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!

About Kevin Duffy

Interim Management and Consulting - Global Healthcare Development. Kevin has over ten years of senior management experience in the delivery of healthcare services in Africa and South Asia. His current focus is on the strategic development of policy, guidance, and tools to help healthcare organisations achieve sustainable impact – balancing the need to become financially sustainable, with the mission of ensuring equitable access to affordable healthcare services.
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