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How to fund a failing health system

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Could Zimbabwe’s new Health Development Fund rescue the country’s cash-strapped clinics and hospitals?
For two years, Widna Chiyangwa from Harare, Zimbabwe, suffered in pain. She was in her mid-40s and had four children to feed. But a broken ankle had left her without an income — she could no longer work as an informal trader because she couldn’t walk. Chiyangwa required urgent surgery to fix her ankle, but she couldn’t afford it.

Private hospital fees in Harare, Zimbabwe’s capital, were completely out of reach for her. Private healthcare centres would charge between $4,000 and $7,000 for the x-rays and operation Chiyangwa needed, says Evans Masitara, secretary general of the group Zimbabwe Association of Doctors for Human Rights. Chiyangwa could also not find help at the country’s public hospitals, where acute drug shortages, ailing infrastructure and ageing or broken equipment threaten even basic healthcare services.

In October it was widely reported in the Zimbabwean media that major referral centres such as United Bulawayo Hospitals suspended surgeries as a result of vital drug stock-outs, including common pain medication.

The cash-strapped government has been struggling to pay health workers on time and in February state doctors went on a three-week strike, paralysing hospitals as they demanded higher allowances and job guarantees for junior doctors.

Nurses joined the strike in a bid to get last year’s bonuses.

At the Beatrice Road Infectious Diseases Hospital in Harare, some health workers complain that they are forced to sleep at work because they can’t afford bus fares. “We are struggling; we are not getting our salaries,” says Winnie Kadzere, one of the staff members at the hospital who went without pay for three months.

Zimbabwe’s health sector needs $1.3bn annually, minister of health, David Parirenyatwa, reportedly told senators in February. But his department got a paltry $281.9m in the 2017 budget, only 6.88% of the country’s entire budget of $4.1bn. The allocation is even less than the 8.27% of the budget that was dedicated to health in the previous year. Recent allocations fall far short of the 15% of national budgets that Zimbabwe and other countries committed to dedicating to health in 2001 as part of the African Union’s Abuja Declaration.

With the bulk of the health budget ($223m) going towards salaries, very little is left for equipment and drugs, says Shingi Bopoto, secretary general of the Zimbabwe Medical Doctors Association.

In an effort to bolster the beleaguered health sector, mobile phone users will now have to pay a levy on airtime and mobile data under the theme “Talk, Surf and Save a Life”. The 5% levy — or five cents for every dollar spent — will be paid into Zimbabwe’s newly created Health Development Fund.

Government has been forced to look for alternative ways to raise money: as Zimbabwe’s economic woes deepen, its formal tax base has been shrinking. Minister of Finance Patrick Chinamasa admits in his latest budget statement that it is no longer sustainable to rely on these taxpayers.

This new fund is also meant to reduce the Zimbabwean health sector’s dependence on donor funds. Zimbabwe is expecting $177m from the Global Fund to Fight Aids, Tuberculosis and Malaria in 2017 to buy antiretroviral drugs and medicines, and to train health workers, according to the budget statement.

The Global Fund will contribute $43m towards malaria control programmes and $11.5m towards tuberculosis initiatives. Development partners, including the European Union, will donate $48.5m through the Health Development Fund.

“The shrinking tax base has constrained government’s capacity to invest in the public health delivery system, which is now being augmented with resources from development partners,” Chinamasa says in the budget statement. “The situation is not sustainable as development partners are also experiencing budget constraints, hence, have reduced their support.”

The money raised through the Health Development Fund will be ring-fenced for buying drugs and equipment for public hospitals and clinics, according to Chinamasa.

Although this will not mean free medical care for all Zimbabweans — those who can afford to pay for medicine will still have to do so — it is meant to improve a situation in which the majority of Zimbabweans can’t get healthcare at all. Matters are compounded by the fact that medical practitioners want cash payments upfront as medical schemes either don’t pay or delay their payments.

Need help, will travel

When Chiyangwa could no longer bear the pain of her broken ankle and it became clear she would not get surgery in Harare, she did what many others with ailments do: she travelled. Although the country’s wealthy have turned to medical tourism abroad — India and South Africa are popular destinations for medical procedures and President Robert Mugabe is

known to seek medical treatment in Singapore — she bused about 230km north, to the Karanda Mission Hospital. In November last year, Chiyangwa went into theatre there for the operation she needed for the fracture.

Limping on crutches towards the waiting room, she explained she had come to have the plaster removed.

“I am happy with the treatment here,” says Chiyangwa, who had used all her savings and borrowed from family members to get the $600 she had spent in total. This includes her transport fees, $300 for the operation, $10 per hospital visit and about $20 for x-rays.

This cost about a tenth of what the same procedure would have cost in Zimbabwe’s private healthcare sector. Despite being in a remote area, the mission hospital draws patients from all over the country and has not only become a major referral point, but has also built a reputation for being a “miracle hospital”.

Here the full-time doctors perform over 4,000 surgeries a year and medical staff see between 200 and 300 outpatients each day.

As the hospital controls its own budget, it buys its own medicine stocks. The user fees largely sustain the hospital, says Friday Chimukungara, matron of the Karanda facility.

“Whatever we get in fees and charges, we use it for medicines and drugs. There is a bit of funding that comes from the government for infrastructure development, but that is not in any way enough. And of late we haven’t been getting it at all.”

Chimukungara, like many others in the health sector, is concerned about how the new fund will be administered.

“It is a noble idea, but with such issues you always want to make sure that the mechanism is okay.”

New fund comes on the back of previous innovative financing mechanisms

Bopoto, of the Zimbabwe Medical Doctors Association, also calls the new health fund “a noble idea, whichever way funds are raised”, but says the medical community is seeking assurances the money will be used only for what it is intended.

“We are concerned that the funds may not be used properly. And we are also wondering why the Aids levy model, which has been well administered, isn’t being replicated for this purpose instead,” he says.

Zimbabwe’s Aids levy has been widely hailed as a resourceful and innovative approach to fund the fight against Aids. The National Aids Trust Fund, as it is formally known, was started in 2000 and is a 3% tax on the income of the formally employed and most companies. Fifty percent of these funds are dedicated to buying supplies such as antiretroviral drugs, and the rest goes towards treatment, care and prevention.

The Aids levy enabled Zimbabwe to secure generous global funding for its healthcare sector, says economist Reneth Mano.

“Because audited accounts have consistently confirmed that the Aids levy funds are being used for the purpose for which the levy was designed, the Aids levy is probably the only tax on labour for which the taxed workers can identify with the outcome,”

Mano explains. But although official figures on employment in Zimbabwe would suggest 81% of the working-age population was employed, Mano points out that economists and industrialists believe unemployment is 500% higher than the official figures.

The deteriorating economy and jobs cuts therefore leave a shrinking pool from which to collect the Aids levy: Aids levy collections dropped from a high of $38.6-million in 2014 to R32.3m in 2016.

With tax collection from the formal employment sector predicted to continue falling, Zimbabwe’s telecommunications industry presents a lucrative alternative for raising funds.

But the new tax comes just two years after Zimbabwe’s mobile network operators were slapped with another 5% levy on all airtime purchases for mobile telecoms. They complain this has resulted in falling revenues — and they’re not sure they can take another hit.

Masitara, secretary general of the Zimbabwe Association of Doctors for Human Rights, stresses that he welcomes any efforts to stop the health sector from collapsing, but says it will be a while before the new fund will make any difference.

“Our health system is of great concern. We are also worried about transparency and the pilfering of money collected.”

Source: Bhekisisa Centre for Health Journalism
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Health

Live A Full Life With Sickle Cell Disease

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Kunle Tometi a Pharmacist, Entrepreneur and Public Health Advocate.

The World Sickle Cell Day is a United Nation’s recognized day to raise awareness about sickle cell disease (SCD) at a national and international level. On 22nd December 2008, the UN General Assembly adopted a resolution that recognizes sickle cell disease as a public health issue and “one of the world’s foremost genetic diseases.” The resolution calls for UN member states to raise awareness about sickle cell on June 19th of each year.

In this article, I would be creating awareness on sickle cell disease, the causes, symptoms, treatment and prevention.

What is sickle cell disease (SCD)

Sickle cell anemia (sickle cell disease) is a disorder of the blood caused by inherited abnormal hemoglobin (the oxygen-carrying protein within the red blood cells). The abnormal hemoglobin causes distorted (sickled) red blood cells.

Occurrence

SCD is more common in certain ethnic groups, including:

  • People of African descent,
  • Including African-Americans (among whom 1 in 12 carries a sickle cell gene)
  • Hispanic-Americans from Central and South America
  • People of Middle Eastern, Asian, Indian, and Mediterranean descent
  • Approximately 2000 infants are born annually with the disease
  • SCD affects approximately 200,000 Americans annually
  • 1 in 365 African Americans
  • 1 in 13 African Americans have the traits (carrying only 1 of the gene, S)

(CDC August 2017, Mayo Clinic)

Economics of SCD

10 years ago; Medical expenditure for children with SCD averaged $12,000 yearly for those with Medicaid and $15,000 yearly for those with commercial insurance.

There were also 113,000 hospitalizations costing over $500,000 paid by Medicare and Medicaid of which 75% of the visits were in adults and each with at least 3 Emergency Room visits per year. Children with SCD miss a minimum of 18 days per school year

Total healthcare costs nowadays for SCD is estimated at $2billion per year.

According to (David A.N et al 2018), ‘In Nigeria, the prevalence of SCD is 20–30/1000 live births. The burden of the disease has reached a level where it contributes 9–16% to under-five mortality in many West African countries. Hemoglobinopathies alone represent a health burden comparable to that of communicable and other major diseases’

Causes of SCD

Healthy red blood cells are round, and they move freely through small blood vessels to carry oxygen to all parts of the body. In SCD, the red blood cells become hard and sticky and look like a C-shaped called a “sickle” and they are not able to carry enough oxygen. When they travel through small blood vessels, they get stuck and clog the blood flow.

The sites most often affected by clogging or stacking of sickle cells are found in the lungs, liver, muscle, bone, spleen, eyes, and kidneys and other parts and tissues of the body: explains why patients complain of a lot of pain in these areas as the symptom of the disease.

Patients also have immunity suppression which leads to infections by bacteria, and viruses.

Symptoms of SCD includes;

  • Excessive fatigue, irritability from anemia
  • Jaundice (yellowing of eyes and skin), may also include retina damage
  • Swelling and pain in hands, and feet, Pain in chest, back arms and legs, also damage of hip
  • Frequent infections,
  • Pain and problems in the spleen, (Nausea, vomiting, diarrhea)
  • Delayed growth
  • Stroke (20–30% of children stroke, 23% in African Americans)
  • Genitalia (priapism, a constant erection, in which severe episodes may lead to impotency)

Treatment of Sickle Cell Anemia

Treatment of SCD pain or crisis is done in the following manner:

Rehydration: with IV fluids, helps Red blood cells return to normal shape

Also Read: The ELMA Group of Foundations Commits ZAR 2 Billion to COVID-19 Response in Africa

Drugs:

  • Antibiotics: used to treat underlying infections. In some cases antibiotic prophylaxis, penicillins are recommended.
  • Pain medications to treat acute pain
  • Hydroxyurea: helps increase production of red blood cells

Immunization: Pneumococcal and Meningococcal vaccines have drastically reduced the rate of infections in SCD

Blood transfusion: improves oxygen and nutrients needed

Supplemental oxygen by mask makes breathing easier and improves oxygen levels in the blood

Bone marrow transplant: for severe complications and matching donors.

Prevention

  • Genetic counselling and testing (better before marriage and at pregnancy) can help prevent the likelihood of passing gene to your child
  • Preventing infections can be achieved by practising simple hand washing techniques at every opportunity. Hand sanitiser gels and wipes are also available and affordable
  • Immunisation is very important and one must assure shots and records are current to cut down on the rate of common infections.
  • Re-hydration with fluids at all times is essential.
  • Avoid staying in places with low concentration of oxygen, e.g. unpressurised air planes, or high altitudes

For more information about SCD, please speak to your Pharmacist or Doctor.

Article by Kunle Tometi a Pharmacist, Entrepreneur and Public Health Advocate.

Ref:

  • https://en.wikipedia.org/wiki/Sickle_cell_disease.
  • Mayo clinic https://www.gstatic.com/healthricherkp/pdf/sickle-cell-anemia.pdf
  • CDC https://www.cdc.gov/ncbddd/sicklecell/data.html
  • Sickle cell Disease: Public health agenda & Social, Economic and Health implications by CDR Althea M Grant, PhD September 2012
  • www.score_international.org/resources/conference_presentations
  • Overview of the management & prognosis of sickle cell disease, Joseph Palermo, D.O.
  • Economic impact of sickle cell Hospitalization. R Singh, Ryan Jordan and Charin Hanlon
  • www.bloodjournal.org/content/124/21/5971
  • Prevalence and impact of sickle cell trait on the clinical and laboratory parameters of HIV infected children in Lagos, Nigeria

Prevalence and impact of sickle cell trait on the clinical and laboratory parameters of HIV infected children in Lagos, Nigeria.

BAO Magazine

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Adaku Efuribe: COVID-19 treatment and the dangers of drug misuse in Nigeria

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Adaku Efuribe (Image credit: Adaku Efuribe)

Drug misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). It has a negative impact on health or functioning and may take the form of drug dependence, or be part of a wider spectrum of problematic or harmful behaviour (Department of Health, 2006).

At the moment there seems to be an increased risk of self-medication and drug misuse especially in countries where prescription only medicines could be bought without prescription. For instance, countries like Nigeria where some patent medicines dealers who are meant to sell GSL medicines end up dispensing pharmacy only medicines and prescription only medicines.

As soon as a new drug for managing COVID-19 is announced by mainstream media, people run off to the shops to buy these drugs, even people who have not tested positive for the coronavirus, indulge in self-medication in a bid to prevent contracting the virus.

I am worried about the recent announcement for Dexamethasone as a new drug for treating COVID 19. Information reaching me shows, following hours of announcing this drug by the media, some Nigerian resident has started trooping to their pharmacy, ‘chemist’ and illegal drug dealers to buy dexamethasone tablets.

Dexamethasone is a corticosteroid, it has high glucocorticoid activity, and it should not be used without the guidance of a clinician. According to the Electronic Medicines Compendium (EMC), depending on the dose and duration of therapy, adrenocortical insufficiency caused by glucocorticoid therapy can continue for several months and in individual cases more than a year after cessation of therapy.

Also Read: Lockdown Bozza: Developed to simplify the lockdown regulations in South Africa

Through immunosuppression, treatment with Dexamethasone can lead to an increased risk of bacterial, viral, parasitic, opportunistic and fungal infections. It can mask the symptoms of an existing or developing infection, thereby making a diagnosis more difficult. Latent infections, like tuberculosis or hepatitis B, can be reactivated.

Dexamethasone also has some side effects; the following side effects are common (occurring in greater than 30%) for patients taking dexamethasone:

· Increased appetite.

· Irritability.

· Difficulty sleeping (insomnia)

· Swelling in your ankles and feet (fluid retention)

· Heartburn.

· Muscle weakness.

· Impaired wound healing.

· Increased blood sugar levels

If only the media companies understood the fact that prescription only medicines could be bought without prescription in some countries, they would thread carefully and choose appropriate wording when announcing potential drugs for COVID-19 treatment.

It’s the duty of the Ministry of health and drug regulatory bodies of those countries where prescription medication could be bought in the market like sweets to continue to create awareness, educate the general public on the dangers of self-medication, drug misuse and drug abuse. They must not relent in their efforts of managing drug distribution/regulation.

My advice to people living in countries where you could buy prescription only medicines without prescription is this:

Do not run off to buy the latest drug announced for COVID-19 treatment.

This drug is a corticosteroid and should only be taken if prescribed by a clinician.

Please do not indulge in medication misuse and abuse. It could lead to adverse effects or even death

Author: Adaku Efuribe is a Clinical Pharmacist & Global consultant in Medicines Management

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Sickle Cell Disease Educational Resources Initiative(SERI)- Our Story

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Sickle Cell Disease Educational Resources Initiative(SERI)

Every year, nearly 300,000 children are born worldwide with this most painful disease and many of them will not survive beyond their fifth birthday. Discovered more than a century ago, Sickle Cell Disease (SCD) is an inherited genetic disease that is transmitted when both parents who carry hemoglobin S transmit it to their child.

SCD comes with many complications such as high blood pressure, kidney failure, kidney stones, growth delay, bone necrosis, stroke, retinopathy and increased risk of infection and sepsis. Treatment options include medications to manage the symptoms and blood transfusions to replace the sickled cells. A stem cell also known as bone marrow transplant might cure the disease. However, this procedure usually involves patients to have a matched donor, such as a sibling, who doesn’t have sickle cell anemia.

Both Agnes Nsofwa and Biba Tinga(Founders of The Sickle Cell Disease Educational Resources Initiative) gave birth to children with SCD type SS. Like all caregivers of children with a chronic illness, they had to face many challenges while managing their children’s health. Agnes, has a little girl who received a bone marrow transplant and was cured from SCD a year ago; She left a career in Business, trained to become a Registered Nurse in order to better understand the disease and care for her daughter. She fought hard for over 10 years to get her cured. Today her little girl is Sickle Cell free, but Agnes is still advocating for others who are still affected by SCD.

Agnes Nsofwa, Co-Founder at SERI

Biba has a young adult son living with SCD, but he is not a candidate for a bone marrow transplant to get cured. He will have to keep fighting every day of his life to stay healthy. As a treatment, he regularly receives Red Blood Cell exchanges or apheresis which allows him to avoid the terrible pain crisis. Their journey which started in Niger continues in Canada.

When they met for the first time in January 2020 in Amsterdam, they quickly realized they had been fighting the same battle. They have both been engaged in their respective communities, advocating on behalf of other families dealing with the same condition. Their combined years of experiences has taught them the need to unite. Because when life becomes a struggle, you engage with family. And sometimes family is someone who shares your life journey. After a short discussion, they knew they were going to join forces against this common cause and become friends.

Agnes had started the project translating sickle cell materials into her native language of Bemba from Zambia since 2018, in order to help others to better understand and care for their children since. When she shared this idea with Biba, she instantly agreed to come on board because she had also been sharing information in her native languages of Zarma and Hausa with parents of affected children.

Biba Tinga, Co-Founder at SERI

Together they want parents, to have access to information so that they can make the best decisions to care for their children. To do this, they created SERI, Sickle Cell Disease Educational Resources Initiative, a platform of educational and informative resources on sickle cell disease in various languages.

As they present it, “we created SERI because without education we could not have looked after our children properly. We want all mothers to have what we did not have. SERI is more than a platform; it is also a movement for awareness and education. Whether you speak Bemba, Tonga, Hausa, English, French, Yoruba, Arabic, Hindi, Twi, Spanish or any other language, SERI will offer the information in the language you understand.

SCD requires long continuous care. When the parents or the patient does not understand the basic information, the consequences could be fatal. SERI will also provide audio recorded version in the local languages to ensure that those who cannot read and write can listen and still receive the education that will empower them to better care for themselves.

Also Read: Lockdown Bozza: Developed to simplify the lockdown regulations in South Africa

SERI will also share the stories and the experiences of those who are fighting SCD because their stories matter.

The stories will tell our journeys, the stories will say who we are. We are SERI!”

Visit: Sickle Cell Disease Educational Resources Initiative(SERI)

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