Cost – Sharing in Primary Health Care

In the year 1987, the World Bank recommended that that the principle of cost recovery be incorporated into an agenda for financing publicly provided health services in developing countries. (World Bank, Findings, Africa Region)
Subject provoked many people across the globe to debate and react over it. Controversy and debate over cost-recovery system not only limited to the subject itself but also pointed so many issues relating to that. Issues like will poor able to pay? What about Government’s commitment towards peoples’ health? What about peoples’ right to equitable health? And the debate was not confined to a group, country or region; it challenged the very intension and commitment of United Nations commitment for Health for All. And now the Millennium Development Goals (MDGs).

Cost- recovery in most of the poor countries in Africa, Latin America and Asia is the bi-product of Structural Adjustment Policy or Health Sector Reform initiatives, and also a compulsion in the part of the poor National Government to adopt this because of its poor economic condition that denies free health care to its people.

What ever the reason behind the present cost-recovery system (cost sharing) there in but the ultimate truth is it does not benefit any one, neither the country nor its people. Most of the people in the third world countries are already far from the access to health service due to so many factors and the present cost-recovery system develops more gap between the people (poor) and health care. If we analyse the cost benefit or profit and loss of present cost-recovery system we will find there is little benefit or profit but more loss and burden. The poor people in the cost-recovery system are either forced to take loan from relatives or money lenders by mortgaging household assets to avail the health service or just remain in ill health and disease. Both the activities create economic burden to the family and the country. If people lost household assets or remain diseased that further breaks the chain and system of capital formation and productivity and put people vicious circle of poverty and disease. To get recover from the vicious circle of ill health and poverty both Government and People will have to spend more resources in terms of money, material, manpower and time than actually they contributed for the health services in the cost sharing.

The recent study conducted by Somali Red Crescent Society in two health centres in Somaliland where cost sharing (cost recovery) system has been initiated gives very grim picture of the initiatives.

The target set by the ministry of health for the project period that is 30 months as the community contribution in terms of user fee was 26 % of the total project cost for both of the health centres. Government contribution 5 % and rest the donor contribution. At the end of the evaluation it was estimated that local Government had contributed 2 % in one health centre and 3 % in another. Community contributed 1.5 % in one health centre and 3.5% in another centre.

The findings are revenue generated for the purpose was very small and negative impact of user fee scheme on attendance. User had resulted in reduced utilization of services and some people cannot afford the fee. Poor people are excluded from the services and many did not come for the service and some could not finish the complete treatment because they could not pay for the whole course of treatment. Study says that in Adadley health centre 1 in every 4 household had to borrow to pay the fee. Even in during drought period many patients were not exempted because health centre did not know their economic conditions.

Though the government policy says about exemption of user fee for poor, destitute, chronic patients, medical emergencies, mentally handicap without having family support, women in child bearing age, preventive services for under five children, immunization service but in reality lack of data to identify exempted persons and guidelines on user fees exclude people to get benefit of the government policy.

Here with I conclude that the paying capacity of the people, Government’s exemption or waiving policy & guideline and its enforcement, quality care and service, provision of low cost drugs, improve accessibility, etc are the key to the success of cost-sharing system.

The debate continues………………….

Struggle for Co-Existence

“The Appropriate code of conduct for a Globalised world should be the five principles of Peaceful Co-Existence and not the over-lordship of one super power or group of nations” said former Indian President K.R.Narayanan addressing a two-day international seminar on Five Principles of Peaceful Co-Existence in Beijing on 15th June 2004.
Today is the 50th anniversary of the five principles (pancha sheela) agreement initiated by India, China and Myanmar in 29 June, 1954. The five principles are on mutual respect to each other’s territorial integrity and sovereignty; mutual non-aggression; mutual non-interference of each other’s internal affairs; equality and mutual benefit and peaceful co-Existence. Even after 50 years Five Principles remains extremely relevant and valid framework for peace and sovereignty in the world. The five principles has relevance to the changing world of today and tomorrow where every one struggle for Co-Existence.

The Five Principles:

The word “Pancha sheela” denoted “Five Taboos” in the ancient Buddhist scriptures governing the personal behaviour of Indian (later Chinese and other foreign) monks. This was taken from the holy book by the first Prime Minister of independent India Pundit Jawaharlal Nehru to be applicable for international behaviour and order. It is also stated that Jawaharlal Nehru was borrowed the idea from Gandhian Philosophy of Satyagraha – the non-violence to use for peaceful coexistence with the neighbouring countries. Nehru was convinced that five principles would bring changes in the international relation and would help in bridging gap between United States and former Soviet Union.
Peaceful Co-Existence have become the basic norms in developing and maintaining state to state relations transcending regional social, cultural and economic barriers. The five principles of peaceful coexistence are diametrically opposed to power politics which have been in dominance in the international relations over the last few centuries.

Relevance in present world context

Five principles has undoubted relevance in the present world order to bring mutual understanding and cooperation among the nations. The major primary beneficiaries of the principle agreement have been India and China. India and China resolved their long standing border issue through this agreement. The present world where border issue has been the cause of conflict for many African and Asian countries like India, Pakistan, Somalia, Somaliland, Israel and Palestine, Indonesia and Timor etc . The five principles will help in building an environment for mutual trust, security and reconciling border issues.

Equality and mutual benefit was one of the basic principles of Pancha Sheela. Under the agreement both country had decided to open trade centres in different places of the countries with mutual understanding and respect to trade and traders. In the present world system where countries are struggling for trade and commerce and there is a huge gap between International and multi national companies and local producers could learn lessons from the agreement. The agreement says “the Trade Agencies of both parties shall be accorded the same status and same treatment”. The article of the agreement says,
“Inhabitants of the border districts of the two countries, who cross borders to carry on petty trade or to visit friends and relatives, may proceed to the border districts of the other party as they have customarily done heretofore and need not be restricted to the passes and route specified in Article IV above and shall not be required to hold passports, visas or permits”. This article will not only encourages inter – country or inter-region trade and relation but also at the present context enlightens International Trade Organizations like WTO to think over this.
“Pilgrims of both countries need not carry documents of certification but shall register at the border check post of the other party and receive a permit for pilgrimage”. This article profoundly establishes relationship between the people of both countries and spreads cultural and religious harmony among the nations.
Mutual respect to each other’s territorial integrity and sovereignty as one of the principles demonstrates respect to the country and its sovereignty. In the present world context it would help to build peace and would remove conflict between the countries.

Challenges before Co-Existence
Co-existence means learning to live together. Co-existence is accepting diversity and implying positive and truthful relationship among the humanity. Co-existence should not be seen within a limited framework of inter-state relation but should be perceived as intra-state, intra-community, intra-religion paradigm. The present world is separated in races, groups, clans, rich and poor, north and south. The great challenge is to build confidence among people and countries. Provide scope and opportunity to understand each other and to build up relationship and trust. Co-existence between people, races, religious groups, clans, tribes within a broad spectrum of distinctiveness will be the real test for all of us in the coming years. Human dignity and freedom of independence will be the measuring rod for the civilization.
Our Commitment:
The commitment for institutionalizing co-existence should be the agenda for all. It should start with the people, community, and civil society as a social movement not as a political agenda. Education is the basic foundation for the coexistence. Stronger education system with a responsive civil society and effective governance together can bring changes in the present world order.

Diagnosing the health of Medicines

Medicines that are dispensed at the health facilities by both Government and private hands in Somaliland do need to check its health, suggested one of my Telesom friends. You must be wondering about two factors one is Telesom friend and Health of medicine. Isn’t that? In Hargeisa town one private telecommunication company named Telesom provides unlimited talk time on the telephone over a fixed charge of amount per month. So most of the people like us take this advantage and chat for a long hour on any topic. This facility also helps to make friendship with people both known and unknown and I call them Telesom friend.
I light heartedly replied to my telesom friend, all over world only few drug companies are in collapsing stage or already collapsed but majority of them are always with high fever if you see the stock exchange bar you can know. Most of the drug companies’ health is good. My friend annoyed with my reply and said we should not joke for everything. This is very serious concern for all of us. I kept quite. The phone line then got disconnected when I tried to reconnect but there was no signal available.

The Situation

In the country the provision of drugs is left to the hands private suppliers. Except UN agencies, who procure drugs for their programme from their own secure sources, all most all agencies including Government buys from local open market through an open tender. I do not have statistics to comply what percent of people gets UN supplied drug but I roughly estimate more than 90% people buy from outside.

The prevailing situation in this country is no one obtains free medicines except some vaccines and few other medicines in Government Health Centre. Everybody has to pay for medicines. Paying for medicines is not always easy for people mostly poor. Many poor say, sometimes paying for drugs is more painful that disease itself.

Drug choice by people and also service providers in both rural and urban areas is mainly rest on two things one is drug name and another is drug manufacture country name. the general perception among people and health professionals about drug is, supplies come from India, China, Pakistan (Asian country) are relatively less qualitative than supplies from European nations. Reasons may be some drugs really are effective or may be it is only perception or propaganda. What ever reason may be there in, the real pain in neck is most of drugs suppliers do not keep drug efficacy report or laboratory test report of all drugs with them and many buyers not only individual but also institutions do not ask for it.
It is not that drugs available in the market do not have proper documentation but it is simple error in part of people not seeking for it.

The cost of drugs

There is no single rate for any drug all over world. But for the people of Somaliland the drug price is exceptionally high and many times not affordable. It is obvious because all drugs are imported and there are lot of taxes and duties are levied on the drugs. By calculating everything and including profit margin definitely drugs will be expensive.

Essential drugs

Putting a lot of medicines both essential and non-essential on sale would definitely raise the overall price of the product. Because investment cost, any loss or damage, expire etc will add to it. But important thing about essential drug is there is no list of essential drug to follow by the Government and Private practitioners. Many drugs available in the health institutions and shops are not necessary at all and drugs prescribed by the doctor and pharmacists do not always follow essential drug category. Self medication and taking drugs from drug retail store is a practice and rampant in both the urban and rural area. This is may be because there is lack of doctors to appoint for each area, lack of access to doctor or hospital and may be people’s ignorance about the subject.

What we can do now?

In my understanding we should focus on four or five major areas,

First is develop essential drug list, supply only essential drugs to health centres and train health service providers on use of essential drugs and motivate doctors to prescribe essential drugs. Enforce the follow up system.

Secondly, Develop pharmaceutical formulary of drugs according to the requirement of the country. Categories them as drugs indispensable for general use, drugs reserved for specialists use and high risk drugs to be used only under strict protocols.
List of drugs only can be sold by doctor’s prescription.

Thirdly, Government can buy essential and other live saving drugs from world market in bulk. Government can take loan from any individual or aid agency or company and sell the drugs to Government institutions and private parties. Or Any aid agency can buy the bulk amount of drugs from international market by making international tender and sell to government and private and run the operation through a revolving fund managed by Government or NGOs.

Fourthly, Encourage individuals to set up drug manufacturing unit or any Multi National pharmaceutical companies to come and set up units in the country.

Fifthly, Government to ensure drugs coming to the country has proper documented and certified by the international or recognised lab.

After all it is our responsibility as Government, drug supplier, consumer, doctor, retail shop owner, health professional, administrator, planner and development organization to protect million lives of the country through an effective and quality service. It is our self conscience, professional ethics and morality that helps a country to move forward and shine.

Water harvests Water

Last week I was in Dar E Salaam District head quarter. Dar E Salaam is one of the districts of Somaliland. It is nearly 13 kilometres from Hargeisa, the Capital of Somaliland. I visited the health centre of Dar E Salaam with one of my colleague. We had meeting with the Traditional Birth Attendants, Community Health Committee members and Health staff of the Health Centre. My friends in the health centre suggested us to visit nearby farms. I was little surprised after hearing the word farm. With my all eagerness, I asked what they mean by farm. They said it’s a farm, Mango Farm. Out of my curiosity I decided to see the farm. I could not believe my eyes when I saw a green belt of trees and plenty of mango, Guava and lemon spreading all over under the trees.

Dar E Salaam has been a favourite place for most of the farmers inside and outside of the area. It is all because of available water in all the seasons. Farmers are successfully use ground water by water lift points and irrigate trees through pipe water irrigation system. Most of the trees in the farm are matured and some are even more than 20 years old. Each matured mango tree bears on an average 200 to 300 Kilograms of mango in a good harvesting season. An orchard of 25 to 30 trees is more than sufficient for a family to sustain livelihood.

But all areas of Somaliland are not fortunate enough as Dar E Salaam. Where farmers get enough water for the trees and animals. The question comes to my mind; can it be possible to have water for the agriculture and pastoral activities? Different study and development projects claim that small scale water harvesting structure can have increasing water security in the area. Water harvesting structures like sub-surface dams will be most effective in the areas. And also small scale water conservation methods like construction of check dams and contour and gully points will help to check rain water run off and restore water for pastoral use. It will also help in recharging the ground water. Though rain water harvesting structure and system is under developed and in very infant stage in the country. Very few demonstrated and effective model are available.

The general livelihoods of the people are mainly based on agro-pastoralism activities in the area. Development of livestock and agriculture is the main challenge before the people and Government. Sustaining and strengthening pastoral activities through proper management of natural resources is the concern for all. Large scale dry season migration has posed very negative impact for the both human and cattle population. In order to minimise large scale dry season migrations and to sustain agro-pastoral activities it is necessary to harvest and sustain water for consumption of human and cattle. Construction of more water bodies in the basins to harvest rain water could be one of the activities towards the same. With this increasing reservoir capacity would also help in drought mitigation and would reduce large scale migration. Community owned small watershed would definitely make differences in the sustaining livelihoods. Development agencies can work with the pastoral community on watershed management and natural resource management. Nature has not given us plenty but what ever is there if managed with sense and wisdom could bring changes in the life of people. It is sure that we could experience more like Dar E Salaam in near future.

Conditionality, reminds me the money lending practices in rural India.

The International Money lenders:

I was born and brought up in rural India. More than half of the population in rural India are living with poverty. Access to money has never been a problem for the poor if they have good rapport and access to money lenders. Money lending is mostly considered as family business and very particular caste and sub-caste members are involved in this business. In a very narrow economic sense it is called informal system of banking. In recent past, most of money lenders have stopped their business because of people have alternatives and choices. Alternatives are in the form of nationalised banks, rural banks, cooperatives and self help groups.

From money lenders to present cooperatives and self-help groups, there are two major things involved in money lending one is money and second is conditions for availing money. In money lending practices the conditions such as, borrower has to have some mortgage against loan, may be in terms of cow, land, gold, any house hold assets and some time their labour. Other conditionalities are like repay amount with certain compound interest rate, invest certain part of loan money in productive assets. But the most interesting part of the money lending system is that the money lender forces borrower to buy rice, clothes, fertilisers, agriculture implements, and other materials from the money lenders. Most of the money lenders have small business shops of their own or their relatives. Though this part of conditionality is not the part of original agreement but it is taken as unwritten condition. If the borrowers do not accept the conditions they do not get loan. Money lenders are always the winner because they not only have control over resources but also choices of the poor.

Why I am putting all these things because recently I read a report from Action Aid, UK, on AID CONDITIONS enforce by international Money Lenders like IMF and World Bank on utility privatisation in poor countries. Report says that Aid money, new loans and debt relief are still contingent on governments accepting highly specific economic reforms that are conceived, designed and approved in Washington, by the IMF and World Bank and their boards, not in the countries where they are implemented. If countries fail to comply with these stipulations, both multilateral and bilateral donors will withhold funds. The report also finds that in large number of low income countries donors are pressuring governments to sell off and sub-contract services in water and electricity to private companies. The evidence suggests that donor conditionality distorts and undermines domestic political processes and the reforms have a poor track record of meeting the needs of the poor communities.
The study conducted by Action Aid not only questions the very intension of IMF and WB but also challenges the policy makers, planners, politicians and common people of the Nations who are highly affected by the conditionality.

The African Story:

In the year 2001, the report on Africa Debt revealed that, The 48 countries of sub-Saharan Africa spend approximately $13.5 billion every year repaying debts to rich foreign creditors for past loans of questionable legitimacy. These debt repayments divert money directly from basic human needs such as health care and education, and fundamentally undermine African governments' fight against the AIDS pandemic and their efforts to promote sustainable development. Then African Nations lobbied for debt relief or debt cancellation or waving. The key point of all discussions of debt relief was rested on certain conditionality. Conditions like adopting economic reforms by the countries and supervision by the IMF and World Bank, developing Poverty Reduction Strategy Paper (PRSP). Though the approach was not fully defective or full of demerits but the process was problematic. African countries realized that the conditions are not only meant to control African economy by the rich country but also intervene in the internal policy of the Governments. Beyond philosophical problems there were also practical problems with implementation and many agencies realized that conditionality was fundamentally inappropriate.

These discussions and sharing had some effects in debt cancellation but Africa could not make free from the clutches of International money lenders.

At Last:

Let it be money lenders in rural India or International Giants like IMF or World Bank in Global South. The objective of both is to lend money and collect money. In order to ensure that their money is not misutilized and are in safe, they design and enforce certain systems and conditions. Some times it favors poor, both people and country but many times fails. Often it is argued that the conditionality compels Government to maintain transparency, encourage private participation, involve civil society, promote sustainable development, etc but at the same time it increases outsiders intervention, imposes external idea and program, creates unbalanced political and economic structure and reduces opportunity for participation of poor. It not only hampers the capacity building process of the Government but at the same time creates dependency.

Welcome to Somaliland Calling

Welcome to Somaliland Calling, the website of Jitenda Panda.

Over the coming months this blog will highlight my experiences as a development worker in Somaliland for the Catholic Institute for International Relations.