systems strengthening.

The WHO interim panel’s report on Ebola  recognised that “Risk assessment was complicated by factors such as weak health systems, poor surveillance, little early awareness of population mobility, spread of the virus in urban areas, poor public messaging, lack of community engagement, hiding of cases, and continuing unsafe (e.g. burial) practices”.

Community engagement.

As late as October 2014, 2 months after the WHO announced the Ebola outbreak as a “Public Health Emergency of International Concern”, donors were unwilling to fund large-scale social mobilization activities designed to facilitate community prevention work and treatment-seeking behaviour. There was little real understanding of community realities, beliefs and practices, or the different roles of community women and men.

Things only changed when it became clear that community engagement through trained local community health workers (CHWs) was critical for the success of the work of the treatment centres. Such work was essential for contact tracing and for encouraging people to report fevers. It also helped to change decades of unsafe burial customs that were critical for halting the spread of Ebola.

As Ebola is becoming under control it is essential that the work of building trust between communities and the authorities continues. Therefore, global and national strategies to deal with health crises must:

  • Enable CHWs to continue their role as the trusted front line workers for individuals and communities. CHWs must be an integral part of building resilient health systems;
  • Include other influential community actors – such as religious leaders, women’s groups, youth leaders and traditional healers – in outbreak control and response;
  • Make government and donor resources available to strengthen community linkages to district and national planning and implementation;
  • Implement accountability mechanisms to empower communities and civil society organisations to monitor funding for public health.

Resilient Health Systems

My biggest fear is that the health sector is not improved.

George Caulae, New Kru Town, Liberia, February 2015

Resilient health systems are a global public good that requires long-term commitment from national governments and international donors in order to provide universal health coverage that is free at the point of use and to respond to disease outbreaks.

The Ebola outbreak was a magnifying glass that revealed chronic under-investment in public health services. Health systems collapsed under the pressure of Ebola. Many health centres closed and people had nowhere safe to seek medical care. Maternal services came to a standstill. As a result there has been more maternal and child deaths than before Ebola.

Since then there has been a strong emphasis on developing disease surveillance and laboratory capacity. Yet for these functions to work all elements of health systems need to be built simultaneously.  Resilient systems require six essential elements:

  1. Adequate numbers of trained health workers, including CHWs. Oxfam calculated that training the missing 9,020 doctors and 37,059 nurses and midwives in Sierra Leone, Liberia, Guinea and neighbouring Guinea Bissau would costs $420m. Once they were trained, a total of $297m annually would be needed to pay their salaries for 10 years
  2. Low cost medical supplies (medicines, diagnostics and vaccines)
  3. Robust health information systems (HIS), including surveillance
  4. Adequate infrastructure of well-equipped health facilities, laboratories, and clean water and sanitation
  5. Adequate public financing. No country has achieved UHC without public funding. Governments should act immediately to increase their budget allocations to health. However, their ability to spend sufficient resources is blocked by an unfair global tax system that must be reformed. Donor countries must also increase their aid targeted to building country capacity in health and education
  6. A strong public sector to deliver equitable, quality service during both normal and outbreak times

For the countries that suffered from Ebola, external funding is urgently needed. Last July (2015), donors’ pledges to the recovery efforts of the three affected countries reached US $ 5 billion. However, it is not clear what funds have been disbursed to date and what programmes will be financed. Therefore, it is critical that governments, with donors’ support, implement mechanisms for clear accountability and transparency including community and civil society participation in monitoring programme funding.

 

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni