Affordability, Rationing and Aid

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.

Mothers attending baby clinic at Charis

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.

Sophie putting IV into baby Job with severe malaria

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!

Coke and Primary Healthcare

It’s a simple pleasure; ride my bike through the local communities until exhausted – which for me in this heat and with these hills doesn’t take very long. I’ll admit, at times it might have been better described as “there’s Kevin taking his bike for a walk…”

When exhausted stop at a local shop (for local people) buy an ice-cold coca-cola and drink it from the bottle.


It doesn’t matter where you are in Uganda, you can always find somebody selling Coca-Cola, usually from one of those red fridges and often cold. That made me think about the delivery of primary healthcare. Now I’m not about to equate the distribution and supply of a cheap commodity such as a soda with PHC, but I do think there are some principles that we could adopt.

Coca-Cola is available, accessible and affordable to all in Uganda. Those buying it can be assured of its consistent quality and the price is known to all parties before the transaction begins. Sometimes we may choose to pay more, for nicer surroundings, to have it brought to the table and served in a glass with ice – but it is just the same coke as that bought from the shop in the picture above. There is something quite equitable about this.

Healthcare planners should be seeking to ensure that primary healthcare is available, accessible and affordable to all in Uganda. It will take some effort and perhaps legislation or self-regulation to ensure a consistent quality of care. The price thing is something that should be easier to make happen. Wouldn’t it be better if there were set prices for consultation, test and treatment of the common ailments; so that those wanting to use the services know, before coming, how much they will be asked to contribute? Making it affordable, that’s the next challenge.

Isn’t it great when you get to freewheel downhill, makes all that effort seem worthwhile.

Primary Healthcare in East Africa

Dr. Nick Wooding kindly asked me to write a preface for a book about to be published by International Health Sciences University which discusses the many aspects and issues related to the delivery of primary healthcare in the developing world, and in Uganda specifically.


PHC in East Africa: Preface

If you are a healthcare practitioner or student you will know that there are already thousands of books exploring and expounding each and every aspect of Primary Health Care. So why have we added another one?

It may be wrong to claim that specific health issues facing Uganda are unique but perhaps we can at least say that when combined together in the local context they become unique. It is that local context that we have set out to explore more fully in this book. We have written about primary healthcare as it applies to Uganda and we have written it for those that are providing, and for those that hope to provide, healthcare services to its people.

Healthcare policy in Uganda is very well designed and documented. The second National Health Policy (NHP II), issued in 2010, lays out those elements that are a particular focus for the period up to 2015. This policy seeks to prioritise the effective delivery of the Uganda National Minimum Health Care Package (UNMHCP) and the policy is operationalised in the third Health Sector Strategic Plan (HSSP III). These two documents detail the services that should be provided and the organisational structure required for delivery. There is a very close fit to the key principles proposed in the Alma-Ata Declaration on Primary Health Care. UNMHCP comprises these four clusters:

i. Health Promotion, Disease Prevention and Community Health Initiatives

ii. Maternal and Child Health

iii. Prevention and Control of Communicable Diseases

iv. Prevention and Control of Non-Communicable Diseases.

The HSSP III outlines the organisational architecture, strongly promoting a decentralised structure in which delivery starts in the community through specially trained volunteers (VHT) who are supervised by, and can refer to, nurse/midwife led health centres (HCII) which are located very close to each community. In turn the HCII can refer patients needing specific medical care, e.g. c-sections, to a nearby HCIV. District and referral hospitals complete the structure and are tasked with general surgery and an expanding set of tertiary services. The strategy details the services that should be provided at each level, the cadres and numbers of staff that each level of facility should have and the numbers of each different type of facility needed to serve the whole population, ensuring equitable access for all, in the most efficient manner possible.

NHP II clearly states that seventy five percent of the total disease burden in Uganda is still preventable through health promotion and disease prevention. The above strategies and plans are designed for doing exactly that. So why then is the country still struggling to reduce the very high rates of mortality and morbidity? Why are we seeing slow progress on reducing the under-5 and maternal mortality rates that are measured by the Millennium Development Goals 4 and 5? Why is the country still suffering under a very high burden of malaria, which significantly impacts the quality of life for the individual and the economic performance of the country as a whole? This is measured in MDG 6, as is the prevalence of HIV, which after some notable reductions during the 1990s and early 2000s is now beginning to rise again.

What’s going wrong and what must we do to make it right?

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