Accessibility to health care in developing countries
Accessibility to Health Care in Developing Countries Jaap Koot, M.D. MBA, Public Health Consultants, Amsterdam 1. Introduction
World-wide the average health status of people is improving, expressed in termsof increasing life expectancy and reducing infant mortality. As we all know, thehealth status of a population depends more on economic development, levels ofeducation and sanitation, than on health care provision per se. However, theseaverage figures are frequently used to demonstrate progress in health caredelivery, which is incorrect. Still 1.3 billion people in the world live below the absolute poverty line, earningless than $ 1 per day.1 Malnutrition, ill health and early deaths are more prevalentin the poorest countries or in the poorest groups within countries. Inequity inhealth status is the result of many factors, of which inequity in access to healthcare is one. Accessibility to basic health care is one of the basic human rights accepted by allgovernments in the world. Many non-governmental organisations, especiallyreligious organisations consider it to be their vocation to contribute to provisionof basic health services especially for the poor. Memisa has long-lasting relationswith many of these organisations in developing countries.
Despite the tremendous growth in number of health institutions and primaryhealth care activities over the last 30 years, the coverage of health services inmany countries is still low, especially in rural areas and urban slums. There ismore and more evidence that the accessibility to health services is not improvingor even decreasing in developing countries.2 3This paper takes stock of a number of factors contributing to low accessibility ofhealth care, in particular of Non Governmental health institutions. It givessuggestions for improving accessibility to health care. 2. Factors contributing to low accessibility
Both community factors and service provider factors constrain the access tohealth care. Often there is a myriad of factors, with differences per healthinstitution, region or country. 2.1 Demand
All developing countries know a considerable growth in population. In manySub-Saharan countries there is an increase of 3% or more per year. Increase innumber of health institutions does not keep pace with that growth. Epidemiological changes contribute to a higher demand. AIDS is still increasing:in many developing countries about half of the patients has an AIDS-related
1 The Human Development Network, Health, Nutrition and Population, The World Bank Group, 19972 Sara Bennett et al. Health Insurance Schemes for people outside formal sector employment, WHOCurrent Concerns, ARA paper number 16, 1998. 3 WHO Health for All in the 21st Century, World Health Organisation, 1998
illness. The world-wide increase of Tuberculosis for example can be attributedmainly to the spreading of HIV. Due to poor public health, due to irrational useof drugs and other man-made factors, diseases are spreading to new areas orbecoming endemic. Malaria is on the increase again, especially chloroquineresistant malaria. Dysentery and cholera are becoming endemic in some regionsin Asia and Sub-Saharan Africa. 2.2 Solidarity
In developing countries traditionally organised social structures play animportant role in social security. The (extended) families, the clans or the“villages” have always contributed to care at home or in the hospital or topayment of medical fees if needed. Over the last decades there is a weakening of the traditional social structures indeveloping countries, due to urbanisation and increased social mobility. The experience of AIDS home based care projects in Sub-Saharan countriesshows that nuclear families or individuals in urban slums often lack thetraditional support of their extended families. New types of solidarity are beingorganised in e.g. co-operatives or neighbourhood self-help projects, but this stillleaves many people unsupported. There is also a change in mentality. The global expansion of free markets hasspread the ideas of individualism undermining collective responsibility. Thedivision between the rich and the poor is much more visible and - in relativeterms - much bigger than in Western countries. Research has shown that indeveloping countries the rich are profiting more from subsidised health care thanthe poor are. 2.3 Economy
“The present economic crisis in Asia, Russia and Latin America does not affectAfrica, because Sub-Saharan countries were never part of the economic boomingof the nineties”, said one cynic in a Dutch newspaper in October 1998. Indeed 14countries, of which 9 in Sub-Saharan Africa did show an economic decline overthe last years and many other African countries did show an economic growthhardly covering the increase in population. Per capita economic growth has beennegligible in most developing countries. Structural Adjustment Programmes imposed by the International Monetary Fundhave led to a liberalisation of the economies of developing countries and havebrought introduction of “market forces” in the social sector. In the health caresector the numbers of private (for profit) providers have increased, and costsharing has been introduced. In many countries basic health care provided bygovernment institutions was free of charge until the late 80s or early 90s. Inmany countries introduction of patient fees has lead to enormous drops inattendance of health care services. Even after introduction of “structural adjustment with a human face”, thegovernment budgets for health care in most developing countries have notreached the level of $12.= per capita, which is the absolute minimum accordingto World Bank standards. Many low and middle-income countries spendbetween 3 and 5% of their national budget on health care, while Westerncountries spend about 10% of their national budget. One of the reasons for the
low health budget in poor countries is the international debt servicing. Thesecountries are faced with longstanding debts, which require up to 30% of thenational budget mostly for payment of interest. This results in a net-flow ofmoney from developing countries to the Western world. At the same time, donor support to the poorest countries in the world is reducing. Support to countries in East-Europe is “competing” with support to developingcountries. In the case of the Netherlands for example, costs incurred to receiverefugees are deducted from the development co-operation budget. For mission institutions the withdrawal of international congregations andmissionaries is not only felt in missing highly qualified human resources but alsoin missing additional funds, coming in small funds or donations in kind. 2.4 Health Sector Reforms
Most countries (in the North and the South) are involved in some kind of healthsector reforms process. In many countries the health sector reforms is part of thecivil service reforms, where the government “withdraws” from service provisionand accepts a limited role of “regulator of markets”. Privatisation is the slogan ofthe day. At the same time the government decentralises, and leaves managementto lower levels (district or provincial levels). In a period of transition this is leading to instability in management andfinancing. Roles and responsibilities are being reshuffled, leading to uncertaintyin many places. Health institutions become dependent on newly createdparastatal health boards or private health management organisations. Part of the health sector reforms is the liberalisation of the markets. Theentrepreneurial risks are pushed from the government to the health careproviders. Instead of guaranteed payment, contracts and competition are beingoffered to health institutions. For example: health institutions become employersinstead of having government staff on secondment. Introduction of competitionand free markets leads to the increase of private for profit providers, who enterthe most profitable segment of the market (i.e. outpatient care in urban areas),whereas governmental and non-for-profit private providers are left with thehospital functions and preventive health care.
As said before the myriad of factors mentioned above reduces accessibility tohealth services. The poorest in the society, more exposed to diseases, who cannotrely on their communities for social support and who cannot pay high fees forhealth care, suffer most in this situation. Non-for-profit private providers and government health care services are facedwith huge financial and managerial problems as result of liberalisation ofmarkets in an economically insecure situation. The health institutions are caughtbetween their goal of serving the people (especially the poor) and keeping theirinstitution financially viable. 3. Challenges
The present situation calls for an innovative approach in management of non-governmental health institutions.
First of all, increased cost-effectiveness is required within the NGO institutions. The health institutions should work more as small businesses in all aspects: betterplanning and monitoring of resources and stronger human resources management(including career development and capacity building).
NGO health institutions have to realise that they are no longer functioning ontheir own. In the past, NGO health institutions and Diocesan organisationsconsidered the government mainly as one of the funding parties. They developedtheir own – more or less independent – health policies and programmes. Nowadays, the non-for-profit health institutions are part of the district health careservices and have to seek close collaboration with governmental (or parastatal)health organisations. They have to discuss health care packages provided, healthservice areas, collaboration in logistics or supervision schedules, etc. If NGOsfail to do this, their institutions will be put on one line with for-profitorganisations and will be made subject to similar tax regulations etc.
NGOs may have to reposition themselves in district health care delivery system. If their vocation is to provide quality health care at the lowest possible costs andif they want to increase accessibility for the poor, it may be more relevant to putemphasis on primary health care, instead of prestigious hospitals with specialisedtreatment.
The Health Sector Reforms will require innovative approaches in contracting ofservices and in establishing new relationships between Government HealthServices and NGOs. Part of this will be increased accountability (both financialand service performance).
Finally NGO health institutions, Dioceses and other umbrella organisations haveto enter into new alliances to negotiate (or even lobby) with the nationalgovernment the necessity of guaranteeing a minimum social security. Thesealliances should clarify to the national government the limitations of the freemarket forces in the social sector. Liberalisation and introduction of free marketsmay not lead to further deterioration of the health status of the poorest.
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