Creating a functioning health system for all: Lessons from China.

Workers at the Robert Gabriel Mugabe Airport in Harare coordinate the transfer of Sinopharm vaccines donated by the Chinese government to Zimbabwe. PHOTO: CGTN Africa/Farai Mwakutuya

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By Joseph Nyero

A heath system comprises all organisations, institutions and resources that produce actions whose purpose is to achieve good health. Its building blocks include; governance, human resource, health information, health finance, service delivery, medicines, vaccines and appropriate technology.

All these components work together interrelatedly with an intrinsic goal of providing good health. A breach in one of them make lead to the collapse of the whole system. Take for instance, if there is not health finance, the medicine will not be bought and the service delivery will be poor. It is therefore vital to develop the system as a whole and to do a full systems analysis if there is need to fix any problems in a health system.

Several studies have confirmed that having well-functioning health systems is a forward in eliminating unnecessary and controllable deaths.

While it is not like a picnic to build a strong and good health system, we can borrow a leaf from some of developing countries that have succeeded in this aspect.  China for example had its first health system reform in 1996. The effectiveness and efficiency of the reform was questioned after a couple of years because people still had the same problems, they had in the first place.

They still had high out of the pocket expenditure, most of them didn’t have health insurance. A large proportion of the people couldn’t afford the health that they needed. In a closer look, these are almost the same problems faced by the health system in developing countries like Uganda.

People at times have to sell off their assets just to afford medical care which pushes them right to poverty even if they had escaped the poverty line. It is important that we look not only at prescription drugs but also make sure that health care is a major focus.

Following a failure from a top research institute, the former reform of 1996 had failed. China then embarked on planning another reform in 2007 where they consulted and worked with very many of their ministries. In 2009, the central committee of the communist party of china issued a policy. Its major aim was universal health coverage by 2020 through strengthening health care delivery, health security and provision of essential medicines. This policy reform is a long-term endeavor but the returns are worth the investments. Even when it is quite challenging for the African setting, we ought to start on our own reforms. Like the Chinese say, a journey of 1000 miles starts with a single step.

In order to get the job done, the state council set up a state council health systems reform office where the activities of the reform would be coordinated. The following were the policy reforms.

Under social health security, the social health insurance package was extended, medical aid was extended to the eligible poor and those with catastrophic medical expenditure.

The payment system was also reformed. Through this, 95% of the population has been covered by health insurance schemes by the end of 2017 and catastrophic health insurance introduced in all provinces.

Such a system in Uganda would reduce the burden of out of the pocket health expenditure. Often a times I have seen families who just take their patients back home because they can’t afford any more bills.

These people die from cases that could have been well managed if they had some form of insurance. Such a policy in Uganda would thus reduce mortality.

For the essential drugs, the new policy promoted rational use of antibiotics, removing price mark ups of drug and reforming the drug procurement system. This decreased the unnecessary use of anti-biotics and also made the drugs more accessible to the public. One of the issues in Uganda is over use of antibiotics which will eventually lead to resistance.

It bothers me a lot when I see how a wonder drug like ceftriaxone is used in cases where a milder antibiotic would work just fine. Antibiotic resistance is real and a day can come when a drug that did magic can no longer do a thing. A good example is penicillin. When it was discovered in 1928, it greatly improved mortality. Right now, bugs can have it for lunch! Such a policy in Uganda would not only reduce unnecessary bills on antibiotics but also delay the incidence of resistance.

As a doctor, sometimes I have had to walk through the pharmacies in Kampala to determine their prices. This is because I know that’s the first question patients ask upon presenting to them the treatment options. And from the search, the prices are shockingly different. I then send my patients to the cheapest pharmacy for the respective drugs. If we had a policy like the one China put up where the prices are controlled, medical care would be cheaper.

People even opt for traditional medicine that ends up messing their livers and kidneys the more. This is worse if the patient presented with a liver or kidney failure and they add on herbs to the problem. The people actually don’t want the herbs, they just can’t afford the modern medicine.

On the policy for primary health care, the Chinese government increased the capacity for training and created contracting systems for general practitioners. This was able to increase the number of doctors and improve health care. One of the major challenges in the developing countries like ours is few doctors and poor recruitment by governments. Having such a policy would increase the number of training institutes and ensure more doctors while also providing new jobs to the staff in the institutes. Another reason patients avoid government hospitals in Uganda is the long waiting time. This would provide a solution to this as there would be many doctors seeing the patients.

The other policy introduced by the Chinese to strengthen its health system was basic public health package. Here the government provided subsidies and promoted programs that control the main public health concerns. This made the bills cheaper and reduced the occurrence of non-communicable diseases. As indicated earlier, high bills are still a problem for Uganda. Non-communicable diseases are also on the rise in developing countries.

The last policy was about public hospitals. Through this, they encouraged the creation of consortium or alliances of healthcare providers. They also established a tiered health system where every healthcare provider knew exactly what its functions are. They also encouraged the use of clinical guidelines. This created an organized system with a standard of care that is uniform and a regulatory body. We have a clinical guideline in Uganda but it is not yet widely used and every doctor manages patients their way.

This makes some of the patients to get substandard care. In the Ugandan system, health center IVs are supposed to carryout surgeries but there are those which don’t. such a system would make every health center offer healthcare to the best of its abilities thereby helping reduce congestion at reginal and national health facilities where many tend to run even with cases that could be managed at health centers.

Upon emulation of such policies in to our setting, Uganda shall have tremendous health benefits. More people will visit and afford hospitals, poverty levels will drop, patient waiting time will decrease etc. the end result will be a good sustainable health system for all.

The writer is a research fellow at Development Watch Centre, a Foreign Policy Think Tank, and a fourth-year medical student at Makerere University.



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