Kenya: Healthcare hurdles in Nairobi’s slums

Quality healthcare is a luxury often beyond the reach of those who live in Nairobi’s slums, such as mother-of-seven Grace Awour Opondo.
NAIROBI, 11 July 2008 (IRIN) – When you are sick you buy medicine from the local shops,” Opondo told IRIN. “If you are lucky you recover because the medicine is not usually the right one.

“Sometimes there is no medicine even in the hospitals, so they send you out with a prescription,” she said. “Then the chemists are expensive so often one has to make do without the medicine.”

According to Sakwa Mwangala, a programme manager with the African Medical and Research Foundation (AMREF), the fact that people are squatting on government land often prevents them from accessing essential services. Slums are regarded as informal illegal settlements, which means they are underserved in terms of infrastructure development and access to basic amenities.

“Government health facilities are also not easily accessible for most slum residents,” said Mwangala, who heads AMREF’s Kibera integrated healthcare programme. Kibera, on the southwestern edge of central Nairobi, is one of the largest and most densely populated slums in sub-Saharan Africa.

Most people operating health “facilities” in the slums are quacks, he said. “There is a lack of quality control, with the people in most of these clinics lacking skills.”

The urban poor fare worse than their rural counterparts on most health indicators, according to a report, Profiling the burden of disease on the residents of Nairobi slums prepared by the African Population and Health Research Center (APHRC).

Pneumonia, diarrhoeal diseases and stillbirths account for more than half the deaths of children under-five, while HIV/AIDS, tuberculosis, interpersonal violence injuries and road traffic accidents account for more than two-thirds of deaths among people aged five years and older, stated the report.

The poor health status of slum children is in part due to continuous exposure to environmental hazards coupled with a lack of basic amenities.

“The chances of one becoming sick are high because of the poor sanitation; most of the houses are also poorly ventilated,” according to Leonard Wawire, a teacher in the Mathare slum.

Changing the way we buy medicines

Researchers in the United States propose consumers buy yearly ‘medicine licenses’ as new way to pay for prescriptions.
Changing the way consumers pay for prescription medicines so that the system more closely resembles paying for cell phones or computer software could increase medicine use without altering patients’ out-of-pocket spending, health plan costs or pharmaceutical company profits, according to a new RAND Corporation study.

Researchers propose that consumers pay an annual “license” fee that would entitle them to a year’s worth of medicine for each prescription they take on an ongoing basis, with a very small or no co-payment for each monthly supply.

Such a system could be used to pay for medicines that treat chronic conditions such as high cholesterol, diabetes or asthma without increasing the cost to consumers and may reduce the periods when patients go without such medicines because of the cost, according to a study published in the journal Health Affairs.

A new way

“We propose a fundamentally new way for consumers to pay for medicines that are taken for long periods of time to treat chronic health conditions,” said Dana Goldman, corporation chair in health economics and director of the Bing Centre for Health Economics at RAND, a non-profit research organization. “We believe this approach can help improve patient care without costing anyone more money.”

Researchers suggest that a pilot study be organized with the cooperation of health insurers and medicine manufacturers to test the benefits of the proposal.

The “two-part pricing” scheme outlined by researchers is used to pay for products in many areas outside the medical world. Payments for Internet service, cable and satellite television, all-you-can-eat buffets and country club memberships are all examples of the pricing plan. Consumers pay a set fee to cover a period of time, with unlimited access to the services. Consumers can use as much or as little as they need.

Maybe the best example of the pricing plan is computer software, researchers say. Instead of paying a fee every time a computer is turned on, consumers pay a one-time fee to buy a license for unlimited use of a company’s computer software operating system, for example.

Low production costs

What makes pharmaceuticals similar to these products – and different from other health services – are the very low costs of production and the existence of few good substitutes, researchers say.

The article in Health Affairs outlines how a medicine-licensing system might be used to pay for statin medicines – the most-popular form of prescription medication used to treat high cholesterol. Researchers examined the current costs of the medicines and how the new pricing plan might affect patient compliance – whether patients are taking medicines as prescribed by their physicians.

Researchers propose that consumers pay a $195 fee for an annual license for the statin medicines – equal to what most consumers now pay out of their own pockets each year if they have insurance plans that require $25 per-prescription co-payments. Insurance companies would pay an additional $374 to pharmaceutical companies for each statin license.

Because there would be no monthly out-of-pocket payments for consumers, researchers suggest that patients would be more likely to take their prescriptions. Analyzing past research about the impact of rising co-payments on patient compliance, researchers suggest the average annual use among patients taking statins would climb from 7.8 months to 9.8 months under the new pricing plan.

The increased use of the medication among patients may result in fewer long-term health problems and lower overall costs to insurance providers, according to the study.

Make it easier to pay

“The up-front cost may discourage some patients from starting medicines, but that could be overcome by allowing monthly payment plans,” Goldman said. “Research suggests that eliminating or greatly reducing co-payments for individual prescriptions will encourage patients to stick with their medicine regimes and that will improve the quality of medical care.”

Spending on prescription medicines has outpaced the growth in total spending on health care in the United States, growing 10% from 1998 to 2003 compared to 5% growth in all health care costs.

Rising medicine costs have caused many insurance plans to increase the co-payments made by consumers, leading to greater concerns about patients skipping medications because of cost. Physicians regularly distribute free samples to patients and some insurance plans have even begun requesting that enrollees engage in pill splitting – dividing higher-dose tablets to avoid buying additional prescriptions.

Cote d’Ivoire authorities work to stamp out uncontrolled sale of medicines

People in the Ivorian commercial capital, Abidjan, can be seen leaving the doctor’s office, prescription in hand, heading not to the pharmacy but to Roxy market in the Adjame neighbourhood, where the same medicines can be had for a fraction of the price.
That is a problem, according to health officials who recently launched a campaign to stem the uncontrolled sale of prescription drugs.

“When people buy medicines in the streets it poses many problems, including inappropriate medicines for the condition, incorrect dosage, lack of knowledge of interactions with other medicines, and lack of surveillance by a medical professional,” said World Health Organization spokesperson Daniela Bagozzi.

She added, “It’s part of an overall problem of the supply of quality medicines in the developing world.”