Over the past few years, there has been a trend towards free or subsidized health care for certain groups in several West African countries. To me, this always appeared to be a positive change. Wouldn’t free health care mean more people receive the treatment they previously couldn’t afford? However, as more evaluations are conducted and reports compiled, there seems to be a hidden cost to the free or subsidized health care.
When it comes to seeking medical treatment, cost is one of the largest barriers. Unable to pay for hospital visits, many women give birth at home, without the skills or equipment to deal with any complications that may arise. By lowering or removing the cost of maternal health care, more women are given the opportunity of choosing a hospital birth. Indeed, after Sierra Leone introduced free health care for women and children under five, hospitals saw a large increase in the number of patients. In the first year of the program, hospitals treated three times as many children and over 126,000 women gave birth in a hospital, compared with the previous year’s number of 87,000.
At the same time, introducing a free or subsidized health care program can also be a cause for concern. Without a comparable increase in medical professionals and supplies, the free health care may result in a lower quality of care. As more individuals visit hospitals, doctors have less time to spend with each patient, and fewer resources to help assist them. For health centers relying on user-fees, the introduction of free or subsided health care means administrators need to find a new source of revenue to keep their hospitals running. For some hospitals, this means an increased reliance on private donors and foreign aid.
In addition, while health care may be nominally free or low-cost, there are still expenses associated with the medical treatment that puts it out of reach of the poorest patients. In many countries, hospitals are understaffed and lack even basic supplies. Patients are often required to purchase items such as clamps and needles at local pharmacies before a doctor can take action. Uganda in particular has come under the international spotlight after the families of Jennifer Anguko and Sylvia Nalubowa decided to take legal action against the government. Both women died in labor, despite the fact that they arrived at hospitals in time to be saved. Jennifer Anguko, a member of the district council, bled to death in the maternity ward of a 400-bed hospital. Although she arrived early at the hospital and brought with her the necessary supplies, she was not seen by a doctor or midwife for 12 hours, after which time it was too late. Sylvia Nalubowa faced similar circumstances at a rural hospital. Although her family was able to gather the money for the items the hospital lacked, they were unable to pay the $24 bribe demanded by the nurses. As a result, Ms. Nalubowa’s family contends she was left unattended and bled to death.
Reports of similar neglect by nurses and doctors have become more widespread. A recent Human Rights Watch report examined the health care system in South Africa, and unveiled numerous accounts of patient abuse. Reports of women being turned away from hospitals while in labor, and allegations of physical and verbal abuse demonstrate that the health care system has become increasingly flawed. Despite the fact that South Africa spends a large amount of money in providing free maternal care to its citizens, their maternal mortality rate has quadrupled, going from 150 per 100,000 in 1998 to 625 in 2007.
As the complaints towards health workers mount, nurses and doctors report feeling unjustly blamed for a larger systemic failure. Analysts note that there are just not enough health workers to address the growing demand. Health workers are stretched to the limit for low pay, causing them to become frustrated and encouraging them to lash out. In most cases, doctors and nurses have not been properly compensated for their time. Instead, they are expected to work for the feelings of nationalism and altruism, payment that overworked health professionals find insufficient.
As health workers lose motivation, the relationship between patient and doctor becomes increasingly strained. In South Africa, women report being unwilling to turn to health workers for care, because of the poor treatment and corruption they expect to face. However, in Côte d’Ivoire, doctors report a similar apprehension when it comes to dealing with patients. After the government decided to prolong a free health care program for the nation, doctors have been seeing many more patients for consultations, but lack the medicines to help ease their patients’ ailments. For many community health centers in Côte d’Ivoire, facilities are user fee funded. With the introduction of free health care, centers are unable to raise the money to purchase and store medications. As a result, doctors now must provide patients with instructions on how to purchase the expensive medications from private pharmacies. After expecting free assistance and leaving with prescriptions they may be unable to afford, patients suspect doctors of simply being unwilling to help, rather than unable.
The problems faced by countries as they transition to free or low-cost health care shouldn’t always act as a deterrent. Rather, there needs to be a careful planning process and an established system for accountability. In looking at the issues faced by Côte d’Ivoire, doctors suggest a lack of consultation as a major issue. As some doctors argue, by failing to take into account the perspectives of those who would be carrying out the health program, Côte d’Ivoire set itself up for failure. In order to ensure a more sustainable health care policy, it’s necessary to gain the support of the health workers. While establishing higher pay for doctors and nurses may be a large expense for countries already struggling with an overloaded budget, it may be one of the best ways to recruit more health professionals and ensure a better quality of care for patients.