Contribution to MMI Annual Report 2015

Everyone who deals with this topic knows it: Ensuring financial sustainability of social services is very hard work. Especially health services are nearly never fully financially sustainable businesses. This is not even the case in Germany and other so-called “industrialized countries” and much less in countries of the global south where financial resources are even scarcer.

In most of the cases, public health services must be subsidized in order to be able to provide affordable and reasonable services to all its constituents. This concerns particularly the less affluent but very in need patient groups who cannot afford the often present expensive, private clinics in developing countries.

action medeor just finalised a project with our long-term partner Madre Tierra Mexico that provides a good overview on possible successes, difficulties and problems that can appear. The aim of our project was to reach the provision of primary and basic health care for mainly indigenous and small-scale farmers´ families through a health centre and training of health promotors focusing on sexual and reproductive health and rights. The duration of the project, originally 3 years has been extended to 4 years by action medeor and our co-funding partner the German Federal Ministry for Economic Cooperation and Development in order to reach better long term sustainability. Particularly, during the last year, together with our local partner, we focused strongly on building financial sustainability.

Sustainability does not only refer to the financial aspect but has many different facets including a social one which we thought in our case is mainly related to creating acceptance and ownership within the local target group. Although considering it as a potential risk in the beginning, acceptance and ownership did not turn out to be a problem which is probably partly due to the fact that the health centre established by the project constitutes the only health service offered within the region and its far-spread, surrounding rural communities.

Excellent social sustainability, contributions from varios actors

In fact, the centre was excellently accepted. The local council donated the territory as well as working hours over hours to move ground, dig trenches, cultivate the health centre´s garden, painted the centre and helped with everyday work. The population happily visited the health centre, brought their families, and saved time and money because they did not have to visit any of the other far situated health institutions any more. In the beginning the services provided by the health centre were also highly in demand due to the fact that they were offered free of charge. However, afterwards when small fees were introduced to increase financial sustainability together with our partners we made the bitter experience that even very low fees could not be payed by the target group. This was also due to the fact that the shortage of personal and familiar financial resources was intensified by a severe drought and the effects of the El Niño-phenomenon that still haunts large parts of Central America.

Could this situation be solved at all? And if yes how could it be solved? Both questions have to be answered taking different point of views into account:

From rather negative news…

First of all, it has to be said that the problem was not solved and unfortunately will not be solved unless a government develops or adopts a suitable health strategy, manages to budget sufficient funds for an affordable health care for all its citizens AND at the same time achieves to implement all planned elements. Mexico is not an exceptional case, also Guatemala and other Latin American countries are in a process of privatization of health and other social services guaranteed by the human rights carta. In fact, all the mentioned problems will most likely never be solved unless monetary poverty can be eradicated.

…to quite positive news:

“It is still possible to at least partially achieve financial sustainability of health services. The partners we worked with are extensively active in developing relations with external actors. Exchange of knowledge and resources, publicity, a favourable culture of recommendation, affordable prices, friendly services, etc. are crucial in an environment that does not offer monetary incentives.”

During the 30 months of health services offered in the project period, the health centre received several times direct financial support in order to pay salaries for medical personal over the period of 12-18 months (i.e. for the dentist and the general practitioner) and were offered administrative services of an employee of another international NGO. Our partners are moreover cooperating with international volunteers that are qualified for medical specializations offered at the health centre, and in the future with brigades that posess expertise in additional medical fields that cannot be offered at the health centre. This not only saves money that may be spent for other expenses, but also fosters the exchange of knowledge and contacts. Glasses can be sold as a result of cooperation with an international NGO.

Although the financial support was mainly received from international sources, successful cooperation with local authorities could be achieved in several cases. An example for this is a local foundation which equipped the health centre’s dental office with furniture, instruments and consumables, another example is the good relationship with the regional civil protection institution which now regularly uses the existing rooms for training measures. In exchange, it installed a mobile radio communication system, lent general support in risk-related communication for emergency medical treatment, and provided an alarm system.

The local police seems to consider the service of the health centre as valuable as it supports each night from 22pm to 6am with security staff. 11 health promotors resume medical and administrative tasks, offering by this a permanent service. They maintain the routine i.e. when the medical personal changes. The promotors receive a regular salary (better: a rather small stipend) generated by the incomes of the pharmacy. Additionally, these health promotors offer primary health services in their community as well as perform a health, nutrition & hygiene programme in the regional radio at prime time on friday afternoon. Further, being a registered health centre, it also attracts national medical students during their practical year.

An attempt to summarize a difficult question

Despite all these encouraging activities, there is still a constant monetary pressure on the successfully established integrated health centre for indigenous and small-scale farmers´ families: the payment of the medical staff – sums that again and again have to be raised from private funds, as public support will also in the future not be a probable source of income. In summary, the response of the question in the beginning can partially be answered positively by referring to the illustrated diversification of efforts and of services.

Contribution by action medeor to the Annual Report 2015 of the MMI Network

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