Making health access more equal

steth

There is a growing move at the international level towards universal health coverage (UHC) as an essential way of reducing financial impoverishment caused by spending on healthcare and of practically ensuring that everyone obtains full and equal access to key health services. For many developing countries, the main way of achieving UHC has been through the adoption of Social Health Insurance Schemes.

In 2003, Ghana made the bold decision to implement a National Health Insurance Scheme (NHIS) which aimed at universal coverage, despite vocal opposition from donors and technical experts. This was a great breakthrough considering that for over two decades the country had implemented a cost-sharing approach to healthcare financing. But while the user fees era helped raised the needed revenues, it brought about needless deaths and lower usage of healthcare services, especially by the poor. The NHIS sources of funds have primarily come from VAT, social security contributions, premiums and budgetary allocations.

Over the past decade under the NHIS, Ghana has made substantial progress in extending healthcare and increasing usage of health services for many poor people who previously could not afford it. But there are challenges. Currently, children, most formal workers, pregnant women and the aged are exempt from payment of the insurance premium, but a large proportion of the population who are in the informal sector are mandated to pay or renew premiums annually if they want to enjoy the scheme’s benefits. This arrangement is creating barriers to access and there are still over 50% of the population who are not covered by health insurance. Besides, the financial sustainability of the scheme is also seriously threatened. In 2009, it was running a deficit of GHC 19. 5m which more than doubled to GHC 47.3 m at the beginning of 2011.

In the past months, I have been writing articles with the aim of proposing some other sources of funds which Ghana could consider to generate funds for the NHIS. First, over 70% of the funds for the NHIS has been contributed by the National Health Insurance Levy (i.e. VAT). I therefore join the growing calls to consider increasing the NHIL by about 0.5-1.5% from its current 2.5% to a maximum of about 4%.  This increment is important to enable the NHIA to meet its ever increasing costs on claims, operations and administration.

Secondly, I call for the consideration of so-called “sin taxes” as another avenue of raising new domestic resources without necessarily increasing income tax rates or generating significant opposition from the public and corporate bodies. These are taxes levied on products considered harmful to health. Examples are tobacco and alcohol. A WHO report shows that by raising tobacco taxes and taxes on other ‘harmful products’ by 50%, low-income countries like Ghana could generate new funds for health to the tune of about $1.4 billion each year. The good thing about “sin taxes” is that they raise money while also protecting health. This is an important source we can look at to finance our new NHIS.

Thirdly, we could also look at the telecommunications sector. Ghana has nearly 18 million active telecommunication subscribers and if each subscriber is deducted at least GHC 3 (about $1.50), for example, which is spread throughout a year to finance the scheme, GHC 54 million ($27m) could be generated.

Fourthly, wouldn’t it also be a good idea to focus on the financial sector to ensure it makes a fair contribution to society? Considering that commercial banks alone make over GHC 100m profit each year, a tiny tax of as little as 1 % applied to financial institutions and transactions (shares, bonds, currency and their derivatives) could raise tens or even hundreds of millions in revenue to meet the cost of pursuing the objectives of the NHIS.

While calling for increased sources of finance, the fifth recommendation is for the NHIA, the Ministry of Health and other stakeholders to implement a number of cost-saving measures by tackling the inefficiencies, cost-escalation, corruption and abuses in the health sector. These could be used to support the NHIS. In the 2011 Budget, it was reported that a nationwide clinical audit in 2010 helped realise nearly GHC 8 million – which gives an indication of the fraud and abuses in the system. Recent research estimates that if we pay attention to reducing the ‘waste’ in the health system, nearly GHC 374 million could be generated annually to support the financing of the National Health Insurance Scheme.

For the NHIS in Ghana to progress further towards UHC, business-as-usual is not an option as our inaction will cripple the functioning of the scheme. These funding sources should be considered before the scheme collapses.

*Albert A. Arhin (2012) is doing a PhD in Geography. He was previously a Research and Policy Manager for Oxfam in Ghana working on health, climate change and agriculture. Picture credit: Sheelamohan and http://www.freedigitalphotos.net.

 

Hunger feeds a healthy brain

fat

The unprecedented rise in obesity is now a global epidemic. It is widely known that the accumulation of excess body fat increases the risk of chronic illnesses, such as Type 2 diabetes, heart disease, and certain forms of cancer; however, recently there has been growing consensus that obesity also has detrimental effects on the brain. For example, obesity is associated with a greater risk of cognitive dysfunction and increases the likelihood of developing a neurodegenerative disorder, such as Alzheimer’s disease (AD) or another type of dementia.

In fact, because insulin deficiency and insulin resistance appear to act as mediators of Alzheimer’s-type neurodegeneration, some researchers even claim that AD is “type 3 diabetes”, which selectively involves the brain. Identifying this important link between metabolism and cognition is not new. For years, researchers have recognised the benefits of reducing daily food intake on overall health, longevity, and cognition. Reducing the number of calories consumed each day has been shown to reduce age-related cognitive decline in humans and several animal models, while also augmenting the production of new brain cells.

The mechanisms underlying this relationship are not well understood; however, there is evidence that the gut hormone, ghrelin, may be responsible. Ghrelin is a chemical-signalling molecule synthesised and released from the stomach in the absence of food. This important hormone is responsible for mealtime hunger, and regulating body weight and adiposity [human body fat]. Although ghrelin is not produced in the brain, it is released into the bloodstream where it then circulates throughout the body and can then act on particular areas of the brain.

Whilst seen predominately as a potential target for anti-obesity treatments, this potent appetite stimulant also appears to have cognitive-enhancing properties. Ghrelin treatments provided to normal and aged rats and mice have consistently been shown to improve performance on tasks measuring a variety of cognitive processes, including spatial memory.

In addition to improving cognition, ghrelin appears to cause positive physical changes in the brain, such as increasing the production of new brain cells in structures critically important for memory. This creation of new brain cells is called ‘neurogenesis’, and is thought to underlie some of the cognitive benefits of restricting calorie consumption. Because reducing daily food intake and fasting naturally elevates ghrelin levels, some researchers believe that this rise in ghrelin may underlie the increased neurogenesis associated with low-calorie diets. Together, this suggests that ghrelin may be one mechanism connecting nutritional status with cognitive function.

Importantly, there is a growing body of literature suggesting that a disruption of the normal modulation of ghrelin secretion may contribute to both the metabolic changes and cognitive impairments associated with AD. Involuntary weight loss and nutritional deficiencies are common in individuals diagnosed with AD, and these metabolic changes appear to precede cognitive impairments.

Identification of modifiable risk factors to delay or prevent the progression of AD could have a dramatic impact on the prevalence of this devastating disease. Because ghrelin is an important regulator of appetite, as well as cognition, it may be a potential target for early detection and prevention of AD. The aforementioned research further establishes the important relationship between nutritional status and cognitive function.

Knowing this, along with the old adage, “prevention is the best medicine”, suggests that keeping ghrelin high by reducing daily food intake may be a powerful way to protect your brain. Not only does maintaining a healthy weight avoid the deleterious effects of obesity, but the higher levels of ghrelin may be protective against age-related neurodegeneration.

*Brianne Kent is doing a PhD in Experimental Psychology. Picture credit: www.freedigitalphotos.net and Ohmega1982.

Lessons from Egypt’s past could prompt optimism for the future

limerickstudent

Amid a drawn-out civil war in Syria, sectarian tensions across Libya and Bahrain and a stalled political process in Yemen, Egypt has emerged among its neighbour states as a paradox of post-revolutionary change in the ‘Arab World’. Egypt has not devolved into civil war, but almost two years after the initial uprisings in Tahrir Square, Egyptian politics remains chained to the edge of a precipice. Charges of widespread intimidation, voter fraud and the absence of international monitors discredited the recent constitutional referendum. The Muslim Brotherhood-backed constitution passed but only by the slimmest of margins and was rejected outright by voters in Cairo and throughout the Delta governorates of Monufia and Gharbia.

Worsening the political dislocations, Egypt’s economic woes remain unresolved. When demonstrations erupted last November in response to pre-referendum manoeuvring, the government halted a set of austerity measures designed to lay the groundwork for a pending $4.8 billion IMF assistance package. The end of the year witnessed a further run on the Egyptian pound and commercial banks and exchange bureaux are increasingly unable to service clients with US dollars.

Social and sectarian divisions enshroud these prevailing cleavages. The crowds that convened in the Coptic-heavy district of Heliopolis last November were predominantly Christian. Media reports fixated on the ‘affluence’ of the protestors and their ‘middle class’ demographic, juxtaposing them against the ‘baladi’ character of regime supporters. ‘Baladi’ is a catch-all term in Egyptian Arabic. It refers generally to ordinary, working people, but more precisely means ‘folk’. Cynics labelled the protestors ‘bultagiyyeen’, or thugs.

Regionally, a dismal geopolitical forecast continues to weigh in adversely on questions of capital flight and trade imbalances. On-going neighbouring conflicts highlight Egypt’s inability to assume its traditional role as an arbiter of intra-Arab disputes and fuel speculation about continued uncertainty and the prospect of violence within Egypt’s own borders.

And yet, despite all of these indicators, the reasons for optimism are compelling. The many challenges, in fact, are not unique to the aftermath of the 2011 uprisings. They resemble notable flashpoints in Egyptian history and none more so than the chaotic and prolonged struggle surrounding independence in 1922. Far more so than the Revolution of 1952 and Nasser’s subsequent crafting of an effective one-party system, early twentieth century Egypt saw multiple and disparate players vie for the lead role on Egypt’s changing political and social stage.

History

Like today, Egypt’s political scene following World War I was intensely complex. Similar to the regional upheavals that accompanied the uprisings from Tunisia to the Gulf in early 2011, the end of the war reconfigured the former Ottoman Middle East and realigned the region according to new British and French colonial regimes, the Mandates. As the Peace Conference convened in Paris to settle the post-war territorial and economic questions, Egypt’s leading statesmen lobbied for a say in the deliberations, but were rebuffed by their British overseers. Egypt’s most visible nationalist agitators, including Saad Zaghloul Pasha, were arrested and deported to the island of Malta in early March 1919.

Rallying to the defence of their leaders, Egyptians initiated widespread strikes and demonstrations that rocked the governing British regime. As in 2011, immediate political catalysts triggered the Revolution of 1919, but Egypt’s crippled economy, reeling from years of wartime hardships, accounted for much of the instability. In an effort to guarantee supplies to its army, Britain shut down the Alexandria Bourse and attempted to set price controls on major staples and commodities. Inflation soared, however, to 200 per cent. Camels and livestock were requisitioned in the provinces while urban workers experienced wage cuts and struggled with food shortages over the course of the war. On the eve of the upheavals of 1919, Egypt’s economic predicament was dire.

To control the emerging protests, Britain deployed army units reinforced by military police to safeguard Egypt’s main transportation routes and garrison its larger towns and cities. Shirking discipline, the colonial troops responded violently to the political turmoil, attacking doctors in Heliopolis, pillaging shops and houses in Cairo and burning an entire village near Zagazig in the Delta, among scores of other crimes and atrocities.

The violence backfired. It strengthened the resolve of Egypt’s nationalist movement which eventually won concessions from a British colonial government impaired and weakened financially from the effects of the war. Britain was forced to compromise and, despite its flaws, the constitution granted to Egypt in 1922 set the parameters for parliamentary elections and awarded the country a degree of autonomy unseen since Britain’s occupation began in 1882. Although the ensuing system was not immune to further pressures and personal rivalries – including the appearance of the Muslim Brotherhood as a force in local politics and the growing rift between Zaghloul Pasha and his chief adversary, Ismail Sidqi – it functioned relatively unencumbered through the interwar period and oversaw an expansion and stabilisation of the economy.

Recent Egyptian history, therefore, provides a model for overcoming a protracted period of uncertainty, a disruptive military presence in politics, a growing Islamist movement and a deteriorating economy. If imperfect, the period that emerged following the aftermath of World War I in Egypt was unprecedented for its transparency and promotion of civil society. Egypt’s contemporary revolutionaries would do well to study it.

*Max Reibman [2010] is doing a PhD in History. Picture credit: Creative Commons and LimerickStudent.

Mind your language

grenadaimage

The audacity of some Caribbean linguists today is simply appalling! They mindlessly campaign for the recognition of ‘creoles’ (they call them) as legitimate languages. Some even dare venture the walls of prestigious institutions with noble aspirations of studying these corrupt tongues. The abomination is inconceivable. National languages? Tokens of our identity? The lofty labels given to these languages are a cause for concern, when in fact they are just what we have known them to be all along: ‘bad talk’, ‘bad English’, ‘broken English’, ‘broken French’…they’re all just broken. If God, in his infinite wisdom, were to torment the Egyptians with an eleventh plague, he would certainly have to release the scourge of all languages – CREOLES.

It is saddening that sentiments like these often surface, and violently I might add, when one mentions the creole as a valid language or even a field of study. Among the sparsely described languages of the Anglophone Caribbean is Grenadian English Creole (GEC), spoken on the island of Grenada. With English being the official language and Grenadian French Creole (GFC) spoken in minute pockets on the island, GEC functions as the main vernacular in commutative discourse. Both creoles however, are reservoirs of Grenada’s rich culture and history. It is no secret that GEC is frowned upon by many of its speakers. In education, it is often perceived as a hindrance in learning Standard English! Bonjay!* Excuse my dialect! (I’m one of those mindless linguists). The irony that lags behind this notion is that a complete understanding of the creole itself is in fact a catalyst and not an obstacle to acquiring Standard English. Analyses of GEC grammar may very well explain why so many Grenadian students find difficulty with problematic areas such as subject verb agreement, tense and aspect. Although GEC and Standard English share a lot of the same vocabulary, their grammatical structures are quite independent of each other and therefore must be distinguished.

I love how English words are manipulated in GEC to give completely new and culturally specific meaning. So when Scholar, a notable Grenadian calypsonian, renders a social commentary in song: Dey ha dey Belly which translates to “They have their bellies”, the average Grenadian is certain he does not mean that the political leaders are physically holding their stomachs but that they are bold and audacious. Likewise, when he sings She rel hol’ him roughly;She really held him”, he doesn’t mean she has stretched out her hands and embraced this man, but that she has possibly captivated his soul through obeah “witchcraft”. Much of GEC research and literature celebrate the uniqueness of its expressions and cultural implications. The Dictionary of Grenadianisms provides a list of some of these expressions and a recent publication by Thomas and Zara Chase (2011) offers similar and even more, with historical mappings and folkloric information. Despite these, Holbrook notes that the research done in GEC so far “has only scratched the surface of this creole”.

Among the numerous areas of potential focus, of which Holbrook documents some aspects of GEC syntax, my research seeks to describe the phonetic and phonological aspects of GEC, in other words, its sound system. Why is it that many Grenadians, when speaking Standard English, find it a task to consistently pronounce “th” in words like: those, that, teeth and with? Could it be that these sounds are absent in the native tongue, the one in which they think most naturally? Why is it that many are guilty of saying likkle for “little” or bokkle for “bottle” – an occurrence which seems to mysteriously happen when the sounds ‘t-t-l-e’ come together? Many children are furiously corrected when they say plaskit instead of “plastic”. Alterations and reordering of sounds can be systematically described through phonological investigations.

The average Caribbean person can sense distinctions in various Caribbean accents, all of which may sound quite similar to the non-Caribbean native. The phonetician however, can dissect these distinctions even further, with acoustic analyses of vowel quality and consonant articulations, arriving at a more precise documentation of the sounds of the language, in my case GEC. Whenever I hear ignorant disdain for creoles, I always remember that English, now prized and prestigious, was once regarded as inferior and being in the shadow of Latin. So there is hope after all. It is therefore time to move beyond the misguided, negative associations of the creole, to embrace the beauty and novelty of its expressions and to apply rigorous linguistic investigation.

*Bonjay – an expression of shock or outrage, derived from French Bon Dieu “Good God”

*Jill Paterson [2012] is doing an MPhil in Theoretical and Applied Linguistics. Contact: jrp73@cam.ac.uk. 

Picture Credit: Haron Forteau http://www.flickr.com/photos/haronf/