What would you do if you were detained in a hospital for not paying the bill? A month ago I met Sanaa, a 34 year-old leukemic patient who was brought to our ward by her relatives. Sanaa was detained in a private hospital for 14 days after not being able to pay her hospital fees. With each passing day, her debt increased, and when I asked her, “How did you manage to get out?”, she said, “I sold all my gold”. Sadly, that wasn’t a surprise to me. Everyday, after I finish my rounds in the leukemia ward, I make my set of phone calls. I reach out to charity organisations, companies, private banks and colleagues to fundraise for my patients.
University teaching hospitals are the largest and most funded, yet budget deficits are becoming the responsibility of the patient and their treating doctor. It is disheartening that out-of-pocket health service and detaining patients to pay their bills are a reality.
In developing countries, the average citizen doesn’t have full access to health care at all times. By the word ‘access’, I mean medical services are easily delivered, convenient, and affordable. Health coverage has been an idea since the 1880s when it was first proposed by the German government. Since then, countries have adopted the concept of offering their citizens adequate, subsidised health service once they fall ill.
At the 1978 International Conference on Primary Health Care in Kazakhstan, almost all World Health Organisation (WHO) and UNICEF member nations witnessed the declaration of ‘health for all’, a concept considered ambitious and too idealistic at the time. The Declaration of Alma-Ata called for “the attainment by all peoples of the world by the year of 2000 of a level of health that will permit them to lead a socially and economically productive life”. Sixteen years after the target, we are still lacking accessible, funded health service for all.
In order to fulfill the Declaration, the WHO presented the concept of ‘universal health coverage’ (UHC) , which is defined as “all people receiving quality health services that meet their needs without exposing them to financial hardship”. For a developing country to achieve UHC, it means they must achieve impactful healthcare practices, progressive human rights and equity policies, economic growth, social cohesion, and a commitment to achieving the SDGs.
Very promising right? Unfortunately, it is not so easy.
In Egypt, the difference in mortality rates between rural and urban areas is 50%. Around 40% of state-run hospitals provide suboptimal medical services due to lack of facilities, well-trained staff, and medications. According to the World Bank, out-of-pocket spending on healthcare amounts to 72% in Egypt. These figures indicate that healthcare provided by the national governmental plan is either too minimal or tremendously failing. I read a devastating statement in a WHO publication, ‘Diseases of poverty and the 10/90 Gap’: “Over 10 million children die unnecessarily each year”. The term “die unnecessarily” is still incomprehensible to me.
One of the biggest challenges that face developing countries in achieving UHC is their leadership. Health finds itself at the bottom of government priorities, particularly with regard to financial support, human resources and reform ideas. There is great disparity in the availability of health services between urban and rural areas. The distances patients must travel to reach efficient health facilities is another major obstacle.
Hope is reignited when we do see developing countries creating UHC-based health agendas for their people. 24 developing countries are doing so, with Ghana, Nigeria, Rwanda and Kenya in the lead; these countries have received great media attention for their reforms. The World Bank released a series of analyses examining their success stories. Being a developing country with major poverty, illiteracy, inequity issues is challenging, but those with enough dedication and reform ideas have achieved better health access and services that have also contributed to their economic growth.
Based on my role in medicine, and from what I see on a daily basis in health units, achieving UHC in our countries is not an impossible dream. Modest solutions can be summarized as followed:
Insightful leadership & aspirational attitudes
- Health reform is a crucial step in providing wide-scale service. Ideas that should be considered seriously include diverting state revenues to the health sector, building a strong base of human resources, seeking international accreditation, and creating a sustainable and equitable funding pool for health care.
An operational agenda
- Successful organizational protocol is about prioritization and adequate distribution. Every country has its own disease profile, demographic considerations and epidemics. Kenya successfully implemented the risk pooling mechanism, where they provided intensive health coverage to civil servants, a heavily affected demographic, and improved their health outcomes. They increased the benefits of national hospital insurance funds to this population after the Union of Kenya Civil Servants’ Secretary General clearly demonstrated the occupational hazards involved and poor health-care offered to them and demanded a proper insurance system. In this context, adequate statistical analysis and distribution of service are greater challenges than financial considerations.
Private sector involvement
- Based on out-of-pocket spending rates, it is idealistic to say that governmental support will be able to provide full financial coverage. The private sector can play a positive role in developing countries by increasing the funding pool for the health agenda. This can be achieved in two ways: first, with the ‘competition and choice’ idea, where national and private hospitals offer the same, efficient service, giving patients the ability to choose which to go to; second, with ‘complementary actions’, where private sector hospitals take on advanced health interventions that state hospitals cannot perform. National banks, private companies and pharmaceutical industries can participate in lifting overall health quality.
Advocacy & civil society involvement
- It is challenging to have a government that lacks vision, one that fosters a corrupt, old-fashioned society, and it is heart-wrenching to see impoverished people suffer and pass away due to insufficient healthcare. I believe what I have discussed would provide the impetus for any health activist to start advocating for equality in health rights.
Monitoring and evaluation
- The metric of progress here would be based on health outcomes and out-of-pocket expenditure. Of course, measurement methods would vary according to each societal variability. But once developed, governments and health systems should be held to account. Tight evaluation tools of successes and failures will guarantee resources are not wasted, and will contribute to the progression of a successful, inclusive health care system.
The dream of equitable and affordable health care is a dream of justice. Falling ill is a weakening situation that all of us go through, but just imagine it in the context of poverty and indignity. Calling for universal health care in our facilities can prevent the death of thousands, alleviate the pain of millions, and provide justice to countless families. We need to reach a better common understanding, and reinforce wide-scale cooperation in achieving such noble goal, a goal that will ultimately equally help the rich as it will the poor, the young as it will the old, and the community as a whole.
Alia Hashim is a One Young World Ambassador from Bahrain living in Egypt. She is a Hematology resident at Alexandria Main University Hospital, working mainly with Leukemic patients, and a member of Leukaemia Friends Society, and is working on launching the Doctors in Action society, targeting leukemic patients who face poverty. Alia has also conducted many workshops through the International Federation of Medical Student Association (IFMSA) to educate others about medical issues. Alia is also an active member of Peace Revolution, an organisation promotes for peaceful co-existence through education and raising individuals' self-awareness.