Market failure or informational asymmetry in weak health systems of one of Ebola-stricken West African countries: What can the private sector do?
The Sierra Leone health system is currently heavily challenged by the Ebola Virus Disease (EVD) outbreak. The first case of Ebola was identified in Sierra Leone in April and May 2014. In July 2014, a national emergency was called by the President’s Office Since then, a total of 8600 cases were confirmed and 3538 deaths are reported. .
This outbreak crisis has revealed several weaknesses of the health system; one can mention weak early response mechanisms on contagious/infectious outbreaks, shortage of health workers, a practically inexistent referral system, weak health information and a very centralized health system. The absence of equipment and supplies has led to some closure of some health facilities while they were critically needed.
While customer care has been qualified very poor in public health facilities, the EVD outbreak has contributed to the loss of trust of patients and the population in the system. The health system has also been underfunded and remained vulnerable to shocks from health emergencies despite lessons learned from a cholera outbreak two years earlier.
The government has embarked on an ambitious post-Ebola health sector recovery plan and in collaboration with regional and international development partners and donors, more efforts are being made to build a more resilient health system.
While I am here for a short term assignment, given my usual search for why and what to do, I am more curious and want to understand in a supply and demand perspective the market mechanisms of the country’s health system and the possible impact on its performance. Once more, in such circumstances, one would think that the health need priority number one for a lay person would be their concern about the people dying or affected by the disease. To my surprise, this is not the case. One of several locals I had opportunity to talk with revealed to me that the Sierra Leone Health Systems is typically characterized by a lack of customer care, unethical and unprofessional behaviour of some health professionals, and last and very crucial one, financial barrier to access to basic health care services in the country.
They went further to tell me that given they and their family, although with very limited financial resources, have never visited and will never visit the public health facilities because of their worst customer care services.
This struck me when more than 95% of health care providers in the country are publicly oriented facilities. Furthermore, a free care policy has been implemented since 2010 for under five children, pregnant women and lactating mothers, with tangible outcomes on the utilization of services for this target population but there are long ways to go to insure universal health access for the population.
In 2010, the out of pocket expenditure accounted for about 68% of total health expenditure, which was the highest in Africa and 88% of households reported cost as the main barrier to access health services in 2008.
So then what can the private providers do or how can they invest in health sector in this country?
The pluralistic Sierra Leone’s health service delivery system is dominated by government-run health service providers, with some faith-Based Organisations, local and international NGOs and the private sector all providing services, the latter in urban area. There are public, private for profit, private not-for-profit, public-private partnership and traditional medicine practices. When compared to other countries in the region such as Ghana, the private sector in Sierra Leone is underdeveloped.
The 2010 Basic Package of Essential Health Services identifies the services to be guaranteed, the minimum staff required, defines technical and management competencies, the essential drug list at each level of care. This is also in the context of decentralization the Local Government Act of 2004. Despite this, the Sierra Leone healthcare system is still over-centralized, under-funded and under-staffed.
Although no information is yet available, I came to know dual practice is allowed given the critical shortage of specialist doctors in the country. Is the supply of health workforce enough to the market demand? The answer is no. Is population able to pay? At the moment, this is not a problem, the problem is about access to care due to lack of health personnel, of drugs, of attention and specialized and diagnostic services. These are some of failures where the private sector can chip in. However, more sound research is needed. One important note: the environment is very conducive in an economy promising to grow.
The country’s main economic sectors include mining, agriculture and fisheries. The agriculture sector accounted for 51% of the country’s GDP in 2010. Sierra Leone’s manufacturing sector continues to develop and consists mainly of the processing of raw materials and of light manufacturing for the domestic market. The service sector has been growing mainly due to a number of commercial banks and telecommunication companies entering the market. And there is much potential for growth in several sectors including health sector.
The author, Dr Alex Hakizumana, MD MPH MBA is a Consulting Partner with BlueCloud Healthcare.