DEVELOPMENT PARTNERS IN HEALTH: A BLESSING OR A THINLY VEILED INJUSTICE?

The financial year 2016-2017 has not been a rosy one at the Ministry of Health. It has been hard hit by industrial action by health workers with no end in sight, rocked by financial scandals of mammoth proportions and now, withdrawal of financial backing by development partners. The health sector is in a very difficult space right now, and there does not seem to be a clear road map to reverse this situation.

But, while donors and development partners have, for years, supported and continue to support important pillars of our health, what has this meant for us as a country? Our babies have been able to access life-saving vaccines, our HIV-positive patients have been able to access life-saving anti-retroviral drugs, our tuberculosis patients continue to access medications that have kept death at bay and malaria prevention, treatment and research has been sustained for years.

However beyond all these key interventions, there are a multitude of others whose benefit is not very clearly visible. Some of them may be interpreted as outright discriminatory. Why do I say this? It is shocking how health interventions are classified according to economic regions. Therefore, the first world gets to have the best evidence-based interventions adopted as guidelines and then variants of these are made for the aptly named low-income countries. 

This implicitly implies that if you are deemed to be poor, you do not have a right to the highest attainable standards of care, but rather, are made to do with what you can afford. This has been entrenched in our country as public hospitals and low-level private/faith based institutions adopt what are deemed as cheaper alternatives in health care and international good practice in only available in the high-end private facilities.

This is demonstrated in the day to day patient care. A mother receiving ante-natal care in a private facility will have at least two ultrasound imaging tests done in the pregnancy duration as part of standard care, the one in the public hospital care system will find out her baby has an abnormality after delivery. Even the health workers undergo a mindset switch when they move from the public hospital to the private in the line of duty. They literally feel spoilt for choice when they can access all the diagnostics and treatment options that exist as a stark comparison to the make-do in the public hospital.

On the larger scale of things, the same thinking is adopted for countries. It is therefore not surprising that Europe, North America and Australia will always have the best treatment guidelines while make-do options are adopted for Africa, Asia and South America.

A common example of the above was HIV care. In the high income countries, HIV positive patients were initiated on treatment at a higher CD4 count (a measure of the strength of your immune system) than in the low-income countries. Soon after, all patients were initiated on treatment once diagnosed as HIV positive irrespective of their CD4 count while in Kenya, we stepped up the level instead. It took years to adopt treatment for all, despite evidence showing that all patients should be treated. Why does this happen? Because as a country we are not paying for the drugs ourselves. We are relying on donor support for such a critical aspect of health. For this reason, the donor will dictate what happens.

Another one close to my heart is the issue of cervical cancer screening. First world screening protocols depend on cytology (pap smear), Human Papilloma Virus screening and biopsy of abnormal looking lesions as a gold standard. As the third world, we have been told we do not have capacity to do the same because we do not have enough pathologists to read our biopsies and that we cannot afford HPV testing.

Instead, donor money was spent adopting a visual inspection method as a cheap alternative, protocols were developed and hundreds of thousands of dollars spent training thousands of health workers across the country on how to do it. Then came the part where the ‘See and treat” method was adopted as a one-stop shop to prevent cervical cancer: the woman came for screening, the health worker would visualize the cervix and if it appeared abnormal, he/she treated instantly with a hand-held freeze gun that killed off the abnormal cells (cryotherapy).

This method has been widely justified as being cheap, with better compliance and on the spot diagnosis with subsequent immediate treatment. The development partners have given themselves a pat on the back for enabling what they regards as ‘lower cadre’ health workers to do what is otherwise the preserve of specialists in their world.

So, why are specialists not warming up to this cheap grand invention? Because when all is said and done, they are left cleaning up the mess. No self-respecting female gynaecologist will opt for cryotherapy treatment option for their own care because their teaching taught them to rely on scientific evidence. Cryotherapy destroys the abnormal lesion and does not give the doctor something to take to the lab to confirm that indeed it was not cancer (which is the whole purpose of screening). Now, as cases of women who have undergone cryotherapy, come back to the gynaecologist with full-blown cervical cancer are on the rise, what does this say?

We must admit that cheap is necessarily cheap. If our problem is inadequate pathologists, why not spend all that money giving scholarships to deserving doctors to train? Why not pump it into equipping county hospitals with pathology labs instead? Let our nurses do what they are good at and trained for, educate women, counsel them, screen them and refer them to get the highest attainable standard of care which in this case includes utilizing the services of a pathologist.

It is time our Ministry of health called out this donor bluff. If there is money to be spent, let it be spent where there is need, to attain the highest attainable standard of care. A patient with a medical condition is a patient irrespective of their geographical location and economic background. The world hasn’t invested in all the expensive research so that we can selfishly water it down for those we regard as third rate patients. It is immoral, discriminatory and goes against the very basic foundation of human rights.