Access to Health Care In Developing Countries

Executive Summary

Current health policies on malnutrition and HIV infection are focused in achieving the Millennium Development Goals (MDGs) of the United Nations. Specifically, these goals include reduction of malnutrition incidence since 1990 by 50% and reversal in the trend of HIV epidemic by 2015. This essay aims to critically analyse these two policies in achieving their respective aims and objectives and the factors that contribute to the success of these policies. A brief discussion on the Western concepts of ill-health and how these relate to the concepts of ill-health in developing countries is also made.

Results of the analysis show that engaging communities and allowing them to take ownership of strategies to prevent malnutrition is effective in reducing incidence of malnutrition. The Scaling Up Nutrition (SUN) campaign illustrates how developing countries could positively respond to healthcare policies introduced by developed countries. However, not all developing countries are nearing or have achieved the 50% reduction in malnutrition incidence. Lack of community involvement has been shown to affect the progress of the SUN campaign. The same principle of community-based interventions is also used on the policy for HIV infection. Success rate for HIV policy is high with millions of affected individuals accessing healthcare services compared to only 400,000 in 2004. This would show that policies to increase treatment have succeeded. However, prevention of HIV infection remains challenging. Analysis would show that engaging in risky sexual behaviour is a critical factor in developing HIV infection in Sub-Saharan Africa. Changing the behaviour of a target population is established to be difficult.

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While community-based interventions and participation have contributed to the success of these policies, analysis would reveal that there is a need to increase the technical competencies of the stakeholders in the communities. This would ensure sustainability of programmes long after external aid has stopped. The differences in the concepts of ill-health also appear to influence the success of policies in developing nations. It is also argued that achieving all the aims and objectives of the policies might not necessarily solve the problem of malnutrition and HIV infection. Both conditions have multiple underlying causes and addressing all these would take considerable time and effort. In conclusion, policies have made great strides in improving nutrition of children and mothers and decreasing the incidence of HIV infection. Concerted effort from various stakeholders is still needed to make changes sustainable.

Introduction

The main aim of this brief is to critically analyse the policies, ‘Reducing Hunger and Malnutrition in Developing Countries’ (Department for International Development, 2013) and the global policy on HIV/AIDS Epidemic (KFF, 2013). Both healthcare policies are designed to improve the health and well-being of mothers and young children and those suffering from HIV/AIDS in developing countries. The first part describes these two policies while the second part discusses the Western concepts of ill health and how these limit policies and projects aimed at developing countries. The third part provides a theoretical assessment of the policies. A discussion on the underlying assumptions and views of healthcare in terms of belief structures and philosophy will be included. The fourth part presents the practical problems with implementation. Finally, a conclusion will summarise the main points raised in this essay. Recommendations will also be made at the end of this brief.

Policies on Malnutrition and HIV/AIDS

The ‘Reducing Hunger and Malnutrition in Developing Countries’ (Department for International Development, 2013) aims to help individuals gain access to nutritious diet, ensure that food is distributed fairly across the world and mitigate environmental risks and damages that could influence food production. In line with the Millennium Development Goals (MDGs), the policy has set out several objectives that should be achieved by 2015. This includes reducing malnutrition since 1990 by 50%.

Meanwhile, the ‘Global HIV/AIDS Epidemic’ policy (KFF, 2013) aims to stop and reverse the spread of HIV/AIDS. This is consistent with the United Nation’s MDGs that by 2015, the HIV/AID epidemic will be controlled and incidence will decline. It is estimated that a total of 18.9 billion USD have funded HIV/AIDs preventive and treatment programmes in 2012 (KFF/UNAIDS, 2013). Although there is a global decrease in the trend of this epidemic, incidence of HIV/AIDS is still high in middle and low-income countries (UNAIDS, 2013). Most of those suffering from this health condition do not have access to healthcare services, treatment and management (UNAIDS, 2013). Importantly women and young girls are more susceptible of the infection compared to men (British HIV Association, 2012). Of the 35 million individuals believed to be suffering from the condition, 3.3 million of these are children (UNAIDS, 2013). Majority (71%) of persons living with HIV/AIDS reside in Sub-Saharan Africa (Health Protection Agency, 2012). The objectives of this policy include decreasing HIV prevalence amongst the young population aged 15-24 years; increase condom use especially in high-risk sex; increase the proportion of young people with correct knowledge on HIV/AIDs infection; and increase the proportion of individuals with advanced stages of the disease gain access to antiretroviral medications.

Western Concept of Ill-Health

Western concepts of ill-health could limit the policies on malnutrition and HIV/AIDS when introduced in developing nations. First, definitions of ‘ill-health’ could vary between Western and developing countries. There is variation in how ill-health is perceived even amongst professional, academic and the public (Wikman et al., 2005). Ill-health is also viewed differently across disciplines. For instance, the medical model of health has been accepted for several years in Western healthcare in the past (Wikman et al., 2005). This model states that ill-health is caused by pathogenic microorganisms or underlying pathologies (Dutta, 2008). However, even this concept has changed within healthcare systems. Today, many healthcare professionals have recognised that ill-health is not only caused by pathogenic organisms but social determinants of health such as poor nutrition, unemployment or stress could all influence ill-health (Dutta, 2008). Wikman et al. (2005) acknowledges that ill-health could be understood by using a multi-perspective approach.

Concepts of ill-health are also considered as historically and culturally specific (Blas and Kurup, 2010). This means that ill-health varies across culture and time. For instance, in Western culture, obesity is considered as ill-health (Blas and Kurup, 2010). In other countries, obesity is viewed as socially acceptable since this is a sign of wealth. In Western culture, findings of scientific publications are used to underpin health policies against HIV (Bogart et al., 2011). Use of condoms to protect against HIV infection is viewed as acceptable. In some African countries, use of condoms is seen to reduce one’s masculinity (Willis, 2003; MacPhail and Campbell, 2001). Importantly, anal sex in some of these countries is practised to avoid pregnancy or viewed as a cleansing method against the virus for HIV/AIDS (Bogart and Bird, 2003). Hence, these differences in the concept of ill-health could influence the uptake of global health policies in developing nations. To illustrate this argument, the policies on malnutrition and HIV/AIDS will be critiqued. A discussion how western concepts of ill health influence the uptake of these policies in the developing countries would also be done.

Analysis and Discussion

Attention on acute and chronic malnutrition is unprecedented in recent years (Shoham et al., 2013). The involvement of the UK, through its policy for malnutrition and hunger, with other countries in the scaling up nutrition (SUN) campaign has brought significant changes on the lives of children who are malnourished. The policy on malnutrition is underpinned by the philosophy on health equity and social determinants of health (Ezzati et al., 2003). Western concepts of ill-health focus on the social determinants of ill-health as a factor in promoting malnutrition in developing countries. For example, unemployment of parents, low levels of education, early years, poverty, homelessness are some social determinants of health strongly suggested to promote malnutrition amongst children (Marmot and Wilkinson, 2005). Uptake of policies for malnutrition in developing countries might be limited if these determinants are not properly addressed. Farmer (2003) explains that cultural beliefs on food, poor knowledge on the nutritional value of food and food production practices have long contributed to malnutrition in many countries.

Policies on malnutrition might no be effective if these do not address the root causes of malnutrition, which are poverty, poor knowledge on food nutrition and poor farming practices (Farmer, 2003). Power structure also plays a role in how policies are implemented. Farmer (2003) stresses that unless the poor are empowered and their rights protected would true development occur. In recent years, there have been improvements in the lives of the poor, specifically on nutrition status. Marmot and Wilkinson (2005) emphasise that presence of poverty and unemployment could all influence health. However, there is evidence that in some developing countries, malnutrition policies have gained success. An analysis would show that involvement of the community plays a crucial role in ensuring success of these policies. For example, Shoham et al. (2013) report that the community based management of acute malnutrition (CMAM) approach contributed to its success in some 65 developing countries across the world.

Communities are mobilised and they gain ownership of the programme. Individuals help in detecting uncomplicated severe acute malnutrition (SAM) and refer children to established out-patient centres. Complicated cases are referred as in-patients in the health sector staff. While the UNICEF (Nabarro, 2013) reported that 10% of the 20 million suspected cases of SAM have been treated through the scaling up nutrition campaign, other target countries have not kept up with the campaign. Policies that have gained acceptance in developing countries are those that empower communities to take actions for their own health. Empowering women through education has been shown to lead to more positive changes in the health of children ages 5 years old and below (Farmer, 2003). Policies that increase the educational levels of women were shown to reduce erroneous perceptions on the causes of malnutrition (Wikman et al., 2005). Shoham et al. (2013) observe that failure to implement the CMAM approach and educating women on malnutrition limits the success of malnutrition policies in communities.

A number of studies (Bhutta, 2013; Black et al., 2013; Pinstrup-Andersen, 2013; Nabarro, 2013; Loevinsohn and Harding, 2005) have shown the effectiveness of engaging communities and empowering them to improve the nutritional status of women and children. While factors such as engaging communities and allowing them to take ownership of programmes have been shown to promote uptake of policies, there are still factors that limit policy uptake. These include failure to address the social determinants of health such as poverty, low levels of education, poor support of the children during early life years and unemployment (Loevinsohn and Harding, 2005). It has been shown that when these factors are present, malnutrition is also high (Pinstrup-Andersen, 2013). There is also a need to understand the perceptions of women and children on food and nutrition to better understand why malnutrition continue to exist in a number of developing countries.

Meanwhile, the policy on HIV/AIDS also promote health by engaging communities in implementing projects aimed at preventing HIV transmission (KFF, 2013; British HIV Infection, 2012; Department for International Development, 2013). To date, HIV infection epidemic has stabilised and the number of individuals receiving treatment has increased to 9.7 million in 2012 (UNAIDS, 2013). In contrast, only 400,000 individuals with advanced HIV infection receive treatment in 2004. A closer analysis of the cause of HIV infection would still point to risky behaviours of those engaging in unprotected sex and injecting drug users as factors that promote HIV infection (KFF/UNAIDS, 2013). This is a cause of concern since there is still the prevailing cultural belief in a number of African countries that use of condom is unmanly (Willis, 2003; MacPhail and Campbell, 2001).

Connolly et al. (2004) argue that changing behaviour of the target population is most difficult. Consequences of HIV infection extend to unborn children of mother infected with HIV (UNAIDS, 2013). To date, there have been various interventions to prevent HIV infection. These include behaviour changes, increase in HIV screening, male circumcision, use of condoms, harm reduction amongst in injecting drug users and blood supply safety (UNAIDS, 2013). Amongst these strategies, changing behaviour remains to be an important intervention that could prevent further spread of the virus. Experts suggest that risky sexual behaviour could only be changed through the use of different health models. For example, the health belief model could be used to inform the target population on the risk of HIV (Health Protection Agency, 2012). In addition, facilitators to behaviour change, such as decreasing stigma on HIV infection, increasing access to healthcare services could help individuals adopt less risky sexual behaviour (Greeff et al., 2008). Patients with HIV often perceive stigma from their own healthcare workers (Kohi et al., 2006; Holzemer and Uys, 2004). This could impact not only the quality of care received by those with HIV infection but might also limit them from gaining further medical treatment.

On the other hand, reducing malnutrition by 50% since 1990 has not been achieved in most countries yet (UNICEF, 2014). This is important since the United Nations aims to achieve this target by next year. Food production is continuously affected by stronger typhoons and turbulent weather patterns (KFF, 2013). Droughts appear to be longer, affecting agriculture and livestock production (KFF, 2013). Specifically, the UNICEF (2014) acknowledges that the most vulnerable groups to increasing weather disturbance brought by climate change are the poor people. This is especially challenging in the light of the MDGs since decreases in food production in developing countries could further have an impact on the nutritional status of the women and children (Bryce et al., 2008; Taylor et al., 2013). Climate change has important implications on policies for malnutrition. Even if community-based initiatives are strongly in place and individuals have learned to produce their own food, changes in weather patterns could impact agriculture activities. The UNICEF (2014) has highlighted this issue and using current experiences, community rehabilitation after a typhoon or drought would mean increased challenges in addressing malnutrition amongst the poorest of the poor.

Even if all objective are achieved, there is no full guarantee that malnutrition will be completely eradicated in developing nations. To date, there are best practices (SUN, 2013) showing that community involvement and partnership with government and non-government organisations could arrest severe acute and chronic malnutrition. A number of developing countries, especially in the Sub-Saharan Africa are still struggling with malnutrition despite external aid. The same observation is also made in this region on HIV infection where the poorest amongst the poor remain to be most vulnerable to the infection (SUN, 2013). Hence, it would be necessary to investigate the real cause of malnutrition and HIV infection in developing countries.

There are multiple underlying causes of malnutrition and all interact to increase the risk of children for malnutrition. First, poverty has been highlighted earlier in this essay as an important factor for development of malnutrition (Horton and Lo, 2013). This essay also argues that maternal level of education is a significant factor in the nutrition of children (Black et al., 2013). The World Health Organization (2011) acknowledges that children born to mothers with at least a high school education enjoy better health compared to children with mothers who have lower educational levels. This observation is consistent across literature (UNICEF, 2014; Black et al, 2013) and illustrates the importance of increasing the education level of mothers.

In Sub-Saharan countries that often experience conflicts, malnutrition is often caused by displacement of families and children from their homes and livelihood to evacuation centres with minimal food support (UNICEF, 2014). Apart from conflicts, recent effects of climate change have also changed the way developed countries respond to problems of food security (Taylor et al., 2013). As shown in the UK policy for hunger and malnutrition, funds are also directed to innovations and research on how to respond to environmental damages caused by climate change (UNICEF, 2014). It should be noted that changes in weather patterns, flooding and drought could have a great impact on food security and sustainability (Department for International Development, 2013).

In comparison with the policy on HIV infection, the policy on hunger and malnutrition would have a greater impact on the health of the nation. It has been shown that improving nutrition during the first 1000 days of a child’s life could lead to better health outcomes, higher educational attainment and productivity later in adult life (Bhutta, 2013). Malnutrition during a child’s first two years of life could have irreversible effects on the child’s health (Bhutta, 2013). This could lead to stunting, cognitive impairment, early death and if the child reaches adulthood, difficulty in finding a job (Nabarro, 2013). The number of children and mothers suffering from malnutrition is also higher compared to individuals suffering from HIV infection. However, HIV infection could also have an impact on maternal and child health since infected mothers could transmit the virus to their unborn child (KFF, 2013). Women with HIV also suffer more stigma compared to their male counterparts (Sandelowski et al., 2004).

Recommendations and Conclusion

In conclusion, the two policies discussed in this brief reveal strategies in preventing and treating malnutrition and HIV infection. Responses of developing countries to these strategies differ. Countries where communities are involved in the implementation of strategies are generally more successful in addressing these health problems. This would show that community involvement play a crucial role in the uptake of Western policies in developing countries. However, the lack of success in some countries might be attributed to the differences in the concept of ill-health between affluent and developing countries, socio-economic context of poor countries and difficulty in changing one’s health behaviour. Finally, this essay suggests that a more holistic approach should be taken in addressing the social determinants of health to ensure that children have access to nutritious food and HIV infection is prevented.

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