WINDHOEK – A health expert says any country can offer its citizens the very basics of life: good health, good food, good shelter and a good education, regardless of their economic and social standing.
Delivering a professorial lecture at the University of Namibia School of Medicine, Professor Peter Nyarang’o advanced the thesis that no country on earth can claim to be too poor to give its citizens quality health care.
The title of his lecture was: Is universal access to quality health care attainable in low and medium countries or are we simply feeding a white elephant?
His view is that every effort must be taken to ensure that each citizen is treated with dignity, particularly when they are most vulnerable, pregnant, young, old, sick or hungry.
“That’s the moment when they need their county to stick its neck out and reassure them. The solidarity of the nation should be reflected in how it treats the ones who are weak, poor, old or young,” he said in an interview shortly after he delivered the public lecture.
Health as social justice
Nyarang’o said health is a social justice or human rights issue and so nations must strive to ensure that all their nationals get the best health care possible.
He said what makes the difference between developed and developing countries’ quality of health care are the systems put in place to provide that care. He opined that the time has come to question whether governments should be seen as primary providers of services. His view is that governments must slowly move away from direct service delivery to become regulators, standards setters and allocators of resources.
Recently President Hifikepunye Pohamba appointed a commission to go to the roots of this issue. The Presidential Commission on Health has since produced a scathing report, which some people say is a litany of indictments of the country’s health care system.
Although the report did not say when the rain started to beat the system, it is emphatic in saying that there were few health workers; that the quality of health care was doubtful and unsatisfactory; and that the resource basket was leaking too much along the way to the actual patient.
Other studies indicate that the cost of health care delivery in the country is too high as not to be affordable in the future.
Runaway, unclear costs
Earlier in his presentation, Nyarang’o had called for the generation of hard, counterfactual evidence given that the actual cost of the package of services that patients got was not known for certain.
He gave the example of caesarean section operations, which have been done since the middle ages. In some instances women who desperately need them die before they can have them, while some of those that access them pay through the nose for the service.
“This is something that should be readily available and affordable. We should be able to link such costs to outcomes and the costs should be clearly broken down so that we can see why we are spending so much.”
Available evidence indicates that in Namibia more caesarean section operations than are necessary are performed.
According to the World Health Organisation (WHO), all over the world, caesarean section rates should not be more than 15 percent of all deliveries, while Namibia’s national average rates for caesarean sections are estimated to be at 25 percent, 10 percent more than necessary. Reasons vary.
Some women opt for caesarean section because they think it is ‘cool’. Others think since it is done under general anesthesia, it is less painful, while others choose it to keep unmentionable parts of their anatomy tight. However, women who deliver their babies normally say the pain disappears within a week, while those who opt to go under the knife need up to six weeks to heal.
His view is that although health care services at public health facilities may appear cheap at face value to the patient, there are hidden costs, which can hemorrhage the state and the patient if not reigned in.
Rampant wastage
He also called for developing countries to develop strategies to avoid wastage, which he said is a major problem in their health systems. He reasoned that in some instances wastage in the use of drugs could be attributed to the manner in which patients procure medicine.
Many people who have medical aid seldom pay for drugs from their pockets at the pharmacy. They do so through deductions from their earnings to an almost faceless entity. For that reason they seldom ask their doctor or pharmacist if they really need all the medicines prescribed when they fall sick.
Tales of promiscuous use of drugs abound. A woman who once took her child who had a sore throat to a doctor said she was given an anti-biotic, a pain killer, a cough mixture, multivitamin and lactobacillus, which is used to replenish useful bacteria which antibiotics would have removed in the intestines. Experts say one can get lactobacillus from yoghurt.
“I ended up with so many drugs that I simply kept them in the house until I gave some to my neighbour and threw away the ones that had expired,” she said.
Nyarang’o said whereas rational use of drugs requires that pharmacists use the simplest and cheapest (generic) preparations to treat diseases before using stronger drugs that is not always the case.
He said the offshoot of this indiscriminate use of drugs is very high resistance in some cases, even to second and third generation antimicrobials.
“The sum total of all these factors is that health care costs for any country can easily go out of control without a corresponding decline in the burden of disease or improvement in the health of the nation,” Nyarang’o, who is the Founding Dean of the Unam School of Medicine as well as Dean of the Faculty of Health Sciences, said.
The Kenyan experience
He drew parallels between his native Kenya and Namibia. He said Kenya has very little resources to spare for health. As a result the country spent only 2.6 percent of its Gross Domestic Product on health. Namibia spends about three times more. Dollar for dollar, Kenya, whose population is about 40 million, spends the same amount on health as Namibia, whose population is about two million.
As part of a broader strategy, the country took a bold step to give power to the patient by making health care affordable. Kenya eliminated the need to put the hand in the pocket at the point of care.
Mandatory health insurance?
In line with this thinking, Kenya set up a mandatory health insurance scheme nearly 50 years ago. A state corporation called National Health Insurance Fund (NHIF) was set up to keep the money.
However, a recent study revealed that the NHIF was shortchanging almost everybody in that its operational costs were very high (nearly 50 percent) and it had become a state monopoly. The study also found that the NHIF was not ambitious enough to expand coverage, particularly to the informal sector.
Namibia does not have mandatory health insurance. It is only employees of government or the private sector who contribute.
He said a free market does not work in health and so there is need for safeguards for the contributors, who often do not know how much the services and products offered really cost or if they are necessary.
“Ideally there must be an intermediary who negotiates good rates on behalf of the user,” Nyarang’o said.
In addition to universal health insurance, Nyarang’o advocates the establishment of a health trust into which donors and philanthropists can put money. The money can be used to subsidize the poor as part of universal health coverage. He said health insurance was too complicated to be run as a government bureaucracy.
Well-placed sources say that Namibia is already discussing within the context of social security, whose Act among other things requires support to health care. Observers say this is a major breakthrough in terms of having an existing law on social health protection.
By Moses Magadza