Families stay together at Angkor Children's Hospital Siem Reap.

Healthcare for the helpless

26 March 2013

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Belinda Lawton is a PhD candidate at Crawford School of Public Policy. Belinda is a communications specialist who has worked with several health-related NGOs in Timor-Leste, Bangladesh and Thailand.

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Not-for-profit medical providers are the last best hope for people needing care in developing countries. So why are they underfunded and neglected? By BELINDA THOMPSON.

As the minutes tick by, the distance between life and death gets shorter. The family have walked for days, child in arms, desperate for medical help. With no money to spare, if the care isn’t free their child will almost certainly die. And so they walk and hope that at the other end someone will help them.

In developing nations, a desperate plight with a potentially fatal outcome like that is a common experience.  While in Australia and other developed countries a wait in outpatients of ten hours is a national media scandal, in the poor countries of the world the government healthcare dollar is spread wafer-thin and simply doesn’t reach the average person.

So who fills the healthcare gap in nations unable to look after their own? Not-for-profit hospitals and large-scale clinics end up sandwiched in between over-stretched government services and financially out-of-reach private practices.

Yet they are still viewed as the poor cousin of the heath care world, often struggling to exist and relying on the kindness of international not-for-profit groups for their survival. That status affects every aspect of their operations. From accessing funding from donor governments to linking in to opportunities for free or subsidised human resources and equipment, the lack of recognition of these health facilities limits their ability to provide services. 

Having worked with not-for-profit injury prevention experts, The Alliance for Safe Children, in Thailand and Bangladesh, followed by a stint at Director of Corporate Affairs for the Hospital of Hope Timor-Leste, I’ve seen how desperately these not-for-profit healthcare services are needed.

So in the post-Millennium Development Goals world why aren’t they being heralded as an asset for local health care?

For a start, there isn’t much data about these hospitals and large-scale clinics. Try finding a comprehensive list of them. At least in the public sphere, there isn’t any register that captures where they are and what services they are providing.  There’s no neat association, no coordinating body, no one tasked specifically with looking out for them and furthering their capacity.

There is also no cookie-cutter model of what these facilities look like, in part because they’ve generally grown out of a specific response to a local need. Some, like the Bairo Pite Clinic in Timor-Leste grew around one personality who just pulled their sleeves up and started providing health care post-independence. That drive to help drew other people in; now the team treats 300 people a day and has 50 local and international staff and volunteers.

Others, including the Addis Ababa Fistula Hospital, have worked closely with the in-country government and now boast multiple sites and the capacity to train staff in the treatment of obstetric fistulas across geographic borders. These comparatively large and successful operations have also spawned dedicated fundraising arms which have allowed them to expand and thrive.

The ways they service their communities are as disparate as their pathways to existence. Some wait for patients to come to them, or run occasional outreach clinics. However, with no one over-arching organisation or government setting the rules and the ability to negotiate their service provision model at a local level, innovations like floating hospitals have also appeared.   In Bangladesh, the Lifebuoy, Emirates and Rongdhonu Friendship Hospital literally float from location to location taking health care to the people.  

Such innovations in service provision are a double-edged sword. Without the administration engine rooms that come with scale and growth, the less-developed hospitals and large-scale clinics are often perceived by developed country funders as having limited formal accountability. As a result, risk-averse funding bodies are wary of entrusting government funds to them.

Another major issue is their relationship with national government. Where every dollar counts, some governments view them as cutting into their funding pie, rather than potentially growing the available funds from donors for health care. Others have stepped on government toes, or never managed to develop a close enough relationship with the health care bureaucracy to have healthy dialogue. 

Added to these issues, there isn’t a common understanding of what we’re talking about. We’re missing a step at the very outset - the question of what’s in a name. Does not-for-profit mean free, or subsidised, or just direct cost of treatment without additional charges tacked on? Should government funded services be lumped in with other not-for-profit services? Are private not-for-profit facilities the same as non-government, free services? At what point in a developing country context is a not-for-profit facility bumped from clinic status to hospital status? Is it number of beds, number of patients seen, staffing levels, operational structure, the sophistication (or otherwise) of treatments offered or some combination of all of the above?

So this is where my PhD begins. After years of reading and searching from the sidelines, I hope over the next three years to contribute research which at least starts the journey to clarify some of the knowledge gaps around these valuable organisations.

We owe it those people in the developing world who would think a 10-hour wait in the Emergency department is a small price to pay for proper healthcare, to do all we can.

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