Foreign Policy Blogs

Who is playing God here?

Who is playing God here?

Photo credit: HDPTCAR, Flickr

First, I want to welcome Julia Robinson to Global Health.  Julia joins us with a diverse background in health advocacy and development work – most recently in South Africa working at mothers2mothers and previously in Sierra Leone at the West Africa Fistula Foundation.  As a passionate advocate for women’s health rights and with a lens of social justice, Julia’s voice will be a welcome complement to my more pragmatic and business-minded approach.  Julia’s focus will be human rights and health – a duo that are often like “ships passing in the night“, as her post yesterday eloquently described.  Welcome Julia!

I considered writing today about the US federal budget, which is steering towards a breakdown if compromise can’t be reached by this Friday April 8th.  The current Republican budget proposal represents an 11% cut for global health programs, and a 43% reduction in funding for HIV/AIDS programs.  USAID Administrator Rajiv Shah estimates that these cuts will result in 70,000 childhood deaths as current programs for malaria and immunization are curtailed.

But I actually want to focus on something a bit more personal.  (I’ll get back to the budget cuts, don’t worry.)  Recently I’ve been spending a bit more time at the doctor’s office – I’ll leave the details for now – but it’s been triggering some thinking about healthcare and personal choices.  You see, I’ve recently married a South African and was privileged enough to be able to sign up for my husband’s comprehensive employee health insurance – a luxury that I was previously unable to afford as a freelancer and small business owner in the United States.  The South African health system has some similarities to the US  in that there is a vast disparity between what is available to insured and uninsured patients.  The South African system, however, also has a relatively functioning public health system which provides primary healthcare for free to all South Africans.

So here’s where choice comes in.  When faced with the dilemma of where to go for my healthcare needs, I called several doctors in private practices and was given a similar story.  I would be given options for every health service I could possibly desire, but I would need to pay out-of-pocket and be reimbursed by my insurance up to the government-listed price, and the rest would need to be subsidized by me.  So far, so normal.  But wait a second?  I’m accessing services that are only available to a minority of South Africans – more than 80% of all South Africans are accessing public services for healthcare.  What would this scenario look like for an uninsured woman seeking healthcare?

I started digging around a bit.  The good news is that access is not a problem: for example, 97% of women receive antenatal care in South Africa, and 71.4% of these women go on to attend 5 or more antenatal visits (source).  But what options are available when a person accesses the public system?  Spending statistics give us an idea: the state purchases only 24% of the total national spending on drugs, meaning that 76% of drugs are being purchased for private consumers of healthcare (remember, that’s just 20% of the population).  Employment statistics can also give us a view: most nurses work in private hospitals (exact statistics unknown) and 40% of all pharmacists work in the private sector.  And my personal experiences visiting South African facilities brings to mind the crowded waiting rooms and overworked staff.  Imagine what sort of choices these women face when experiencing crowded and under-funded facilities, lacking health care staff, with relatively little access to medicines.  And South Africa, as I’m continually reminded, is a best-case-scenario in comparison to many developing countries.  (Anecdotally, another South African friend of mine who is currently uninsured has chosen to visit a relatively inexpensive midwife and pursue a home birth – rather than access a public facility.  Her income allowed her to choose – albeit in a more limited way.)

When living in the US, my scope of interest was limited to my own inability to access primary healthcare while uninsured.  My few visits to the doctor were fraught with fear of hospital bills and payment plans, unsure as to what the cost would be at the end of the visit.  Given this experience, I applaud any country that has opened the public purse to provide free primary care for their citizens.  But the questions don’t stop there.  Every country in the world, rich or poor, is grappling with the same questions: How do we decide what constitutes a right versus a luxury?  As treatments become increasingly efficacious (and often correspondingly more expensive), who decides who gets what? 

Who is playing God here?

In some cases and some countries (medical tourism, the USA), the market decides.  In others (interestingly, the UK’s NHS website is called “NHS Choices“), the market is tempered with a public system that functions well.  And, finally, in countries where USAID delivers its funding, the political whims of donor countries get to decide – this includes the public health system of South Africa, which receives considerable funding from USAID through PEPFAR.  (I told you I’d get back to the federal budget.)

I’m livid with the current budget proposal and the decisions by the US Government that it represents.  I’m distressed that global health funding in whole is flatlining due to economic uncertainty, which in real terms means decline (as populations grow).  But look beyond the austerity measures and I see systems in crisis: the fact that the choices of pregnant women in South Africa are subject to the whims of a political system in which they have no voice, that impoverished people the world over will be affected by an economic crisis of which they played very little part – even the much less significant fact that I had to move to South Africa and get married to be able to access healthcare of an affordable sort – these are symptoms of systems in freefall. 

Should an individual’s health choices rely on market forces?  An innate ability to accumulate wealth or a mother or father who possesses such a talent?  Warren Buffet’s “ovarian lottery“, which includes the luck or misfortune of the country in which one is born?

Or can we come up with a system that is more equitable, more distributive of the intellectual and human resources – many of which defy the law of diminishing returns – that we have at our disposal?

We are a smart globe.  We can come up with something better than this.

 

Author

Cynthia Schweer Rayner

Cynthia Schweer Rayner is an independent consultant and philanthropy advisor specializing in public health, social entrepreneurship and scalable business models for positive social change. As a recovering management consultant, she spent several months living in South Africa, and later co-founded the US branch of an organization providing support to orphaned and vulnerable children. In 2009, she was an LGT Venture Philanthropy Fellow, working with mothers2mothers (m2m), a multinational non-profit organization employing mothers living with HIV as peer educators to positive pregnant women. She currently works with individuals, companies and nonprofits to finance and develop models for positive change. Cynthia has an MBA from INSEAD and a BA in English Literature from Georgetown University. She currently lives in Cape Town and visits New York frequently, where she co-owns a Manhattan-based yoga studio, mang'Oh yoga (www.mangohstudio.com).