Corruption in Mozambique’s public health service

Corruption in Mozambique occurs at the last place that it should happen… in the health sector. Sick people wait for hours upon hours outside of public health centers because they don't have enough money for bribes. The people that have money or connections are treated right away. The low wages earned by nurses and receptionists is believed to be the cause of the corruption.

From IRIN, this story looks into how the corruption effects the health of the public. 

Eulalia Laichela caressed her six-year-old son, Leosio, who lay on the pavement, coughing from beneath a blanket. They had been waiting in the park outside José Macamo, one of the largest hospitals in Mozambique's capital Maputo, since early morning.

Laichela hoped her sister-in-law, who works at the hospital, would help find a doctor to attend to Leosio before the end of the day. Waiting in the queue at the hospital's reception area was not an option, she said.

"If you don't have extra money to pay the doctor, there is no point in doing that. There are many people outside waiting, and they sit there hour after hour without being attended to," she told IRIN.

Ansina was among the patients waiting in the queue. She feared she had malaria but lacked family connections or money for a bribe. "Something is wrong. I have number 142, and they are calling 188. I have been waiting here since this morning," she complained to the man next to her. He told her that it is patients’ money that determines who goes first, not their medical conditions.

"That´s why we are still here," he said. Ansina agreed.

Corruption is rife in Mozambique's public health sector. According to a 2006 study by the Centre for Public Integrity (CIP) in Maputo, corruption is present at all levels in the system: from the reception to the laboratory, during appointments with doctors, and even at the morgue.

A 2011 regional household survey by Transparency International found that nearly 40 percent of Mozambican respondents had paid bribes for medical services in the past year - the highest such figure in the region. In Mozambique, it was second only to the percentage that had paid bribes to the police.

Poor pay

The CIP study identified low salaries as one of the main causes of health sector corruption. A doctor identified as Cossa*, who has worked at hospitals in Maputo over the last 18 years, agreed. Doctors earn between US$700 and $1,000 per month, and the lowest paid nurses earn just over $100 - no more than a domestic worker.

Cossa maintained that most bribes are paid to the nurses and other workers who see patients before they reach a doctor. But he added that doctors earn additional income in other ways. For example, most public-sector doctors also work at private clinics; according to the CIP study, this makes them chronically tired. The study links the deterioration of public sector health care to a 1998 government decision to allow public-sector doctors to also work in the private sector.

Cossa noted that by 10am, the majority of doctors have already left the city's public hospitals for their private-sector jobs.

Free medicine program about to begin in Rajasthan, India

One of the most populated states in India is about to begin a free medicine program. 68 million people in Rajasthan can now have access to over 300 generic drugs for free. After people see a doctor and get a prescription they can go to over 13,000 drug distribution centers throughout the state. The government buys the generic drugs directly from manufacturers. Doctors however, are upset by the scheme as it makes it harder for them to prescribe more expensive brand-name medicines for a profit.

From the Inter Press Service, writer Zofeen Ebrahim received a description of the program.

“(This) has broken the cosy relationship enjoyed for decades between doctors and (drug) manufacturers,” Dr. Nirmal Kumar Gurbani, advisor to the Rajasthan Medical Service Corporation (RMSC) that was constituted by Chief Minister Ashok Gehlot to run the scheme, said during a presentation at the Second Global Symposium on Health Systems Research in Beijing last week.

Gurbani, a professor at the Indian Institute of Health Management and Research (IIHMR), added that the ‘Rajasthan model’ is being used as pilot for a similar scheme throughout India, which could bring free drugs to the country’s 1.2 billion residents.

Gurbani, a former secretary of the Essential Drug List Committee for the Rajsathan state government, says medical expenses are the second most common cause of rural indebtedness in India.

Citing official data, he told the audience at the conference that more than 40 percent of those hospitalised in India needed to borrow money or sell assets in order to afford treatment.

The cost of a single hospitalisation has pushed 35 percent of patients below the poverty line. In fact, unaffordable healthcare has prevented over 23 percent of the sick from consulting a doctor.

The scarcity of medical professionals has contributed to healthcare costs reaching astronomical rates. According to the World Health Organisation, India has just 6.5 physicians to every 10,000 patients. By comparison, China has 14.2 doctors, while Britain has 27.4 physicians for the same number of patients.

The expenditure on drugs alone constitutes between 50 to 80 percent of healthcare costs in India. And all this in a country regarded as the “world’s pharmacy”, Gurbani lamented.

India’s pharmaceutical industry is the third largest in the world with annual production of about 25 billion dollars and domestic sales amounting to 12 billion dollars. India exported medicines worth 13.2 billion dollars in the last fiscal and the government plans to double it to 25 billion dollars by March 2014.

And yet, said Gurbani, “two-thirds of the population do not have regular access to essential drugs.”

Mobile health care driving into Namibia

In sparsely populated areas of the under-developed world, going for medical attention is often avoided. The trip to a medical facility can be a very long one. The trip could take all day and you may even have to walk the entire distance if you have no access to other transportation. So many never seek help for chronic issues until they become life threatening. In Namibia; one of the most sparsely populated countries in the world, a new private-public partnership works to bring medical care to the people with a truck.

From the Inter Press Service, writer Servaas van den Bosch introduces us to the mobile clinics operated by Pharm Access.

To fill this gap in primary healthcare provision Dutch non-governmental organisation PharmAccess, together with the health ministry and the private sector have started a mobile clinic in one of the most remote regions of Namibia, in rural Otjozondjupa.

The project called Mister Sister has converted trucks into mobile clinics, receives medicine, vaccines and consumables from the health ministry, and funding from a growing complement of corporate sponsors.

"Mister Sister addresses an extremely important and often not recognised problem," remarked professor Rich Feeley from Boston University and advisor to the project at the project’s launch in mid-June. "Even when the costs are free, getting to the healthcare facilities is a problem."

In June the first Mister Sister mobile clinic commenced its month-long route along farms in the rural Otjozondjupa Region some 100 kilometres (km) from the capital Windhoek. Ultimately the service will operate three mobile clinics with a budget of 230,000 dollars each per year.

The average distance to a clinic in Namibia is 69km, to a doctor 99km, hospitals are approximately 107km away and for a dentist one travels 170km. But these are averages. In a country roughly the size of Pakistan, but with only two million inhabitants, having to travel 200km to access healthcare is no exception.

Though classified as an upper middle-income country by the World Bank, Namibia has the world’s highest income inequality on record and only 15 percent of its people have medical health insurance.

"Private insurers will only service the insured. We wanted to put in place a system that delivered unified care. Farm workers and their dependants have free access to our healthcare, while for teachers or police officers at roadblocks we can claim the treatment from their insurance companies," said Ingrid de Beer, Namibian general manager of PharmAccess in Namibia.

She adds that the system is unique in the way it brings public and private players together. De Beer: "It doesn’t make sense to have a private and a public system servicing the same population. Instead PharmAccess runs the service, with contributions in kind from the government and monetary input from the employers."

Affordable drug supply will end with EU-India free trade deal

India has a generic drug industry that helps to provide Anti-Retroviral Drugs for AIDS patients around the world. India's government doesn't recognize drug patients so it has a allowed multiple companies to manufacture the same drug at a low cost. The low costs in turn have helped to provide those drugs to poeple in poverty who would not otherwise be able to afford them.

The low-cost drugs from India might all come to an end in April because of a free trade agreement with the EU. One of the terms of the agreement would force the generic drug makers to begin testing their drugs in order to make sure they don't violate patents recognized by the EU.

From the Inter Press Service, writer Ranjit Devraj details why health groups are against the deal.

"We hope that Indian negotiators will withstand pressures and ensure that the existing intellectual property rights regime is not tampered with to allow extension of patents, especially as a number of drugs are going off patent, this year," said Mira Shiva, a member of the All India Drug Action Network.

"The World Trade Organisation’s TRIPS [Trade-Related Aspects of Intellectual Property Rights] was bad enough but we are facing a TRIPS-Plus bilateral deal which may prove even worse for public health," Shiva told IPS.

If the India-EU free trade agreement (FTA) introduces TRIPS-Plus measures, people on HIV treatment, for example, may not be able to access second-line treatment when they become resistant to medicines they already are on, Shiva said.

By refusing to recognise patents and by leveraging its large domestic market India has, in the decades since 1970, been able to build up a powerful pharmaceutical industry known for its cheap and efficacious generic versions of patented drugs.

After 2005, India has been implementing changes mandated by the WTO, but these are less stringent than the EU intellectual property regime.

UNAIDS, the joint United Nations programme on HIV and AIDS, notes that the flexibility afforded by TRIPS has brought down drug prices and helped lower the cost of first-line generic anti-retrovirals (ARVs) by as much as 99 percent in the last decade.

The EU can be expected to demand data exclusivity on drugs as it has done in the case of all its other FTAs, said Shiva. Data exclusivity will allow drug manufacturers a monopoly, based on clinical test data generated on the safety and efficacy aspects of a new drug.

"What this means," explains Amit Sen Gupta, public health expert at the Delhi Science Forum, a voluntary organisation, "is that an Indian drug company planning to produce the generic version of a patented drug will have to conduct its own clinical trials before it can be licensed and marketed."

"Fresh trials would naturally add to the cost of the drug, and delay its introduction into the market," Sen Gupta said. Currently the EU grants up to 11 years of exclusive rights based on successful clinical trials and other test data.

Video: Congestion in Kiambu Hospital

From NTV Kenya, a look at a hospital that is grossly understafed and lacks basic services.

Kenyan Health Minister travels to the US for cancer treatment

Kenya's Health Minister created quite a controversy for himself when he flew to the United States to seek treatment for cancer. Because Professor Anyang Nyong'o is a government minister he has the luxury to go overseas to get the best treatment. It is a luxury that very few Kenyans can enjoy and a lack of a political will to fully fund health care may be partly to blame.

From the Inter Press Service, writer Miriam Gathigah describes how politicians throughout Africa have failed to fulfill commitments for health care budgets.

Nyong’o himself has admitted that most Kenyans battling diseases such as cancer have very few choices in as far as access to treatment is concerned. Kenyatta National Hospital in Nairobi is the only public hospital with the facilities - although poor - that can diagnose and treat cancer.

According to the hospital, the cancer waiting list is stretched to September 2011.

Health Budget Decreases

In June last year, the national budget was estimated at 12.5 billion dollars, the largest in the history of the country.

Despite a significant increase over the previous year for the health sector, the share of the budget fell.

Ten years after African Union (AU) member states agreed to spend 15 percent of national budgets on health in the Abuja Declaration, the pledge remains largely unmet by most African countries, with the exception of Botswana and the Seychelles.

Yet the Abuja Declaration remains one of the most vital signs of commitment African leaders can make towards health.

"In this regard, the national budgetary allocation becomes a key indicator of strides that the government is making towards improving the health sector," explains Pauline Amollo, a policy analyst and consultant in Nairobi.

The proportion allocated to the health sector for the current financial year stands at 6.5 percent, down from 7 percent in the previous financial year.

"The national budget is a significant indicator of how public policy is to be implemented and what the government of the day deems to be of national priority," adds Amollo.

"The fact that Kenya is yet to achieve even half of the expected 15 percent allocation of the budget to the health sector is a clear indicator that the sector (health) is yet to be treated with the seriousness it deserves."

NTV Kenya had this story of Professor Anyang Nyong'o returning to Kenya from his treatment in the US.

How Mauritus provides healthcare and education and why the US can too

The country of Mauritius provides free education and healthcare to all of its citizens. All of the free services provided by the government does not drag on the economy either. Mauritius GDP product has grown five percent annually since it gained independence thirty years ago.

In a commentary for the Guardian, Joseph Stiglitz describes how Mauritius can afford to do this, and why there are some lessons for the US and Europe.

Now comes the painful number: Mauritius's GDP has grown faster than 5% annually for almost 30 years. Surely, this must be some "trick". Mauritius must be rich in diamonds, oil, or some other valuable commodity. But Mauritius has no exploitable natural resources. Indeed, so dismal were its prospects as it approached independence from Britain, which came in 1968, that the Nobel prize-winning economist James Meade wrote in 1961: "It is going to be a great achievement if [the country] can find productive employment for its population without a serious reduction in the existing standard of living … [The] outlook for peaceful development is weak."

As if to prove Meade wrong, the Mauritians have increased per capita income from less than $400 around the time of independence to more than $6,700 today. The country has progressed from the sugar-based monoculture of 50 years ago to a diversified economy that includes tourism, finance, textiles, and, if current plans bear fruit, advanced technology.

During my visit, my interest was to understand better what had led to what some have called the Mauritius miracle, and what others might learn from it. There are, in fact, many lessons, some of which should be borne in mind by politicians in the US and elsewhere as they fight their budget battles.

First, the question is not whether we can afford to provide healthcare or education for all, or ensure widespread home ownership. If Mauritius can afford these things, America and Europe – which are several orders of magnitude richer – can too. The question, rather, is how to organise society. Mauritians have chosen a path that leads to higher levels of social cohesion, welfare and economic growth – and to a lower level of inequality.

Second, unlike many other small countries, Mauritius has decided that most military spending is a waste. The US need not go as far: just a fraction of the money that America spends on weapons that don't work against enemies that don't exist would go a long way toward creating a more humane society, including provision of healthcare and education to those who cannot afford them.

Third, Mauritius recognised that without natural resources, its people were its only asset. Maybe that appreciation for its human resources is also what led Mauritius to realise that, particularly given the country's potential religious, ethnic, and political differences – which some tried to exploit in order to induce it to remain a British colony – education for all was crucial to social unity. So was a strong commitment to democratic institutions and co-operation between workers, government, and employers – precisely the opposite of the kind of dissension and division being engendered by conservatives in the US today.

A health worker shortage in the under-developed world

The number of nurses and doctors serving the under-developed world is at crisis levels. The World Health Organization says most poor nations have only 2.3 doctors and nurses serving every 1000 people. Contributing to the problem is the fact that most doctors or nurses educated in poor nations move to rich countries for better paying jobs.

From the Guardian, health writer Sarah Boseley talks to the Global Health Workforce Alliance about how such a brain drain can be remedied.

Dr Mubashar Sheikh, executive director of the Global Health Workforce Alliance (GHWA), set up in 2006 to pull together national governments and other organisations interested in promoting health, says this is "a truly global crisis". Health workers move not only to wealthier nations, but also within their own countries, from the countryside to the towns, seeking better working conditions and pay.

"Mobility is a human right," says Sheikh. "You can't stop people from moving. Our argument is that people have a right to move, but access to health is a human right too. There has to be a balance."

Unless things can be improved, says Sheikh, there will be little chance of meeting the UN's health-related millennium development goals (MDGs) by 2015, but the scale of the problem is daunting.

Of the 57 crisis countries, 36 are in sub-Saharan Africa, which is struggling with the MDG targets of cutting child deaths and the numbers of women who die in childbirth. Africa, which bears 24% of the global burden of disease, has just 3% of the health workforce, according to the WHO. An estimated 1.5 million extra health workers are needed across the continent. According to a 2005 estimate, 334,000 skilled birth attendants would need to be trained globally just to reach 72% of annual births.

This is why the global health movement has been moving in recent years away from treating diseases such as HIV/Aids in isolation to support for "health systems" in general. Five million people with HIV in developing countries are now on drugs to keep them alive, but one survey estimated the treatment programmes took up the services of 20-50% of all health workers in two countries and 10% in a further 10. Today's thinking is that it makes no sense for a nurse to treat only HIV when the woman in front of her may have a child with pneumonia or a baby with life-threatening diarrhoea.

Improving health systems doesn't have to mean building smart hospitals, says Dr Sheikh. "We don't necessarily need fancy infrastructure," he says. The crucial part is well-trained and well-motivated people, who need to be able to access the drugs required and emergency care for patients. "There is a general consensus that health workers are the lifeline of the system." He includes not just the obvious doctor, nurse and midwife but also the lab technician, the theatre assistant, the researcher and the manager.

Bartering for medical care in Zimbabwe

From the New York Times YouTube channel, a video on how the Chidamoyo Christian Hospital in Zimbabwe uses a barter system for providing medical services.

Video: Concern's Child Survival program in Bangladesh

From Concern Worldwide, a story about their child health care programs in Bangladesh.

Special needs care in Romania

Romania's health care is still suffering nearly three decades after the fall of the Ceauşescu dictatorship. There is simply not enough health professionals to care for all of the people. Romania also a cultural bias that thinks that health care should only be for the productive members of society, this leaves many of the poor and disabled out.

From the Guardian, this entry into the newspaper's journalism competition profiles one family in Romania who is struggling with a special needs child.

Anisoara sits on the floor of the family's tiny one bedroom apartment, rocking her son Aurel, six, in her arms to stimulate his senses, wincing as he screams out. It is hard to tell whether it is a cry in pleasure or pain, but the physiotherapist has told Anisoara she 'must keep his muscles moving.' A couple of feet away Aurel's elder sister, Gabriela, 10, and uncle Gheorghe sit back-to-back, immersed in what fills the screens of two aging PCs on opposite walls. In tight living conditions they use headphones to preserve a vestige of privacy. Add a dog and Aurel's grandmother, Gheorghita, both on the sofa, and the home becomes a very packed space. However, this is only half of the family. Six nuclear family members, the parents and four children, sleep in the box bedroom while three of the extended family spread across the living room.

Anisoara cannot work because Aurel, one of triplets, requires around the clock care as he suffers from Hydrocephalic quadriplegia, organic epilepsy and optic nerve dystrophy. Her kind of story is common in Romania, where poverty mixed with disability can cripple a family both financially and socially. Achieving quality care for children and those with disabilities can be a lottery as the country battles to rid itself of challenges inherited from the old regime. The country's medical services are impoverished, struggling to cope often with under-trained staff. Either, children can become ignored by carers who are unable to support all everyone allocated to them for care, or there are those who do as little as is expected of them. Despite a massive improvement in conditions in the past 20 years, residents of Romania still have ingrained attitudes and discrimination towards the disabled and the different.

The government has tried to remedy the problem, implementing laws to help its disabled residents and their families, but in reality the funding is inadequate and public perception is still that care financing should be diverted to those who can make a positive contribution to society, rather than improving the standard of living for all. Romanian employers often prefer to pay the penalties of the law rather than employ disabled persons (ANED).

The country is focused on improving the standard of living, where residents' material deprivation by poverty still stands at 85% compared with 26% in the UK (Eurostats). The government is also concerned about the world's perception of the country following the fall of communism in 1989, and the media's discovery of abandoned children and the disabled living in destitute institutions.

The future of health care in.... Haiti

A pair of health professionals in Haiti are deeply troubled for the future of health care in their country. Jerry and Marlon Bitar not only established their own private practice in Haiti, but also a free clinic for those in poverty. As the medical aid from the earthquake begins to leave, the Bitars' wonder what if any health care will take it's place. Any survivors who where customers of the Bitar's private practice now use their free clinic, some even live there.

From the Washington Post, writer Lois Romano interviewed the pair on their concerns for the future.

But as the immediate crisis starts to wane, more and more patients with maladies unrelated to the earthquake are turning to international health-care teams led by the World Health Organization, raising concerns about Haiti's ability to care for its own once the relief teams pull out and need for rehabilitation and long-term care grows.

The Bitars ask what appears to be a simple question: How can the country's medical structure be rebuilt when hundreds of humanitarian teams are still providing health care for free? The surgeons say they have no income -- not from the poor and not from their private practice. For one, 700,000 people are now homeless with no access to funds. For another, the hospitals, the Bitars and others say, are finding it hard to compete with the visitors. With no end in sight, some of the nation's doctors have already left, and others are considering leaving.

"We have not been able to make payroll for two months," Jerry Bitar said.

Marlon added: "I am very worried that many of our good doctors will leave. The humanitarian hospitals, they don't ask for any money. Yesterday, I went to one and saw two of my private-paying patients getting treatment there."

Indisputably, international organizations are carrying the Haitian health-care system today -- and will continue into the indefinite future. Many Haitian health-care providers were among the 230,000 killed in the earthquake, and others have not shown up for work, dealing with their own losses. The nursing school at the University Hospital collapsed during exams and killed essentially an entire first-year class of nursing students.

"It is a very difficult situation," said Thomas D. Kirsch, a professor at the Johns Hopkins medical school and an expert in developing-world health issues who was recently in Haiti. "If these organizations pulled out, the system would be worse than ever, and as long as there is free care available, that's where the Haitians will go and the Haitian doctors will have no business. . . . There must be a well-planned transition period to subsidize the Haitian health-care system, have [nongovernmental organizations] work directly with Haitian providers, and to train sufficient providers and nurses to be able to meet the population's needs."