Wednesday, 25 September 2013

When free universal healthcare isn't free and isn't universal: a case study in TB treatment from Burkina Faso

As the term of  the current Millennium Development Goals reaches an end in 2015, healthcare workers and reporters worldwide are assessing the efficacy of different global health and development approaches over the last few years. The necessity of improving global health has been one of the highest priorities of development practitioners and activists, the touchstone being universal access and free access.

One project study, which aimed to provide free treatment for tuberculosis patients in Burkina Faso, caught my eye because it illustrates the subtle challenges and difficulties (as well as areas of success) which arise when it comes to the practicalities of delivering healthcare which is intended to be both free and universal. The findings of the research will be vital in shaping world healthcare policies when it comes to the treatment, control and prevention of TB after the timeframe of the current Development Goals.

Based on meticulous year-long research by Samia Laokri, Olivier Weil, K Maxime Drabo, S Mathurin Dembelé, Benoît Kafando & Bruno Dujardin, the study - an abstract is provided here by the World Health Organisation - demonstrates the flaws of a generalised or sweeping analysis, starting with the "theory [that] the removal of user fees puts health services within reach of everyone, including the very poor." They warn,
In the poorer countries of the world, where most people live on less than US$ 2 per day and expenditure on health care can plunge patients and their families into extreme poverty, the removal of user fees for health is seen as a matter of real urgency. Unfortunately, this is unlikely to be enough to ensure truly universal coverage.
A full version of the report is here and I have provided my overview and analysis below. 

The study I'm focusing on, which is part of a larger project [see points seven and eight here], is based on the findings of rounds of interviews with 242 patients who tested positive for pulmonary tuberculosis across the six rural districts of Bousse, Koupela, Ouargaye, Zabre, Ziniare and Zorgho and who were enrolled in the national TB control programme. As the writers state,
The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient’s household. During the course of their care, three quarters of the interviewed patients apparently faced “catastrophic” health expenditure. 
Their analysis of the cause of this US$101 direct cost is interesting: around US$ 45 of the cost was not down to the inherent cost of the medicines or treatments themselves, but to failures in the broader health system and policies; the researchers cites access, medical consultations, out of pocket expenses, unofficial payments to medical professionals and lost wages from their day jobs for both diagnosis and treatment (or even redundancy due to repeated absence). While individual patients bore these costs by strategising. economising and accommodating within their households and negotiating or receiving community and extended-family support, this accommodation weakened their overall economic standing and jeopardised their position in the long term. There was a likelihood of established savings being used, of families being forced to decrease consumption to save money, being forced into the sale of goods or services to raise money or to take out loans to raise money. When this seemingly small monetary figure accounts for nearly a quarter of each household's income, given the generalised socio-economic context of poverty or near-poverty amongst the population studied, there are grave consequences in terms of increased social inequality and economic instability; the stigma of suffering from TB; the 'social debt' incurred by help received by family members and the wider community; and a greater improbability of proper treatment being sought, for all these reasons. The illness itself increased instability, with the researchers citing an average loss of 45 days of work lost by sufferers across the research year from 2007 to 2008. 

The 23% percentage figure of annual income cited for TB treatment costs is alarming as the threshold for a definition of "catastrophic" expenditure which represents an excessive burden on a patient or their household in the rural low-income communities in the study, is 10%. The study analysed all the types of expenses and costs, including non-medical and non-financial costs, which arose as a result of suffering, diagnosis and treatment and identified various failures and weaknesses in the system. They include necessary services that were not covered by the free treatment package (which include diagnosis by spit sample, anti TB drugs and repeat smears to determine treatment outcome) and services that were not necessary but where payment was required. The report states,
Only 2% of the patients interviewed...reported that they had received completely free tuberculosis care. 
The challenges above, as well as other failures in patient treatment (such as extended time periods required for diagnosis and repeat procedures) explain why the rates of TB detection and cure are lower than might be hoped given the MDG and the adoption of international recommendations for TB control. The researchers state that what are necessary are solutions which pull in all practitioners, "political decision-makers, managers of health programmes and health services" to develop meaningful responses and suggest a number of measures including the decentralisation of diagnosis and treatment so that patients do not have to travel, improving community care to enable early detection, help for the poorest households, supporting healthcare providers and also supporting patients not just financially but socially and psychologically through dialogue with former patients. They also call for a rigorous assessment of 'free' healthcare systems with a multilayered analysis of economic and social consequences aimed at fine-tuning policy, identifying and rectifying faults in the system, guaranteeing efficiency and helping (rather than exploiting or exacerbating the problems of) the most vulnerable.

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Wednesday, 18 September 2013

The Man Booker, Raised and Transformed: In Celebration Of A Prize for the 21st Century World

Disclosure: I was made a trustee of the Booker Prize Foundation in spring 2013.

The judges of the 2013 Man Booker Prize have selected what I believe to be the most exciting longlist and shortlist in the prize’s history. Inclusive, innovative, wide-ranging in voice, structure, tone, form and setting, the 2013 Man Booker has embraced the realities of the changing outer world and the infinite possibilities of the art form and shown how each affects the other.

Suddenly, they’re down with the brown. They’re sisters. They’ve gone global. The result? A skilled, bright, fascinating selection that has drawn praise from all quarters.

EDIT: and here's the winner: Eleanor Catton, for her novel The Luminaries:

Photo taken at the 2013 Booker ceremony
15th October 2013
The judges have read without prejudice, with joy, without false distinctions, with heart, without slackening their critical judgement and with full capacity to be inspired, to be moved, to be affected and elevated. Their choices for 2013 are a tribute to the written word, through which we understand unspoken words, thoughts, feelings, motivations; and also to the fictional world, through which understand the real one. The judges’ 2013 Man Booker choices reflect a new reality in which stories and their telling, authors and their ideas, are global. The judges have recognised that even with great diversity of reference, author, context and character there is one unifying and universal force: the passion of readers.

The Booker was launched in 1969 and while its aim was to reward excellence in fiction, it was open to British, Irish, Commonwealth and Zimbabwean writers only.

The Man Booker Prize is stepping up and now joyfully seeks and celebrates the best of fiction written in English and published in the UK, starting with the 2014 prize - although the transformation has already begun, without our direction, in this year’s choices.

These ‘changes’ are nothing more than a vindication of the Man Booker’s original vision, properly fulfilled: to reward the best work of fiction in the English language. The nationality of the author is unimportant, as it should be: writers of all nationalities live all over the world and are inspired by that world, as are readers. The authors’ skill, their vision and their gifts in English literature are what matter, wherever they put pen to paper and whatever the view from their study window. This ‘expansion’ is nothing more than a recognition of great talent and one great work and an acknowledgement that talent in the English language is obviously not confined to Britain, Ireland, the Commonwealth and Zimbabwe but may be found anywhere.

The behind-the-scenes tweaks to the system have been more than eighteen months in the making and were developed with the full involvement of industry professionals, writers, readers, booksellers and many others. The number of judges and the fact that only UK publishers can submit books are unchanged. However, the fear that judges will be overloaded with books has been considered and dealt with. There is a new system of submissions according to which publishers have had books longlisted within the previous five years. Of course, publishers who have had no previous longlistings are also able to make a submission. The convention of allowing all publishers to propose up to five further novels for judges to consider considering also stands, as does the judges’ privilege in calling in any book which has not been submitted but which they feel should be considered.

The new system is so rigorous, so mindfully conceived, so fair and with so many variables worked out to limit the burden on judges and ensure fairness for publishers that it resembles a cross between the notes for a massive multiplayer Mah Jong game and an early instruction leaflet for the world’s first abacus. So please trust them, but don’t ask me to explain it or I’ll fluff it and be off the Board of Trustees before you can say ‘impostor syndrome.’

Let me also point out that being asked to judge the ManBooker Prize is optional and is a joy. It’s not military service. My advice to judges who’ve been approached, but who don’t want to do it, is this: say no. Say no to the discussions, the books, the posh lunches, the increased social status, the networking opportunities, the discovery of new authors’ work, the new friends, the enhanced career standing, the connection to one of the most significant literary prizes in the world and the amazing party at the end. No problem. We’ll ask someone else.

There is very little chance that judges will be ‘swamped’ by all manner of stuff sent over in Jiffy bags from every Post Office in the world. Works will be submitted by the authors’ UK publishers and the overall number of submissions will be balanced out by the new submissions system, so we do not expect an increase in the number of books judges must read. There are relatively few American authors published in the UK so there is no question of UK and Commonwealth authors who might otherwise be considered being squeezed out. 

And now, having kept my diplomacy for a page and a half, it’s time to open a vein and spray some venom.

This is a discussion about literature, not a debate about immigration. This is great news about a prize rewarding literary excellence, not a committee discussing border controls. This is an interesting and joyful cultural shift, not a xenophobic, petty, stand-up knock-down election debate about outsiders or identity or dilution or being threatened by foreigners who are going to muscle in, warp ‘our’ image and take all ‘our’ jobs/prizes/power/whatever. Identity has always altered with context. Identity shifts, it expands, it accommodates and grows deeper according to the surrounding reality. This is not a dilution but a development; not a fundamental weakening but a positive evolution. And if the lurking fear, behind all the bluster, is that perhaps British and Commonwealth writers are not good enough to survive this new world with all its new voices, I say: what low self-esteem, what a boring inferiority complex. Get over it.

Whingeing, resistance and doom-mongering are natural human reactions to change. I must say, I am invigorated by this fauxtroversy because it shows that people are surprised. This venerable prize, this career-making boon, this rich-making establishment honour, The Man Booker Prize, is leading the debate. The rest of the industry and the media are now thinking, analysing, reacting, regrouping, reframing. Critics and snipers have a choice: embrace change or fear it; go with the future world or whinge at home in crabby insularity; welcome others with grace or ostracise them with bitterness; step up your game or get off the pitch; get with the programme or be left behind.