News Countries test new ways to finance care A host of innovative schemes to cushion the poor against the financial risks of getting sick, such as low-interest loans, medical-savings accounts and insurance financed by a community-funded risk pool, are being tested in several countries.

Every year an estimated 25 million in recent years to address one of the sess Freedom from Hunger’s programme, households — more than 100 million greatest but most basic challenges for launched as a pilot in , , people — are plunged into : financing. , and the when they or their relatives become ill Ke Xu, a health economist at in January 2006. However a look at the and they must struggle WHO, says such types of problems it is addressing can to pay for health-care schemes are not about give insight into new, financial-related services out of their Time and health financing or approaches to health care. own pockets. health insurance per Freedom from Hunger is working These out-of- again we hear se, but that they are with a different microfinancing group in pocket payments have from there to protect people each of the five countries participating been identified as one institutions that the from the financial risk in this programme. of the main reasons reason their clients can’t incurred by having In Bolivia, Crecer (Crédito con why people receiving to pay high costs for Educación Rural), a not-for-profit civil microfinance credits repay loans or start health-care services. education and microfinancing orga- default on loan repay- businesses that flourish For many of nization, provides its clients and their ments, says Myka is health problems that the recent schemes, families medical-emergency loans. Reinsch, Director of either they or their Xu says: “The goal In keeping with Crecer’s group- Microfinance and family members are is to turn an out-of- liability requirement, the loan must Health Protection for pocket payment to a be co-signed by a fellow microfinanc- Freedom from Hunger, facing. pre-payment system, ing client, who provides some form of a US-based nongov- Myka Reinsch, Director of Microfinance which is not linked to good-faith collateral such as property and Health Protection for Freedom from ernmental organization Hunger, a US-based nongovernmental your health condi- or livestock. (NGO) that provides organization. tion and not linked Crecer anticipates offering the such credits. with whether you use service to members (borrowers become “Time and again health services or not.” members of the group) who have com- we hear from microfinance institutions These and other pleted two loan cycles so there is a loan- that the reason their clients can’t repay programmes that are piloting health-fi- repayment history. The loan term will loans or start businesses that flourish is nancing alternatives are preliminary. For be for 12 months or less, with weekly or health problems that either they or their instance Reinsch says it’s too early to as- bimonthly payments. family members are facing,” Reinsch says, adding that healthy clients save more money, establish successful busi- nesses, take out larger subsequent loans and continue to be clients. To address the problem, Freedom from Hunger is now working on Micro- finance and Health Protection (MAHP), a programme that aims to address the financial problems associated with health-care access. It is one of a number of develop- ment organizations studying health- care financing alternatives that received grants last year from the Bill and Melinda Gates Foundation. Freedom from Hunger received US$ 6 million and the Aga Khan Foun- dation received a similar amount for a Keystone/AP/P. Rahman Keystone/AP/P. five-year-long life insurance programme, Mohammad Yunus, this year’s winner of the Nobel Peace Prize, is pictured talking to people from a village with plans to add health insurance later. in Bangladesh about the benefits of the microcredit system. Yunus, the founder of Grameen Bank in These are two of several initiatives Bangladesh, won the prize for his pioneering work providing microcredit in the form of small loans to help across the globe that have sprung up poor people set up a business.

844 Bulletin of the World Health Organization | November 2006, 84 (11) News

For Freedom from Hunger’s MAHP education based on Freedom from were still often catastrophic; for another, project in West Bengal, India, the Hunger’s model. programmes that exclude the wealthy microfinance institution BANDHAN Participants, mostly women, are collect limited premiums and may not is developing an informal health given a micro-loan to start a business, be sustainable. Ranson also noted that education system to teach people how but periodic meetings — at which they the amount of money spent on hospital- to take control of their own health and make their loan payments — double ization may have been skewed by items how to access health services in their as education sessions covering health, that don’t carry receipts, such as bribes communities. This ef- nutrition, family plan- and gifts for health-care personnel. fort is combined with ning and sound busi- In Cambodia, the health ministry, an emergency health ness practices, accord- in conjunction with UNICEF and loan. The goal is to ing to Freedom from Médecins Sans Frontières (MSF), tried Freedom from turn an out-of-pocket Hunger’s web site. to address the problem of so-called Hunger’s programme payment to a pre- Such programmes informal payments, which add hidden in Burkina Faso, called payment system, can learn from previ- costs to medical care that aren’t reim- Réseau des Caisses ous attempts to address bursable by insurance. Populaires du Burkina which is not linked to health-care financing It did this by formalizing those (RCPB), is testing a your health condition issues. payments and making them part of the health-savings product and not linked with For instance, official process, which meant they were in which participants whether you use Michael Kent Ranson covered. In addition, such informal pay- put money into a health services or studied a programme ments were prohibited, but in return, medical savings ac- in Gujarat, India, run health-care workers got a bit more count and receive not. by the Self-Employed money. cards listing their Ke Xu, a health economist at WHO. Women’s Association’s With the blessing of Cambodia’s balance. Medical Insurance health ministry, MSF and UNICEF set Participants can Fund. up the Health Equity Fund, admin- take these cards to a local clinic or He looked at what effect reimburs- istered by an NGO specialized in the pharmacy and receive health services ing all or part of the costs of hospital- area, to step in and pay for health care or prescriptions, and the money from ization had on poor families and found for those who couldn’t. the appointment is automatically that health insurance reimbursement It turned out that, according to an deducted from their account. This way, more than halved the percentage of analysis of such a fund in Sotnikum, Reinsch says, patients don’t have to what he termed “catastrophic hospital- Cambodia, published in Health Policy worry about showing up with cash. izations”, that is, those that cost more and Planning in 2004, the Health In neighbouring Benin, Freedom than 10% of annual household income, Equity Fund’s main strength lay in pre- from Hunger is working with the non- and of hospitalizations that resulted in venting expenditures by encouraging profit Association Pour la Promotion et impoverishment. people to seek care before catastrophic l’Appui au Développement de Micro- This system helped to protect the illness. O Entreprises (PADME), which is looking poor, but problems remained. For one, Theresa Braine, City at a programme combining credit with health-care expenses even after coverage

Similar traditions exist across the Pakistan, Afghanistan look to women to improve health care border in war-torn Afghanistan, where maternal and under-five child mortality Women health workers have been vital in improving the health of women and children are high. More women — an estimated in Pakistan. Inspired by its neighbour’s experience, Afghanistan is embarking on a similar 1600 per 100 000 — die in childbirth programme to encourage women to work in the health sector. than in any other country, bar Sierra Leone, according to WHO. Child mor- tality is also among the world’s highest. Khalda Perveen ventures where trained some people don’t accept us and think According to WHO’s most recent doctors rarely dare to go. She is among that as women … we shouldn’t be estimates, 257 children in Afghanistan more than 90 000 Lady Health Workers working.” die out of every 1000 born. who are working to increase health Run by the Pakistani government’s Afghanistan has much work to do awareness and improve child and mater- National Programme for Family after two decades of conflict and neglect nal health across Pakistan, particularly Planning and Primary Health Care, — particularly during the 1992–96 civil in poor rural areas where three-quarters the Lady Health Workers scheme war and subsequent Taliban reign — left of the country’s population live. was launched in 1994 to reach out the country’s health system in tatters. “In remote areas where there are to remote, tribal communities where Now the country is embarking on no doctors, Lady Health Workers strict adherence to social and religious a programme similar to that of the Lady perform an important role: we go to customs has long hampered women’s Health Workers that is credited with areas where other health professionals ability to work as health workers and significantly improving health care won’t go,” Perveen, 29, said. “But still seek health care. across Pakistan.

Bulletin of the World Health Organization | November 2006, 84 (11) 845 News Paul Garwood Paul Shaban Rafik (in blue), a 20-year-old Lady Health Worker, consulting women in the town of Chikar in Pakistan which was badly affected by the October 2005 earthquake.

Great distances from homes to social barriers and distance, Dr Zareef areas. In some areas, the closest basic health centres, widespread illiteracy that Khan, Deputy National Coordinator health unit is seven kilometres from limits educational and employment as- for the programme, said in an inter- someone’s house,” Khan said. pirations of women, and tribal customs view with the Bulletin. But the Lady Health Workers pro- that forbid women to work or be visited The campaign started with 8000 gramme provides at least one worker by male heath workers compound workers in 1994 and now has 92 000 in every village with a population of at difficulties faced by many Afghan and across the country. By the end of 2006, least 1000 (or 150 households). Pakistani women and children seeking 100 000 workers will be in the field A. H. Jokhio, H. R. Winter and health care. and a further 10 000 should be intro- K. K. Cheng found in their study Due to these barriers, few women duced by 2008. published in the New use services that are provided by health Khan, an architect England Journal of facilities staffed by male health workers. of the health worker Medicine in 2005 that A 2002 survey found that only 40% of scheme, said Pakistan’s In remote areas perinatal and maternal Afghan basic health facilities employed high maternal and where there are no deaths decreased sig- female health-care providers. infant mortality forced doctors, Lady Health nificantly when female That is why Nagis, an Afghan the government to Workers perform an health workers helped woman aged in her 30s and who uses improve the delivery of important role: we go train birth attendants just one name, gave birth at home health services to the and connected them recently to a daughter who died several population. to areas [where] other to formal health days later. She said that during her preg- Prospective work- health professionals services. nancy she couldn’t go to the clinic in her ers do three months in- won’t go. “I am very happy village of Rabat, north of the Afghan class training to learn Khalda Perveen, a Lady Health Worker in the work that I am capital of Kabul, because there were no how to provide basic in Pakistan. doing because I am female doctors or midwives there. health services, such as raising awareness and “It is generally considered taboo here , im- working for humanity,” for men to treat women,” Nagis said. munization, hygiene, and maternal and said Sajda Yacoub, who has been a Lady Pakistan has been tackling the child health. Then they do a further 12 Health Worker in Pakistan for 12 years. barriers to women receiving basic months’ work experience in the com- Efforts to introduce similar health care by training an army of Lady munity, before being sent to a village in programmes in Afghanistan are taking Health Workers to raise health aware- the area where they come from. shape, but WHO predicts that it could ness among communities that are cut “Pakistan’s health system is unable be eight years before enough Lady off from hospitals and health centres by to cater for all the population in rural Health Worker-equivalents are in place.

846 Bulletin of the World Health Organization | November 2006, 84 (11) News

WHO’s representative in Afghani- Based on population data and gov- stan, Dr Riyad M. F. Musa Ahmad, ernment targets, Afghanistan needs up said maternal health-care services are to 10 000 midwives to deliver babies unequally distributed throughout the and manage life-threatening compli- country and most cations, according women, especially from to Ahmad. In 2002, rural areas, have little or Afghanistan had only no access to health care My presence 467 midwives. when they are pregnant here has encouraged The new initia- and give birth. more women to tive’s aim is to train In some remote 1200 midwives an- Afghan areas, female come [to this health nually so the 10 000 doctors and commu- clinic] … They feel target can be reached nity health workers more comfortable in no more than eight have been introduced dealing with female years. to provide obstetric and doctors. Afghanistan also gynaecological care, Dr Wahida Jalal Marzada, the first needs between 22 000

Ahmad said. female doctor at a health clinic in the and 84 000 female Garwood Paul Afghanistan’s Min- district of northern Salang, Afghanistan. community health Sajda Yacoub, who has been a Lady Health Worker istry of , workers, similar to in Pakistan for 12 years. with the support of Pakistan’s Lady Health partners including Workers, but to date who last year became the first female WHO and UNICEF, is training com- just 5000 male and female workers doctor at the northern Salang district’s munity midwives and female have been trained. health clinic. “They feel more comfort- community health workers to serve in “My presence here has encouraged able dealing with female doctors.” O the country’s rural areas, where 77% of more women to come [to this health Paul Garwood, Islamabad the population lives. clinic],” says Dr Wahida Jalal Marzada,

Since February 2005, life-saving Maternal health care wins district vote in Uganda ARV medicines have been provided free to patients in Uganda who are HIV One district in Uganda has dramatically reduced the number of womens’ deaths due to positive. pregnancy and childbirth. Now the government is considering how to extend the same Soroti district became the test level of maternal care to women to the country’s remaining 75 districts. ground for a pilot of the WHO programme, Making Pregnancy Safer (MPS) from 2001 to 2004, the central When Dr Godfrey Egwau, a consultant Many women across Uganda give principle of which is to make skilled obstetrician at Soroti Regional Referral birth without knowing whether they are care available for every birth. Since Hospital’s maternity unit, stood for HIV positive. then, the district has parliament in February, voters knew But pregnant continued to provide that if he won he would move to the women, like Connie*, this high level of ma- capital, Kampala, about 280 km who come to the Soroti Our rule is ternal care. Thousands away. hospital receive routine simple: for each mother of women like Connie Women in Soroti district weighed HIV counselling and have benefited. this and overwhelmingly voted for his testing. Of some 500 there must be a baby Uganda is one of opponent. Egwau, who dreamed of go- admissions a month, to go back with and for many countries taking ing into politics, lost the election. 30–40 test positive each baby, there must the MPS approach, Many associate Egwau with the and are provided with be a mother to go back including Bangladesh, high standard of maternal care pro- treatment to prevent Bolivia, Kenya, India, vided here. He is proud of the district’s transmission of HIV home with. Indonesia, the Lao record, but says the good work is not from mother to child. Dr Godfrey Egwau, a consultant People’s Democratic obstetrician at Soroti Regional Referral his achievement alone. When the 22- Hospital. Republic, the Republic “When I stood for parliament in year-old mother’s of Moldova, the Philip- the last elections, they refused to vote result was positive, she pines, Timor-Leste, for me, saying ‘this is our good doctor, was given medicine to the United Republic of he cannot go!’ It’s true, we have suc- prevent her from infecting her daugh- Tanzania and Zambia. ceeded, but we need to move away from ter, counselling, and she was put on “The success of the Making individualization,” Egwau said. antiretroviral (ARV) treatment. Pregnancy Safer initiative in Uganda

* not her real name

Bulletin of the World Health Organization | November 2006, 84 (11) 847 News Carolyne Nakazibwe Dr Godfrey Egwau talking to a mother who gave birth to her 8th baby at Soroti Regional Referral Hospital. is evidence enough that with proper Under the WHO programme, the Lord’s Resistance Army, Kayondo technical, financial and social support according to Egwau, 43% of women stayed on and drove out in his four- of whatever kind, and by working living in Soroti now give birth with help wheel drive to every pregnant mother directly with local governments and from a trained health worker, as op- in outlying villages who contacted him health managers, we can make a differ- posed to 26% before the MPS project by radio or village phone. ence,” said Dr Quazi Monirul Islam, started. The national average stands at Sometimes he fetches women Director of WHO’s Making Pregnancy 38%. The district has also recorded a 20 km away on bad-to-non-existent Safer Department. 100% antenatal attendance (at least roads. “They give me rough directions, According to a report entitled: one antenatal visit), Egwau said. ‘pass the village church and the big Making Pregnancy Safer in Soroti, Serere Health Centre IV, about 27 mango tree. It is the house nearest to presented by Egwau in km from Soroti town, the lake’,” Kayondo said. September this year, provides pregnant Of hundreds of pregnant women Soroti district reduced mothers with most he has transported since he started five maternal mortality We think MPS services, including years ago, two died during the journey from 750 deaths in (Making Pregnancy minor surgery. Women due to excessive bleeding. 2000 to 190 deaths Safer) is something are only referred to the “My business is saving lives. As long for every 100 000 live that can be duplicated main hospital in Soroti as my [ambulance] is okay, I am okay; births in 2006. if they need a Caesarian that is all that matters,” said Kayondo, “Our rule is sim- [in other parts of section or if there are whose ambulance was provided as part ple: for each mother Uganda]. major complications. of the MPS project. there must be a baby Dr Jacinto Amandua, Commissioner Serere has one Despite the lack of resources and to go back with and for Health Services at the Ugandan ambulance driver, shortage of skilled health workers, the Ministry of Health. for each baby, there Yusuf Kayondo, 28, principles of Making Pregnancy Safer must be a mother to who earns Shs 95 000 have been embraced in outlying parts go back home with,” (US$ 52) a month and of Soroti district. Egwau said. “It is an exciting thing to is on call 24 hours a day. Akoboi Community Health work in this district, because you see Even when the district suffered a Centre is run by a nurse who doubles results.” year of insurgency in 2002 by rebels of as midwife. It serves three villages each

848 Bulletin of the World Health Organization | November 2006, 84 (11) News with 25 community volunteers who scout for cases that need urgent medical attention and educate people about reproductive health, and other health issues. The centre has no running water or electricity, and has had no medicines since May, but it does have a bicycle ambulance that transports pregnant mothers to Serere Health Centre. According to one community leader, Akoboi used to lose 30 women a year in child birth while the last year has gone by without a single death of a pregnant mother. Beyond Soroti, maternal mortality is a major concern in Uganda’s 75 other districts. In 2000, average maternal mortality stood at 880 deaths for every 100 000 births. In Kampala, Dr Jacinto Amandua, Commissioner for Health Services at the Ministry of Health, said the government could adopt the MPS model across the country within the existing health budget. Amandua said the government has been recruiting more health workers and purchased 163 ambulances over the last two years. Access to health centres within 5 km radius has also im- proved from 49% to 72%, according to the health ministry’s Demographic Health Survey. “We think MPS is something that can be duplicated [in other parts of Uganda]. It is something for which investment in health is necessary,” said Carolyne Nakazibwe Amandua. O Bicycle ambulance transporting a pregnant mother from Akoboi Community Health Centre to Serere Carolyne Nakazibwe, Soroti Health Centre.

Bulletin of the World Health Organization | November 2006, 84 (11) 849