How can birth outcomes be improved in regions plagued with sexual violence, mass killings, and low levels of security? In countries such as Liberia and the Democratic Republic of the Congo (DRC), war has consumed the nations for past several years. Maternal mortality rates are among the highest in the world and many women are not able to seek medical care immediately after experiencing sexual and/or war-related violence. So many of the citizens in these countries have limited socioeconomic resources and therefore are unable to seek assistance in times of despair. Aiding those most in need in these countries should be a top priority in the field of maternal care.
Establishing clinics like in the Liberia case study seems to be a very promising solution, however, I worry about the fees placed by Ruth on her patients. I understand the need to provide income to sustain the clinic and supplies, but I worry that many individuals, especially in times of war, would not be able to afford any type of medical care. Would there be any effective way of running a clinic like Ruth’s without having to charge patients with a fee for goods and services?
You raised a good question. I think there is a tough balance between wanting to help people by providing free care, but also making something that is sustainable and valued. Having to pay a small amount can actually make people value the service more. But especially in a war situation, this can be particularly tricky. It seems that in this case in Liberia, the clinic had a pretty good system in place, as it did reduce charges for particularly impoverished families, and reduced costs if a women had had antenatal care, thus providing a good incentive. I know that at the hospital my dad was working with in DRCongo, there was a fee for services, in order to try to make it sustainable. But, if someone couldn’t pay, they could leave an object of value of theirs, get the care, and then hopefully one day later come back and get their object and pay it back. This way even if someone only had an extra old cloth, she could leave it and get care. I think that the most sustainable method is to have a clinic with some fees (that may be partially subsided from an outside source), and maybe also to have a fund in order to help those who cannot afford it. But its a tricky question. Other thoughts?
Erik, I agree with Valerie, you raised an excellent question. I think it is important to think about payment, even in small clinics like Ruth’s, in times of war. As Valerie pointed out some payment is needed to sustain the clinic and create value. The payment system Ruth set up in Liberia seemed to work pretty well with reducing prices and giving incentives. People were still able to come in and receive services even during the war. But one way a clinic may run effectively without having to charge fees would be to run the clinic solely on donations or setting up a deal with supply and pharmaceutical companies. However, this may be difficult in times of war when these companies may be facing financial struggles themselves. The clinic I previously worked at had a sliding scale that would be used if patients could not pay the full amount or did not have insurance. At least I think this is how it worked. I didn’t deal much with billing. This may be how the sliding scale works, but what if in times of war or economic struggle, a clinic based fees on the individuals income. They pay a small percentage of their monthly income. A percentage that is reasonable but still affordable for the patient. This way the clinic is still receiving funds for supplies and the family is not spending beyond its means. I do not know the in’s and out’s of economics or financing so this may not really be feasible or already established and it could easily create problems. Like Valerie said this is a tricky question, but the topic of payment during war should be discussed. Especially since so many countries are going through internal and external wars right now.
Everyone seems to bring in a different point regarding payment for services at a health clinic.
Val’s example in the DRC sounds really neat. Did most people come back to get their prized item back? What would happen if they never came back for it? What would the clinic do with those items then? I know long-lost luggage in America often gets sent to different stores (Alabama has one), sold, and then the profits (although I don’t know what percentage) get donated to different charities.
I often think of sliding scale services here in the US, but Lorraine brought it up in the global setting. It sounds like a great idea, but it may be difficult. In my experience, we’ve had patients bring in recent (last 1-3 months) pay stubs to see where they fall on the sliding scale. This may not be feasible in countries where pay stubs are not offered. Going by someone’s word of what they make can also be a tricky aspect to navigate. It does seem reasonable for Healthline Clinic to charge a small fee for different things on the menu. I think they created these fees to reasonable for all people who wish to partake in services.
This reminds me of the $3 co-pay that some public health insurance plans require. Many would agree that $3 is not going to put a dent in someone’s budget or wallet. Oftentimes, my families ask why the weird $3 co-pay? When I was training at the front desk at a pediatrics office, I learned that it was to help defray the cost for health insurance companies (somewhat), but it was also mainly to keep people in check with their doctor’s visits. You wanted it to be enough that people didn’t abuse their insurance plan but low enough that they wouldn’t go broke seeking services for a chronic illness/multiple follow up visits. In my mind, I think Ruth’s and Tage’s fees are the equivalent of a $3 co-pay or $25 office visit.
According to a nurse I met this summer, a lot of the HIV/AIDS drugs in Vietnam are provided by funding from other countries (Australia, Japan, Korea). This is also a sustainability issue because these countries may want to refocus their funds someday on something else, somewhere else. When I asked the nurses and doctors in Vietnam what would happen if these countries pulled their funding, they didn’t really have an answer. They said they would get help from other countries. I think that focusing on prevention would decrease the incidence and prevalence of HIV/AIDS to a level where Vietnam can provide its own medications for its people. Education and prevention can definitely play a key role in sustainability.
I think this topic is very interesting and will be something we will debate for years as various countries continue to be at war. The idea of some sort of payment/co-pay whether it is monetary or something of value, is an excellent idea in theory. In the context of war, especially long-term war, I don’t know how sustainable it can be. In places of war, people are extremely vulnerable. When I was in South Sudan, hospitals were places that were targeted and burned to “disarm” the other side to tend to treating their civilians. Of course, its more difficult to get supplies in time of war. As well, not all hospitals can be available to treat both sides. This is why I think so many places of war have turned to global organizations such as the UN or humanitarian workers that have the funds and the perspective to treat the civilians.
When places are devastated by war, entire communities are devastated in this way as war destroys infrastructure. Similarly, when places are devastated by epidemics, such as the Ebola outbreak in West Africa, infrastructure is destroyed. Hospitals may not be burned, but the fear inhibits people from coming.
That said, in Ruth’s case in Liberia, the monetary implementation was necessary for the continuation of the services, but I think its important to remember the long list of other external factors at place in this setting.