It seems that the Government of Uganda has agreed the need to recruit more healthcare workers. That’s really good news and something that should be positively received. The Ministry of Health will need to make sure that matters affecting morale are also tackled; salaries are too low, health centres are often in a poor state of repair lacking equipment and medical supplies. These issues all contribute to poor morale and staff seeking alternative opportunities. These extra six thousand will not be sufficient to bring the numbers of healthcare workers to the levels that WHO suggest are required, or even to the average in the Africa region. If all 6,172 new recruits are doctors (very unlikely), Uganda would have 1.8 per 10,000 citizens; the average in the Africa region is 2.2.
Right now there’s a lot of debate, and some controversy, about the new health sector budget. The Observer has this excellent piece by Norbert Mao, President of the Democratic Party, in which he makes some very interesting comments about the size of the budget and the overall contributions by the Government, by Donors and by Households.
U.S. Chargé d’Affaires, Virginia Blaser made a statement recently about the on-going support by the USA for healthcare in Uganda and for the fight against HIV/AIDS in particular. You can read the statement in full here.
This statement of support comes at an interesting point in time. The Uganda Ministry of Health has just recently announced that a recent survey shows the prevalence of HIV has increased to 7.3% of adults, that’s about 1.2m people, more than double the number estimated 7 years ago.
In June the Government of Uganda announced that the allocation of national budget to the Healthcare sector would be reduced from 9.8% in 2011/12 to just 7.6% this year. Depending on the exchange rate this is equivalent to about $307m.
In her statement, Blaser starts by reminding us that since 2004, the American people have invested over $1.7 billion in support of the national HIV response in Uganda. Most of this has been channelled through PEPFAR, for which we should always give a note of thanks to former President George W. Bush.
In 2003, Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion to end the suffering and save lives threatened by the AIDS epidemic. In 2008, Congress agreed to provide $38 billion more.
In Uganda an estimated 600,000 people living with HIV need to be treated with ARVs but only 330,000 are currently receiving these life-saving drugs and of those the USA directly supports funding for 314,000. Antiretroviral treatment, ART, means that a person living with HIV can expect to live as long as their fellow countrymen who are HIV infection free.
We know that ensuring early and sustained access to ART for all those that need it will be a very significant intervention in the fight to reduce the growing numbers of new infections. So it is good to hear Blaser state:
the PEPFAR program in Uganda will review its programs to ensure that we prioritise treatment expansion to ensure all who need ART receive it
On July 5th Blaser stated that $425m will be given in Aid to boost Uganda’s health sector. This is more than 60% of the total Aid being given by USA to Uganda and is some 40% more than the GoU budget allocation.
That budget allocation is coming under increasing scrutiny. Blaser urges the GoU to increase the allocation to the 15% committed in the Abuja Declaration. Whether or not the country can afford to reach that target, it should perhaps be a little more circumspect before revealing that it spends some $150m to send VIPs overseas for healthcare treatment.
It is clear to me that fighting HIV is more than just about GoU budget or Aid from USA. That budget and Aid need to be used more effectively, we need to focus our attention on proven interventions that we know will work. Implementation will involve many different partners from all parts of the health sector and as Blaser says:
By working together, we can free Uganda from this terrible epidemic. Let us all fight together for an “AIDS-free generation.”
- Uganda Aids Indicator Survey 2011 – Preliminary Report (suubitrust.org.uk)
- Healthcare Funding in UK and Uganda (suubitrust.org.uk)
- 1 in 13 Ugandans are HIV+ and Reactions to my SMC Post (suubitrust.org.uk)
I have an interest in the Business of Healthcare and in particular how different countries fund healthcare for their citizens.
Jen sent me the following infographic which, I think, gives a very interesting insight into healthcare costs in the USA.
The US spends more per capita on health care than any other country in the world. Americans can’t afford health care. While politicians are trying to find an answer to this crisis, people are struggling to find a way to pay for their medical bills. The average American family spends $19,393 annually for health care coverage. 60% of personal bankruptcies are linked to medical bills.
Click here or on the image to view the full Infographic.
Created by: MedicalBillingAndCodingCertification.net
Healthcare Funding is one of those polarising topics that generates a lot of debate; people tend to feel quite strongly about their particular view on how this should be done. Just consider the debates raging today in the USA about Obamacare, in the UK about NHS reforms and in Uganda about the recent cut in the share of government budget allocated to the healthcare sector (down to 7.6% from 9.8% last year).
The Guardian recently presented data showing the spend on healthcare for 193 countries. Now we may have seen these data before but this time I noticed that the UK and Uganda spend almost the same when measured as a percentage of GDP.
Such a measure or that showing the comparative per capita spend will of course highlight just parts of a complex whole. These are measures of Input and do not tell us about the resulting Outcomes.
One of the problems in measuring just the spend is that we cannot easily tell how such spend is shared across the whole population. We know that the rich tend to access more than a fair share of the healthcare services and we can also see that in each country there are many who cannot always afford necessary care.
% of GDP
|Government spending on health as % of all health spending||84||22|
|Private spending on health as % of all health spending||16||78|
|Per capita total spending on health
(PPP int. $)
|Nurses and midwives per 10,000 population||101||13|
|Doctors per 10,000 population||27||1|
The Guardian says that it intends to add indicators of Outcomes that may help to make useful comparisons and give some sense of which country is doing best or which approach to healthcare funding is most effective.
In the meantime it has published the number of doctors, nurses and midwives per 10,000 population. Now this is not a direct measure of outcome but one would hope that it is a significant driver of good outcomes?
What I don’t understand is how these two countries can be spending similar percentages of GDP and yet the numbers of clinical staff being provided are very different.
It must mean that the budget is being allocated across various costs in very different ways. Perhaps the cost of drugs and treatments requires a higher percentage allocation in Uganda? Perhaps more of the budget is spent on central administration or on capital developments? Perhaps there is just a general lack of cost efficiencies or insufficient management and accountability of the monies being allocated.
In September 2011, in response to the UN General Assembly held in New York, the Uganda Ministry of Health stated that the country had a gap of more than 2,000 midwives, needed to help improve maternal and child health. Adding such a number would simply move the number of nurses and midwives per 10,000 population to 14.
If you would like to access the WHO data for Healthcare Funding in 193 countries and the comparative indicators discussed above then please use this link: http://bit.ly/LpJJMd
The BBC has a good explanation of what GDP is and how it is measured.
- Healthcare spending around the world, country by country (guardian.co.uk)
Over the last few weeks I’ve been reviewing the cost and affordability of our Community Based healthcare services, which are often given free or at a heavily subsidised, low cost to the patient.
During this review, it has become obvious that if we want these programmes to be sustainable then we will have to ration the services being provided and be more selective about the population being served. These have not been easy decisions to make and in many ways are very similar to those being faced by health planners in the UK and USA. I read a thought-provoking, or perhaps simply provoking, article by Peter Singer on the subject “Why We Must Ration Healthcare”; well worth a quick skim.
Affordability is a complex study; we may immediately think that this is simply about how much the patient can afford to pay, but there are many other interested and affected parties.
The actual cost of providing Primary Healthcare in these communities might be as much as £30 per person per year; those receiving care may only be able to afford £1-2 per visit, probably no more than £5-10 per year, per household. A lot has been written about the pros and cons of user fees and the need for patients to contribute at the point of receiving service. This remains a matter that divides opinion.
When we make healthcare affordable for the poor, we have to also consider the impact this has on others who are subsidising that cost. These include tax payers who contribute, and may be asked to pay more, to the government budget. Other government sectors, such as education, may be squeezed if the government increases its budget allocation to the health sector.
Donor funds and Charitable giving are not limitless and deserve to be used in the most effective and efficient manner. We need to ensure that these very necessary funds are put to best use but, because they are limited, there is a tension between use for Prevention or use for Treatment and also in the selection of the most worthy diseases. There are divided opinions about how these limited funds should be shared between e.g. Health, Education and Infrastructure.
Many health service providers serving these communities are operating from a faith or humanitarian basis and want to help serve the poor and needy. They are not doing it for profit and they depend on funds from all of the various sources: the user, the government, charitable giving and donor funds. When these funds are not enough and the sick continue to arrive at the centre, then what should the facility owner do? Do we turn them away or do we treat and dig deep into our own pockets to meet the shortfalls?
Times are hard, perhaps global economies are still getting worse, rather than better, and many in the UK are saying that it would be wrong for the Government to meet our pledge to raise overseas aid to £10.6 billion in 2014-15. Why should we persist in giving to other countries when there are so many problems at home?
The Telegraph writes that Bill Gates, when interviewed on Radio 4, urged Britons to be proud of the positive impact our donations are having on the world’s poorest people.
I agree, we should be proud and now is not a time to consider cutting back. The 0.7% of national income proposed as overseas aid impacts the lives of many millions in ways that are often life-changing.
Just in this last week new research shows that the numbers of deaths from Malaria are actually double what we had thought; now estimated at 1.24m a year. Many of these are children under 5, for whom Malaria causes 24% of all deaths.
When we discussed and agreed our proposed approach to rationing we decided to focus attention on prevention and treatments for Children under 5. We know that Malaria is a significant problem for this population and in the week we decide to ration, we now learn that the numbers of those affected may be double what we thought!
- Primary Healthcare in East Africa (suubitrust.org.uk)
- Malaria toll ‘is twice as high’ (bbc.co.uk)
- Malaria cases around the world: how many are there? (guardian.co.uk)
16 women die every day in Uganda while giving birth or during pregnancy; that’s 5,800 deaths each year. Many more suffer from complications and childbirth injuries such as VVF.
Each year 100,000 babies die at birth, that’s 76 deaths per 1,000 live births.
The shame of these numbers is that these deaths are, on the whole, preventable. Mums need good ante-natal and post-natal care, safe delivery attended by trained staff, post-natal care for Baby and simple immunizations. Such care needs to be provided alongside other healthcare programmes that tackle the major causes of death such as pneumonia, diarrheoa and malaria. This in conjunction with Social and Environmental Health initiatives to ensure access to family planning, safe clean water, sanitation, waste disposal and better housing.
So if we know what should be done and most of it is not so difficult to implement, why does the problem persist and why, in most countries in Africa, does the trend seem to be going in the wrong direction?
Put simply it’s about MONEY and PRIORITIES.
The African Union agreed at the 2001 Abuja Summit that each country should spend 15% of its budget on healthcare. 9 years later most have failed to do so. Uganda spends just about 9% of its budget on healthcare and Maternal Child Health (MCH) gets just a small proportion of that, though this is set to increase to UGX 260b in 2010-11. At the recent AU Summit in Kampala, officials simply stated that 15% was unattainable in the foreseeable future. If all ministries were to be given the budget they were asking for, the total would be more than 150% of what’s available. A very significant percentage (~40%) of the UGX 600b Uganda health budget is provided by other donor countries and those are not able to make any further increases due to current worldwide commercial and economic pressures.
So we’re on our own and it’s even worse than that. Uganda needs to allocate more of its own domestic budget to healthcare. However there is growing evidence that even if it reaches the ‘magic‘ 15% this still won’t be enough. It is just too simple to talk about percentage of overall budget or GDP. One must also look at the actual amount being allocated and spent per person. Currently in Uganda less than USD 10 are spent on healthcare for each person. A 50% increase in budget allocation, to reach the 15%, would take this to about USD 15 per capita. That is still such a long way from the WHO recommendation of a minimum of USD 40 pp pa.
Maternal, infant and child health are the greatest challenges facing Africa ahead of the 2015 deadline for achieving the Millennium Development Goals. The Countdown Report estimates that it will cost an additional USD 8 per person per year to provide the required healthcare interventions mentioned above.
117 African Health, Social Development, Gender Based, Youth, Human Rights Organisations, and Trade Unions have joined together to recommend to AU member states progression towards a more comprehensive health, population and social development formula described as 15 % Plus.
Whilst this laudable and should get our support, I am not at all convinced that AU governments will make, or be able to make, such a commitment and implement it.
There has to be another way.
You can read more about all of the above by selecting from the search results at this Google Link.