Getting to Zero -World AIDS day 2013

Getting to Zero means Zero new HIV infection, Zero stigma, Zero babies born with HIV, Zero death from HIV/AIDS.
That sounds good, right?
Last year I posted my reflections on what AIDS day means to me and called upon everyone of us to contribute to getting to Zero. This year, I ask every one of us to keep the promise and in that regard join the global community to make "getting  to Zero" a reality. The  UNAIDS global report on HIV/AIDS, highlights on  the achievements we have attained to-date on the fight against HIV/AIDS and the challenges ahead.The challenges ahead can not be tackled by a single nation, but a global community that works in solidarity to address the challenges. On his official statement, Ban Ki-moon calls upon all partners contributing to the Global fund to continue to support this most important fund that has significantly contributed to achievements in the fight of the HIV/AIDS pandemic.

VIDEO: The many paths towards universal health coverage

At some point in their lives, everyone needs health care....but today not everyone has access to the care that they need.

Universal health coverage ensures that all people get the health services they need without suffering financial hardship. The goal of moving towards universal health coverage is gaining momentum around the world.

This video, produced by the World Health Organization, explains the concept of universal coverage and uses examples from six countries -- China, Oman, Mexico, Rwanda, Thailand and Turkey -- to show ways that all countries can provide accessible and affordable care for their people

http://www.youtube.com/watch?v=VQ3sHfYzcv8#t=94

Citizens’ lack of information on health policies in Tanzania: Implications for widening inequities

Poor people face a variety of barriers when accessing health care in Sub-Saharan Africa. Some of these barriers could no doubt be eliminated if poor people were actually more aware of health policies, as a lack of information often leads to undesirable results such as delayed medical treatment, improper health seeking behaviours, and even foregoing medical treatment. This situation contributes to morbidities and mortalities among this group of poor people that could otherwise be avoided, at least to some extent. The example of a lady in her late 30s called “Sikitu” (a Swahili name, which literally means “Nothing”), provides a snapshot of how things are on the ground. Sikitu is a widow living with her four children in a village in Southern Tanzania.

Sikitu had symptoms of cervical cancer when she went to see a doctor in a public district hospital. The doctor later on referred her to the cancer institute in Dar es Salaam for further treatment on account of advanced cervical cancer. After physical examination, Sikitu asked the doctor: “How much should I pay you for all these services I have received?’ The doctor replied: “Cancer services in this country are offered for “free” (without payment) like other chronic diseases such as HIV/AIDS and tuberculosis; you are not supposed to pay directly to the doctor if there are associated costs”. Sikitu was surprised to hear that and was pretty much speechless when she reflected on what has been happening to her and other poor people. She went home and sold the few goats she had to get money for her travel and living expenses (when she will be receiving treatment in Dar es Salaam). A few days later, before travelling to the city for treatment, she went back to see the doctor (ready for the journey) in order to collect the referral documents. She offered him some cashew nuts, as a gift. Then she burst into tears. When asked why she was crying, she explained that she had been coming to the hospital almost every month for the past year or so, to see a certain doctor. She had always paid the doctor after the service but the problem was still going on despite the fact that some procedures had been performed on her. She was scheduled to come again regularly for follow-up visits and was required to pay some money whenever she accessed services. She was very surprised that this time (because the usual doctor was travelling) she was attended free of charge, informed of her problem and  referred to the big hospital for further care.

Sikitu’s story is by no means an exception in Tanzania and in other sub-Saharan African countries that still have user fee policies in place, but is just the tip of the iceberg. Many poor people are unaware of user fee exemption policies. Many people, especially the poor, have been denied access to health care and live now in extreme poverty because of lack of information about user fee exemption policies. Corrupt practitioners take advantage of this knowledge gap, induce demand and ask for informal payments (bribes) from their (mostly poor) clients.

There are several reasons as to why ordinary citizens often lack information on available health policies. The (trademark) top-down approach of policy formulation that denies active participation of ordinary citizens in setting the agenda and overseeing the implementation of policies, contributes to this gap. Moreover, the absence of pressure groups that can hold the government accountable if these policies are not addressing ordinary citizens’ problems plays a major role. These two major reasons are interrelated in Tanzania: the political atmosphere in my country (characterised by the dominance of one political party) has for a long time supported a top-down approach and limited democratic practices – in the past civil society organisations(CSOs) that weren’t affiliated to the ruling party were even banned. However, since the end of the 80s (when there was a severe economic crisis), regulation of CSOs has changed  as a result of conditional ties of international aid. The same process also led to the introduction of a multiparty system in 1992.

So the situation is slowly changing, for the better, even if until recently Tanzania could be characterized as a “de facto one party state in a context of multi-party elections”. Little by little, citizens are more empowered (at least in other social sectors) due to actions of CSOs and opposition political parties. In fact, even in the health sector, there have been some active  local CSOs  that work as ‘health policy entrepreneurs’ such as Sikika, but  they have not been vigorous enough to push forward an agenda that promotes poor people’s access to information (in order to empower them to advocate for their health rights). Nevertheless, Sikika has shown the way by using research evidence as an advocacy tool for quality health services in partnership with other local CSOs. Sikika’s activities are geographically confined, though, mainly focusing on urban areas. The capacity of the organization also needs to be improved. Many international NGOs are also working in the country, but it is very complex to understand how they relate to the government and local CSOs, and not the focus of this editorial. More importantly perhaps, the recent emergence of strong opposition political parties that have been challenging the status quo is seen as a window of opportunity. Many of them promote the health sector agenda in their election manifestos for the coming general elections (scheduled for 2015).

It is unfortunate, however, that until now there has never been a serious attempt (and mass movement) to change the current situation that creates major inequalities in the society in terms of access to health care, unlike in other sectors such as education and land rights. This is probably because health activists have never worked in unity to address such issues, and health worker unions are too fragmented to put successful pressure on decision makers and address such inequalities (apart from isolated doctors’ strikes that have typically been suppressed by authorities). The government on the other hand tries to make sure that health issues do not feature in mainstream party politics because of their potential sensitivity; they therefore find ways (sometimes barbaric ones) to suppress initiatives that appear to advocate the right to access health care or that suggest mechanisms which promote equity (not that Tanzania is alone in this – the crackdown on civil society is, unfortunately, a global phenomenon). However, things are finally changing, and it could very well be that the ‘access to health care’ agenda will feature quite prominently in the 2015 general elections, even more so because a series of mediatised actions have happened in the health sector recently such as persistent doctors’ strikes to demand good working conditions and the kidnapping and torture of the frontline leaders of these movements.

Since realities on the ground and research evidence have already demonstrated the inequalities caused by user fee  policies and the fact that people are unaware  of exemption procedures (or sometimes they are aware but  there exists no functioning (social and legal) framework that can support them in the fight for their rights), it seems high time for health activists ( individuals, CSOs and political parties) to join hands and  advocate the right to health and work towards boosting citizens’ awareness  and empowering them to know their right  to health care. They can also start advocating the abolition of user fee policies like in other Sub-Saharan African countries. Obviously, they can and should also jump on the global UHC bandwagon to make universal health coverage a reality in Tanzania.

As Jim Kim noted in his speech at the World Health Assembly earlier this week, “Now is the time to act. WE MUST BE the generation that delivers universal health coverage.”

This article is also available at International health policies (IHP) blog as a guest editorial 

MPs Call for Universal Health Insurance

(AllAfrica.com)Members of Parliament have called for health insurance coverage for all Tanzanians, noting that the government should find ways of making the National Health Insurance Fund (NHIF) accessible to every Tanzanian, regardless of whether they are in the formal sector or not.

Debating budget estimates for the Ministry of Health and Social Welfare here, the legislators decried weaknesses in the current distribution system of drugs and medical equipment and the scarcity of health workers, noting that a sure way of keeping Tanzanians safer was by enrolling all of them in the national health insurance scheme.

Contributing to the debate, Mrs Margaret Sitta (Special Seats - CCM) noted that enrolling all Tanzanians with the National Health Insurance Fund would go far in ensuring access of quality healthcare, singling out mothers and children who are some of the people who need to be kept safe.

She asked the government to fast-track review of the structure of the Medical Stores Department so that it becomes more effective in distributing drugs and medical equipment across the country. She also urged the government to consider using nursing assistants at health centres to offset staff shortage in rural areas.

The Mp asked the minister of Health to explain to the public what pregnant mothers are obliged to pay at a government hospital when they go to give birth. Making her contribution, Josephat Kandege (Kalambo - CCM) also asked the government to devise means of getting every Tanzanian to enrol with NHIF .

Civic United Front (CUF) Special Seat MP Magdalena Sakaya said political leaders should pay attention to the interests of medical workers, arguing that would in turn have a positive impact on the quality of health care they give. She decried some medical personnel who engage in malpractices in rural health centres.

Nyamagana MP Ezekiel Wenje (Chadema) decried the lack of enough health workers in rural health centres, noting that the number was dismal compared with the number of patients. He said financial resources for Bugando Referral Hospital should be increased to enable it handle more complicated cases in the lake zone.

He also appealed to the minister to intervene in his area where two dispensaries have been built, but bureaucratic processes of registering them meant people in the area would still not access health services from the new structures.

US doctors cure a child born with HIV

Doctors in the US have made medical history by effectively curing a child born with HIV, the first time such a case has been documented.

The infant, who is now two and a half, needs no medication for HIV, has a normal life expectancy and is highly unlikely to be infectious to others, doctors believe.

Though medical staff and scientists are unclear why the treatment was effective, the surprise success has raised hopes that the therapy might ultimately help doctors eradicate the virus among newborns.

Doctors did not release the name or sex of the child to protect the patient's identity, but said the infant was born, and lived, in Mississippi state. Details of the case were unveiled on Sunday at the Conference on Retroviruses and Opportunistic Infections in Atlanta.

For more infomation click here

Putting the patient at the forefront of healthcare in Africa

On February 19^th and 20^th 2013, a two-day conference on health care reforms will take place in Cape Town, South Africa. The conference will focus on identifying health care solutions designed to meet patient needs. Healthcare in Africa will once again gather 180+ influential healthcare stakeholders from government, providers, suppliers and patient groups to explore the key issues around healthcare systems in the continent.

Humphrey Opondo’s article provides detailed infomation about the conference. 

Civil society, government officials participate in Tanzania Global Sanitation Fund programme inception workshop

Today, some 65 representatives of Local Government agencies and civil society organisations in Tanzania participated in a meeting in the capital city Dodoma to learn more about the national Global Sanitation Fund (GSF) programme and their own potential involvement in it.

Mr. Francis Mtitu, GSF Programme Manager at Plan Tanzania, is interviewed by media representatives on 23 January 2013 at the inception workshop for the GSF in Dodoma.

Known as the Usafi wa Mazingira Tanzani (UMATA) in Kiswahili, the five-year UMATA programme is funded with US$ 5,000,000 from WSSCC and aims to increase access and use of improved sanitation facilities in the country. It also seeks to positively change behaviours related to sanitation and hygiene on a wide scale for communities.  With an initial focus on three districts near Dodoma, namely Bahi, Chamwino and Kongwa, the programme builds upon the National Sanitation Campaign and existing country strategies.

For more infomation click here

NATIONAL HEALTH INSURANCE CONCEPT: UPDATES FROM GHANA.

By Wulifan K. Joseph,

University for Development Studies, Dep’t of Administration & Management, Wa Campus, Ghana.

Increasing the access of African populations to health care is one of the biggest challenge facing Africa and the global community. At independence, when most African economies were strong, with abundant resources to cater for relatively smaller population sizes, it was possible to provide health care services free of charge, without compromising quality, though geographical accessibility was more limited as compared to today. Rapid population growth, decline of the economies and severe financial constraints in later years have placed great limitations on the capacity of subsequent regimes to continue to support and subsidize or expand health care services. Environmental health risks and the tragedy of disease like AIDS have come to place an even greater stress on African fragile health care systems. As resources dwindled, investment in the health sector also fell considerably. This and other circumstances such as high cost to the user of access to care of acceptable quality, as well as external pressure and conditional ties, services of low quality, ill-equipped facilities and poorly maintained equipment, abuse by the narrow segment of society, frequent shortages of drugs and other consumables made implementing cost recovery systems favorable” (Atim 1998)

Health care financing is under severe strain all over the world and particularly Africa and other developing Countries where health care cost is ever increasing. For over 30 years ago, calls have been made for communities in developing Countries to plan, finance, organize and operate health care services. The question that often arises is how and how much should the poor from poor Countries contribute towards this. The Alma Ata declaration meant community participation was a pre-requisite to the achievement of health for all

The Primary Health Care (PHC) initiative in Bamako aimed at making health care universally accessible through Community financing and management but the question remains as to whether people in rural poor Countries can and should be expected to contribute towards health care. More so, there is strong evidence that, neither purely statutory social health insurance nor commercial health insurance schemes alone can sufficiently contribute to increase coverage and thereby the access to health care to the poor ( as stated by Arkin-Tenkorang) because in the environment of rural and remote areas unit transaction cost of contracts are too high leading to market failure (Jutting,2001). Consequently, in low-income Countries the majority of the population remains uncovered against the risk of illness.

In Tanzania the community Health Fund (CHF) strategy for financing rural health services was piloted in Igunga District in 1996 and by 1999, it was initiated in nine other Districts and later on step by step rolled out to the rest of the districts in the country. This initiative like other community based health insurance schemes are potential to realization of the goal of universal health coverage in developing counties if they get strong political support and are well implemented.

The health sector is central to Ghana Government’s developmental agenda. While improving health is intrinsically desirable, it is broadly recognized that health is a necessary pre-requisite for socio-economic development. Improving health will improve human capital, productivity and wealth (Ghana MOH, 2007-2011 strategic plan). Many health care financing options have been explored and experimented by the government of Ghana since independence till date. Among them include the “cash and carry” which existed since the 1980’s to Health Insurance  which was piloted in 2001 and finally enacted into law in 2003 (NHI Act 650 of 2003).

Health Care Financing in Ghana has gone through a chequered history. Immediately after independence health care provided to the people was “free” in the public health facilities. Financing of health in the public sector was, therefore, entirely through tax revenue. The sustainability of this form of financing became questionable as the economy began to show signs of decline and there were competing demand on the same source. The world economic recession in the early 1980’s led to heavy pressure on provision of social amenities. This led to drastic reduction in government’s expenditure on health care. This mid 1980’s therefore witnessed a withdrawal of health care subsidies.

What is important to note was that the general tax revenue did not allow for a percentage earmarked for health as we now have in the case of VAT funds earmarked for education.

In Ghana, the Provisional National Defense Council (PNDC) government in August 1985 revoked the Hospital Fee Regulation, 1963, (Legislative Instrument L.I.1277) and replaced it with the Hospital Fee Regulation, 1985(L.I 1313) mandating fees to be charged for consultation, laboratory and other diagnostic procedures, medical, surgical and dental services, medical examination and hospital accommodation ) termed as the “cash and carry”, this was a way of raising additional funds from the public to supplement shortfalls in government’s budgetary allocation to the health sector. Though the system has been successful at raising additional revenue, and improving the quality of services, other difficulties were created. Financial constraints led to people either staying at home when they were sick, or going to health facilities so late that not much could be done for them. Some of those who were admitted absconded when they felt a little better.

The policy of cost recovery (cash and carry) led to increasing concerns about equity and access for the poor. Hence charges under the user fee exempted certain specified communicable diseases and people termed as the vulnerable groups from out-of-pocket payments. This policy however was saddled with several institutional and managerial problems. Definition and identification of paupers was difficult because basic data on ages and births, income levels of people were not properly documented. Other problems included, unclear and non-existent guidelines on how to implement the policy, including reimbursement procedures, uneven implementation leading to considerable variations between regions on the impact of the exemptions to target groups and health facilities, inadequate supervision and monitoring, institutions claiming different amounts for similar services leading to differential average cost of the exemptions to the MOH, frequent complain that the budgetary allocations for exemption is inadequate, lack of adequate information to the public about the exemption policy. It is however encouraging that, policy makers are increasingly recognizing that converting revenue gains into productive service quality and access requires some accompanying, or even prior changes in managerial and institutional capacity.

This situation continued until 1985 when the Government introduced the user fees for all medical conditions except certain specified communicable diseases. The free health care policy was badly implemented in that although communicable diseases were supposed to have been exempted; in practice no one enjoyed this facility. Also a guideline for implementing was not provided and no conscious system was designed to prevent possible financial leakages. In the ensuing years the standard of health care provision fell drastically. There was acute shortage of essential drugs in all the public health facilities. Most importantly, the introduction of the user fees resulted in the first observed decline in utilization of health services in the country. In spite of this the government went ahead to institute full cost recovery for drugs as a way of generating revenue to address the shortage of drugs. The payment mechanism put in place was termed “Cash and Carry”. The implementation of the “Cash and Carry” compounded the utilization problem by creating a financial barrier to health care access especially for the poor. It is estimated that out of the 18% of the population who require health care at any given time, only 20% are able to access it. Implying that about 80% of Ghanaians who need health care cannot afford it. Hospitals at the time became death traps due to the ‘cash and carry’ system introduced.

The government noting the problems associated with the “Cash and Carry” system initiated action to replace this out-of-pocket payment for health care at the point of service. The implementation of the programme to replace the “Cash and Carry” was in phases. This approach took cognizance of the fact that uptake of health insurance is dependent on various factors including level of confidence, perceived quality of care, willingness of individuals to subscribe to it and the attractiveness of the benefit package.

Given the high latent demand for health care services of a good quality, and the strong criticism of alternative forms of health care financing and cost recovery strategies like user fees, coupled with the extreme under utilization of health services in several countries, it has been hoped that District-wide Mutual Health Insurance schemes (DWMHISs) may improve access to health care of acceptable quality. The option of insurance therefore seems a promising alternative as it is a possibility to pool risk transferring unforeseeable health care costs to fixed premiums Partly as a response to this lack of social security, to the negative side effect of user fees and to persistent problems with health care financing, non-profit voluntary insurance schemes for urban and rural self-employed and informal sector workers have emerged. These schemes are characterized by an ethic of mutual aid, solidarity and the collective pooling of health risks).  The system of upfront payment at service delivery posed a financial barrier to health care access. By 2001 the government initiated a policy to deliver accessible, affordable and good quality health care to all Ghanaians especially the poor and vulnerable in society. The policy objective of this insurance was that, within the next five years (2003 – 2008), every resident Ghanaian should belong to a health insurance scheme that adequately covers him or her against the need to pay ‘out of pocket’ at point of service delivery (Ghana National Health Policy). While this seems laudable, systemic and managerial problems exist.

The Government is currently financing the DWMHISs through a 2.5% out of the 17.5% Social Security National Insurance Trust (SSNIT) workers contribution, a 2.5% National Health Insurance Levy (NHIL) placed on Value Added Tax (VAT) commodities, Donor support etc. Adult Ghanaian residents aged between 18-70year in the informal sector (non SSNIT Contributors) as well as non SSNIT pensioners pay a yearly minimum of GH¢ 8.00 (Eight Ghana Cedis which is approximately $4.00) and a maximum of GH¢48.00 or Approximately $24.00 according to the categories of ability to pay and economics status.

According to Ghana National health policy and National HealthInsurance Scheme  the categories of persons exempted from the payment of contributions under the Scheme include:

(a) A child under eighteen years of age;

(b) A person in need of ante-natal, delivery and neo-natal healthcare services;

(c) A person with acute mental disorder;

(d) A person classified by the Minister responsible for Social Welfare as an indigent, and

(e) Categories of differently-abled persons determined by the Minister responsible

     for Social Welfare using a means test prescribed by the Minister in

     consultation with the Minister responsible for Social Welfare and the Minister

     responsible for Local Government;

(f) Pensioners of the Social Security and National Insurance Trust;

(g) Contributors to the Social Security and National Insurance Trust; and

(h) Other categories prescribed by the Minister.

It is significant to acknowledge that, the National Health Insurance System in Ghana may not be the panacea to the Health Care financing problems. It is currently not without challenges. The challenges range from general problems of Health Insurance Markets (Risks) such as Moral hazards, adverse selection, Cost escalation to fraud and abuse. Financial Management of the Schemes as well as Existence of Health care facilities and behavior of Health care providers are key to the sustainability of the Scheme and will be discussed later in the next article.

50 years of independence in Tanzania and the state of management of health care organisations

Last year, I attended a conference with a theme “The state of management education after 50 years of independence in Tanzania”. This was one of the major events hosted by department of logistics and management of St.Augustine University of Tanzania and focused on the achievements in management education in various sectors in the country since independence. At every networking break I would meet bewildered people who would ask, "Why is a health professional at a management (business) conference?" 

My presentation was on Management education for health care managers in Tanzania since independence: Which lessons can be drawn from it for improvement for the next 50 years?

I explained how management of health care organisations in Tanzania has evolved from colonial period to date and the prospects in the next 50 years. My areas of focus were management training models, availability and utilization of trained resources, the impact on health status of the citizens and the gaps that need to be filled in the next 50 years.

In the first 50 years of independence, we have seen a progress on how health care organisations have been managed. That is from the colonial power-coercive type of management to modern management that conforms to the practice of good governance  However, there has been a gap in the public-private partnership in terms of training health care managers. The Ministry of health institutions (PHCI, CEDHA) and public universities (MuhimbiliUniversity of Health and Allied Sciences and Mzumbe University) had dominated the training of health care managers.This dominance of the public sector in training health care managers might have contributed to limiting innovations in the models of delivering these trainings ( but may be at this time the private sector had no capacity to do so). Today we see some private institutions coming along. However, one would ask whether they will come with innovative  models of teaching or it will be a copy and paste of the old models used by their counterparts. It is inevitable that there is a need of improving or changing the training models, that is, to do away with the traditional models and replace them with modern models that accommodate the rapidly changing health care industry.

On the other hand, there has been no essential progress on the way of utilizing the trained managers, especially in the public sector; local politics have dominated on who to lead health care organisations regardless of the level of education and training in management. For example, the post of a District medical officer has been too much politicized to the extent that it has become useless. In this position  you will find people without any management training appointed as heads of departments (from a clinical officer to a public health or medical specialist).No standards. The Minister of Health and social welfare when asked about this  will say that the  Public service Management (UTUMISHI) is responsible for that.The Public service Management Minister will say that the Minister of Prime minister’s office and Local government (TAMISEMI) is  responsible for that and vice versa.

  Although the private sector has managed to improve its way of utilizing the adequately trained health managers, it has a limited capacity to have a desired impact in the health sector in Tanzania. The private sector ( particularly in curative services) is mainly operating in urban areas and reaching a certain class of people. As it is obvious that in Tanzania nowadays the upper class is struggling in all ways to exploit the poor .You know the phrase, as you saw, so you shall reap. Absolutely nothing new and exciting has emerged for helping poor people in rural areas to improve their health status, leave alone to protect them from catastrophic expenditures when they fall sick, as there is no viable social protection mechanisms that are pro-poor and most of health facilities are corruption zones .  

At a conference like this, mashing people from different worlds together is a major goal of the event. At best, new collaborations are born, and at worst, new perspectives emerge from hearing a different mindset.

In the world I was used to, clinical care, public health and Health care organisations are the terms used without question. However, within a few conversations I realized that most of my audience simply thought that health care organisations are like closed systems where the business community should just leave it to doctors and other health professionals, and they were amazed with the seemingly new teachings that management as a discipline cuts across all sectors and does not require much expertise on that field. 

The second issue I picked up about managing health care organisations was from the outset, it sounds hopeless. What the hell should we as business people be engage in this, while we have health professionals who can do that? I began re-framing the message and said “using business skills to manage our health”. It sounds so much better, right? This sounds like a subject that could inspire a promising young student to study as a health care manager to a career creating innovations in the health care sector. And there were several undergraduate students listening to this presentation.

Finally, and most importantly, I learned that everything about health care management in Tanzania is still focusing on the bio-medical model that treats people as victims of the situation and sidelines the holistic approach of modern management. How can we expect policy makers, public supporters, or researchers in health care management to connect? Personally, this conference revolutionized my mindset and thought of creating awareness to the public that health care is for the people and managing health care organisations needs a concrete management education in additional to the professional training. The month after that conference, I returned to the workplace and began an effort to crowd sources of management of health care organisations with three questions. To engage health care managers trainers and practioners in their own subject and asked what their motivations were accepting their positions, what were the biggest tasks or risks to their carrier, and what could make things better.