The crisis in the horn of Africa continues to escalate as the UN declares famine in three more regions of Somalia. The Economist in an article titled Chronicle of a Famine Foretold (after Gabriel Garcia Marquez’s Chronicle of a Death Foretold) echoes the conviction of Amartya Sen that famines do not occur in functioning democracies because leaders would be more responsive to the demands of the citizens: “the difference does not lie in the severity of the drought.
It lies in what local governments and aid agencies have done to bolster people’s resilience to it.” The famine, like many others in the past was foretold: “when famine threatened Niger in 2005, the cost of help was put at $7 a head. No one did much; the famine struck; the cost of help ended up at $23 each.” But political considerations have always trumped economic incentives and early warning signs, just like in the case of Barack Obama and the Republican led congress who narrowly managed to work out a compromise, but not without continued worries that foreign aid remains an easy target for funding cuts.
The play of politics and economics is the story of health care and systems globally. It shows once again as Shell accepts full liability for oil spills in the Niger Delta after decades of environmental degradation and social injustice sustained by corruption and collusion with Nigeria’s ruling elite. One of the goals of a health system is to ensure that households receive a fair share of public services and are protected equally from financial risk. In an analysis that lacks detail and critical reflection, Maria Belenky of the Center for Health Market Innovations highlights successful features of health insurance schemes with examples from mostly African countries. The Nigerian example of the Hygeia Community Health Plan which “covers over 75,000 individuals… and allows members access to a broad package of services for about $2 a year” fails to mention the issue of sustainability as the plan is heavily subsidised by the government of the Netherlands and the World Bank. There is also the need to plug the insurance plan into the National Health Insurance Scheme (NHIS), with funds provided for in the recently passed National Health Bill which however awaits presidential assent.
Nigeria’s National Health Bill rightly focuses on primary health care, placing a lot of responsibilities on the shoulders of the National Primary Health Care Development Agency(NPHCDA), which synergises with its oversight on primary health care in Nigeria. The structures are being debated and processes being defined. However, the biggest question in the Nigerian health system is how to make governments, especially at the state/provincial and local/district levels take their responsibility for health care seriously and a priority. Perhaps the question is really how to make the people in a democracy, such as Nigeria, demand such responsibility and accountability from their governments as constitutionally, local/district governments are responsible for primary health care and state/provincial governments for secondary level of care. The NHIS scheme is still rudimentary, but working with NPHCDA may help channel the funds that the bill will make available, but also possibly funds meant for primary health care that have hitherto been directly allocated to local governments, unaccounted and unaccountable.
Health is politics, health is about rights of the people and how empowered they are to make things happen for themselves. Therefore, the litmus test of health systems going forward will be how well they are able to deal with chronic lifelong conditions like HIV/AIDS, diabetes and hypertension. A systematic review of retention in HIV Care between testing and treatment in sub-Saharan Africa published in PLoS Medicine shows substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. There is need for systems that allow patients to be tracked between service delivery points to properly evaluate loss to care, not only in HIV/AIDS care, but also for chronic non-communicable diseases. The press picks up another important systematic review this week, showing that Europe has its own largely unspoken burden of “tropical diseases” predictably worst in Eastern Europe, Turkey, former Soviet states and the Balkans, but also affecting as far west as Italy, Spain and southern France. The blame goes again to weak states, war, economic recession but also migratory populations with Gypsies, African immigrants and children destined for international adoption being particularly vulnerable. There again, politics and economics right in the mix.
Seye Abimbola and Remi Oyedeji