Africa Renewal (United Nations)
Mary Kimani
4 January 2008
(Page 2 of 2)
However, Dr. Bergevin argues, such austerity also had the negative effect of reducing funding for health care. Health centres became dilapidated and there was limited hiring of new health workers, especially doctors. Those already on the payroll left in large numbers because of poor pay and bad working conditions. Many doctors emigrated to developed countries. "Africa has never recovered from that," he explains. "While the adjustments were necessary to improve financial discipline, it has had a terrible effect on the health sectors."
The Millennium Development Goals (MDGs) call for reducing the number of women dying during pregnancy and childbirth by three quarters by 2015.
In an effort to overcome the decline in government financing, many hospitals and clinics began asking patients to pay more for services. In Kenya, the government introduced "user fees" at public health facilities like Pumwani Maternity Hospital in 1989, as part of a World Bank push for cost-sharing in public services. "We are asking people to die because they can't [afford to] be treated," Dr. Shadrack Ojwang, a gynecologist at the main hospital, was quoted as saying in a joint report by the Federation of Women Lawyers in Kenya and the Centre for Reproductive Rights, a US non-profit group. "We can't do anything about this until parliament repeals cost sharing. We went into this blindly. Nobody thought of it properly."
The report by the two groups notes that in the face of the negative impact on health care systems, the World Bank has backed away from promoting user fees. It now supports the provision of less expensive basic health care, including maternal health services.
Unequal impact
But since enough financing is not available to provide free care, many African health facilities remain locked into "cost sharing" practices. Such a "pay-for-service" model, notes Dr. Bergevin, has had a catastrophic impact on the poor, who cannot afford to pay fees. As a result, they have less access to health care.
The situation at Pumwani Maternity Hospital is typical. Up until May 2007, patients wishing to receive maternal care had to deposit 1,200 Kenya shillings (US$17). Women without the money were turned away. It costs Ksh3,000 for a normal delivery and Ksh6,000 for a caesarean, along with Ksh400 to cover the bed charge for the first day. Daily bed charges of Ksh400 accrue throughout a woman's stay at the hospital. The hospital's fees are low compared to those charged at private facilities, but significant for the 60 per cent of Kenyans who live on less than Ksh140 ($2) a day.
In Ethiopia, which has a similar model, a rich woman is 28 times as likely as a poor mother to have a doctor available during delivery, according to the UN's Department of Economic and Social Affairs. In Chad and Niger, the gap is 14 times or more.
"We cannot accept systems which do not provide access to everybody," says Dr. De Bernis. "If the poor have no access, we will never reduce maternal mortality in a meaningful way." He notes that charging for services might improve access to medical care for those who can afford it, and thereby reduce the total number of maternal deaths. But leaving the poor behind would be unacceptable. "We need to ensure that maternal mortality reductions are based on reduction of deaths for everyone, rich or poor."
Concerned that high costs were impeding access to maternal health care, Kenya's then Health Minister Charity Ngilu in May 2007 abolished maternity fees in public hospitals such as Pumwani. But the money still has to come from somewhere. Dr. Frida Govedi, the doctor in charge of clinical services at Pumwani, points out that the hospital already struggles to get the limited subsidy it is entitled to from the Nairobi City Council. The council currently owes the hospital Ksh100 mn. Without that amount and without user fees, the hospital simply "can't run," she says.
Dr. Ojwang is a member of a task force set up in 2004 by the government to study the running of the hospital. He notes that the Nairobi City Council has been marked by mismanagement and corruption. "Money was disappearing from the treasury," he explains. Only recently has the hospital begun to gain greater control over the funds.
'Unacceptable'
Across Africa, spending on health remains limited. "Currently sub-Saharan countries are spending less than $2 per person for maternal health," Dr. Bergevin notes. "Most experts agree that you need to spend at least $8. To see a fully functioning health system, you need to spend $40-50 dollars per person, excluding anti-retroviral drugs."
Some donors are seeking to bridge the financing gap for maternal health. In October 2007, at the launch of the Deliver Now campaign, Norwegian Prime Minister Jens Stoltenberg announced that his country will give $1 bn over the next decade towards improving maternal health worldwide. He also called for maternal mortality to become a higher priority. "That there is hardly any progress on maternal health is unacceptable," he said. "It is so simple to do something about it. It is cheap and we know what to do. We would never have accepted that kind of a death toll if it was white rich men who were dying. Something would have been done a long time ago. So this is obviously also a question of gender and financial equality."
Mr. Stoltenberg pointed out that while a billion dollars may look like a lot, "it is not much. It is a small fraction of our development aid." Norway's official development assistance is currently 0.97 per cent of its gross domestic product, higher than the international community's agreed goal of 0.7 per cent. The average for all donors is about half that level, however. So, Mr. Stoltenberg argued, much more would become available if donor governments met their promises.
Dr. De Bernis warns that efforts to introduce free health care should not depend entirely on donor assistance. Given the uncertainties of external aid, "this is not sustainable."
But there are other options, he adds. "In West Africa, we have seen examples of useful cost sharing," so that the burden is not placed solely on the patients. "A calculation is made of the health cost, how much the government can afford to provide and the rest of the financial burden is shared with the community," he explains. "This helps improve the quality of care and involves the community. If the ambulance is not working or drugs are not available, the community will ask why." Even in such schemes, the really poor should still be exempted from paying, he argues. "The community has to agree on how to do this."
Despite the challenges, his compatriot, Dr. Bergevin, is optimistic. "We know that maternal mortality can be reduced. We know what to do, and how to do it. Other countries are on track." The biggest challenge lies with 66 countries in the developing world, including 45 in sub-Saharan Africa. "We know it can be done."
Social hurdles to better maternal health
Young mother in Ethiopia: Girls between the ages of 15 and 20 are twice as likely to die in childbirth as those in their twenties.
Even when maternal health facilities are available, expectant mothers in Africa do not always get timely care. A study by the Africa regional office of the World Health Organization (WHO), Reducing Mortality Rates, reports that sometimes women or birth attendants "fail to recognize danger signals and are not prepared to deal with them." One answer, argues Dr. Yves Bergevin, senior adviser on reproductive health for the UN Population Fund (UNFPA), is to improve the skills of birth attendants and the knowledge and capacity of women, their families and their communities.
Involving men is important, says Lucy Idoko, the UNFPA's assistant representative in Nigeria. Most men, she says, do not know the risks of going through labour. "Maternal health is not only a woman's issue but also a man's issue, and important to society as a whole."
Cultural practices can also affect women's health risks. WHO cites genital mutilation, early marriage and multiple pregnancies. Women who have undergone infibulation, a form of genital mutilation where the external genitalia are stitched, are more likely to suffer from obstructed labour. UNFPA data show that girls who give birth between the ages of 15 and 20 are twice as likely to die in childbirth as those in their twenties, while girls under 15 are more than five times as likely to die.
"Adolescent girls face the highest risk of premature delivery," says Dr. Grace Kodindo, former chief of maternity at the Ndjamena general hospital in Chad, now working at the maternal mortality programme of Columbia University in New York. "Because their bodies are not yet fully mature, they risk obstructed labour. This is why we encourage young women to postpone their first pregnancy."
Dr. Kodindo argues that both young age and the low status of women in society often leave them with little power to determine if, when and with whom to become pregnant. They also have little choice in the number and timing of their children. "Women should be able to decide the spacing of their children," she told Africa Renewal. "But in Africa the woman cannot make this decision freely. Her status in society is often determined by how many children she has, and women often have children even when they don't feel like having more. Many men don't want family planning because they want the status that more children bring."
In 2004, WHO reported that about 4 mn abortions take place annually in Africa. Since abortion is illegal in most countries, most of these are performed in unsafe conditions, contributing to nearly 30,000 deaths, about 13 per cent of all maternal deaths in Africa.
WHO believes that some 90 per cent of all abortion-related deaths and injuries could be avoided if women who wanted to avoid pregnancies were able to use contraception. Yet overall, less than 25 per cent of African women are able to obtain contraceptives. In West Africa, fewer than 10 per cent can. "If family planning could be made available, we would reduce maternal deaths," says Dr Kodindo.
She is optimistic. "We are seeing positive indications. The economic burden of many children is making men more cooperative." Such a shift is especially notable in the Democratic Republic of Congo, Dr. Kodindo observes. "My only regret is that it is only in the urban areas. There is much work to do in the rural areas."
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