Could Elizabeth Have Been Saved?

Why Health Systems Matter  

Elizabeth was Mary’s seventh child. She died at the age of three due to complications of malaria on February 17, 2008, at a clinic in San Pedro, one of the poorest municipalities, in a hypothetical but all-too representative country. Why did Elizabeth die? What does health system strengthening have to do with saving her life? Elizabeth’s death had everything to do with a broken health system in desperate need of repair.

The single disease. Why Elizabeth died perhaps seems obvious. She caught malaria, developed a cerebral form of the disease, and a common, treatable infection killed her. But why Elizabeth? Had her family not received free bed-nets to prevent the infection? Was she not diagnosed and treated in time? What happened?

The broken system. Finding out why Elizabeth died took so much time that Dr. Joy Macumbo, the local public health authority, almost gave up trying. So many children die every day in her district, how could she spare time to investigate just one? Finding out anything was so hard. There were almost no records of Elizabeth’s last few hours in the hospital or of her previous health history in the clinic. Dr. Macumbo was puzzled. According to her district data, for three years San Pedro, Elizabeth’s town, had been receiving free bed-nets and antimalarial drugs from the Ministry of Health (MOH). However, the district hospital was still reporting many cases of complications from malaria from the San Pedro area. Dr. Macumbo went to San Pedro to investigate.

Dr. Macumbo discovered that the health center where Elizabeth should have received a bed-net and been diagnosed and treated early-on, had not had a health worker for at least 18 months. Bed-nets and drugs arrived from the MOH program, but often nobody was there to distribute the nets, and no one was there to diagnose and treat the patients. Some community volunteers helped visiting health workers catch up with distribution and treatment, but there were no guarantees (or records) of whether drugs had been stored properly (so they stay active) or administered correctly to San Pedro’s children. In some cases there were no records of what happened to the free bed-nets. Elizabeth had either not received (or used) a bed-net, and had either not been diagnosed and treated in time or had not received treatment at all.

Why had the health center gone so long without a trained health worker? Dr. Macumbo asked San Pedro’s mayor—management of health centers had been decentralized from district to municipalities five years earlier. Any trained health workers San Pedro managed to hire did not stay long in the poor town. The mayor said the job had been advertised for months, but the few qualified applicants did not want it. Working conditions in San Pedro were much harder than in South Port, the district capital, but the pay was the same under civil service regulations.

To make matters worse, health workers on the center’s payroll often showed up late—because, the mayor discovered, they were moonlighting during the center’s working hours. Some small, private providers paid them case by case, a supplement to their monthly salary.

The scant records from Elizabeth’s stay at the district hospital and interviews with her mother Mary and hospital staff showed that Elizabeth, with very advanced malaria complications, had arrived at the hospital on a weekend, long after the onset of the symptoms. Why did she arrive so late?

Elizabeth’s mother said she could not afford to take her children to the hospital on a weekday. Dr. Macumbo was surprised—public hospital services are free in San Pedro. However, Mary said she had to sell one of her two cows and borrow money to cover expenses related to Elizabeth’s sickness. A trip to the hospital takes a full day because doctors show up late, so Mary would lose a day of work. She had to pay for transportation, under-the-table fees for treatment as well as for additional supplies (antimalarial drugs are free but the supplies are not). Years ago when her first child died, Mary endured a similar financial catastrophe. The community mutual aid scheme she joined after the death of her second child had gone broke after only three years.

Around the world every day, there are thousands of cases like Elizabeth’s. Strengthening health systems is vital to prevent other deaths like Elizabeth’s. It is about ensuring that the international community’s commitment to supply a San Pedro with bed-nets and drugs will not be wasted by the wrong chain of events. Strengthening health systems is about setting up the right sequence of events so that others survive.

The right chain of events. The right sequence of events might have saved Elizabeth. Strengthening a Health System can mean:

Ensuring the right logistics so that bed-nets (and other drugs and supplies) will reach the poor families at risk and that antimalarial drugs will not lose potency through poor storage.

Helping the government change salary incentives so that workers show up for work at health centers to diagnose and treat children, and at the same time, at a marginal cost, conduct well- child consultations, educate parents, and distribute micronutrient supplements to expectant mothers (to help prevent low birth weights and malnutrition, which compound the effects of malaria), and deliver other services.

Enhancing public-private partnerships (e.g., with community and / or faith-based organizations) in the delivery of services to complement each other and reduce supply gaps.

Setting the right payment mechanisms for providers, linking workers’ salaries to both attendance and performance and reducing incentives to spend health center and hospital time on income-generating activities outside their workplace.

Instituting governance arrangements that empower patients and the community to address issues such as informal payments and provider responsiveness.

Setting the right insurance and / or public financing mechanisms (including donor financing) so that the cost of illness will not prevent a mother from taking a sick child for treatment and will not throw her and her family into destitution, forced to sell family assets.

Taking advantage of decentralized decision making and management while, simultaneously, putting in place compensatory mechanisms for capacity and equity issues.

Having many more doctors and dedicated health professionals like Dr. Macumbo, so that countries and districts can identify and follow systemic problems without needing external assistance.

Having information systems that address all the key diseases so that doctors and health personnel can treat patients instead of filling out multiple, duplicative reports for each disease to each donor, government agencies.