Feature - New scheme aims to improve healthcare

Abraham Feleke is the only surgeon at his 150-bed hospital south of Addis Ababa, a facility that caters for two million people. When not performing surgery he also acts as the hospital director, ordering or arranging for medical equipment to be repaired and monitoring its 58 strong staff. “I am carrying out about two or three operations every day,” says Dr Abraham, who is on call 24 hours, seven days a week. He is paid US $290 a month. “The system has all but collapsed,” he adds wearily, explaining why he is the only surgeon at the hospital. “It has got to such a state because of the poor service and lack of money.” Situated some 300 km south of the capital Addis Ababa, Yirga Alem is seen as a flagship medical centre. But even there the facilities are appallingly inadequate. “I feel we are totally undervalued as a profession," says Abraham. HEALTH INSURANCE PROJECT A health insurance project, successfully implemented in some West African countries, is now being touted as a way of putting a brake on the massive drain on resources. It is hoped the scheme will boost the faltering public health system by injecting cash. The scheme offers a radical approach to enhancing public healthcare in Ethiopia by drawing on the well-used private health system. Bruno Galland, director of research with the French-based International Centre for Development and Research (CIDR), is heading the project. “Healthcare is important in Ethiopia as it is in the rest of the world,” he told IRIN. “The main problem here is that it is heavily under-financed.” The scale of the under-funding is enormous. The impoverished government spends a tiny US $1.50 per capita per year. Financial support from international organisations boosts that figure to just US $4.50 per capita. CIDR believe decentralisation of management where decisions, responsibility and finances are taken at local level would help. Currently half of all hospital fees – bills which are picked up by sick patients paying for treatment - must be returned to the government. The research group argues that a system of health insurance would inject cash, raise standards and offer greater access than the current exemption certificates used by the poor. The vouchers, which are handed out by government officials, are aimed at giving the poor free access to healthcare. But hospitals, not the government, often end up footing the bill. “Health insurance can be one of the tools to improve the management of healthcare services,” Galland said. “It can bring additional resources and be part of the strategy to improve quality of care because it introduces control to the patient which is important.” The money from the insurers would be paid to public hospitals – money that could then be used to improve services and potentially pay higher salaries to staff. PITFALLS The insurance system is also widely understood and mimics a local Ethiopian practice called iddirs – where communities collect money to pay for funerals. The scheme is expected be piloted in three southern towns in Ethiopia Debre Zeit, Shashemene and Awassa. Yet there are pitfalls. “The health insurance notion is a good idea but there are things that need to be improved,” says Dr Abraham, who has been involved in the planning. “The quality of service needs to be improved if people are going to use it. Health professionals need to be motivated. Facilities also need to be improved.” Ethiopia’s dire health service is reflected in official statistics. Life expectancy is just 45 years and one in six children will never reach their fifth birthday – the majority dying before they are one. Dr Abraham says his hospital receives a subsidy from the government of around US $17,000 a year. In total, the hospital’s annual budget is US $290,000 and much of this income comes from fee-paying patients. Unsurprisingly in a 150-bed hospital catering for a population of two million, wards are quickly filled and corridors and tents become makeshift wards. Medics in the country also point to the wider problem of low morale and lack of services which would preventing the scheme from getting off the ground. Salaries are rock bottom. Many seem keen to leave the public sector for private consultancies abroad – a flight the insurance scheme seeks to halt. Doctors in the country often joke that there are more Ethiopian surgeons in Washington DC than in Ethiopia itself. At present there are just 220 surgeons in the country where average annual incomes are around US$100. The population is 67 million and rising fast. Surgeons like Dr Abraham who work in government hospitals are banned from holding private practices or consultancies. “The government cannot afford to pay for us so they should let us work in private services as well,” he told IRIN. “They should change their policy in dealing with health professionals.”