User fees hamper malnutrition fight

Health user fees in Côte d'Ivoire are hindering the fight against child malnutrition in the west, health officials and aid workers say.



Acute malnutrition in the west and north are on average at 3.6 percent and 5.4 percent respectively; while chronic malnutrition is at over 40 percent on average in both regions, according to preliminary results of a 2009 nutrition study done by the Health Ministry, with help from UN Children’s Fund (UNICEF), the World Food Programme (WFP) and the Office for the Coordination of Humanitarian Affairs (OCHA).



The western region of 18 Montagnes has the country’s highest severe acute malnutrition rates at 4.5 percent.



Wasting is the main characteristic of acute malnutrition. It occurs as a result of recent rapid weight loss, malnutrition or a failure to gain weight within a relatively short period of time. Severe acute malnutrition (SAM) is the most dangerous form of malnutrition and if left untreated, can result in death.



Chronic malnutrition is commonly referred to as “stunting”, which occurs as a result of inadequate nutrition over a longer time period.



Christophe Konan, who runs a therapeutic feeding centre in Danané hospital, 80km from the regional capital Man, told IRIN the number of moderately malnourished patients has dropped from 4,250 in 2007 to 1,215 in 2009 to date; while the number of severely malnourished patients has dropped from 390 in 2007 to 338 in 2009 (as of 10 December).


















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“Rather than a decrease in malnutrition,the drop in consultations is most likely due to the introduction of user fees,” said Konan. These were introduced in March 2009, six months after NGO Médecins Sans Frontières, which set up the hospital’s nutrition centre, withdrew.



High poverty levels, a prevalence of kwashiorkor  – a form of malnutrition marked primarily by oedema – and high levels of food insecurity contribute to severe acute malnutrition in 18 Montagnes, according to the health authorities.



Under the hospital’s cost-recovery scheme, each family must pay 5,000 CFA francs (US$10.80) per child requiring intensive therapeutic feeding.



“People are reluctant to pay…and we can no longer go out village to village to look for new cases,” Konan told IRIN.



Doctors do not turn patients away if they cannot pay, but they urge patients to find the funds during their stay, he said.



Mother, Marina Bwa hitch-hiked 45km to the centre with her two-year-old son who has kwashiorkor and is undergoing intensive feeding. “How am I going to pay 5,000 CFA francs? How is that possible?” she asked IRIN.



Many women who come in cannot afford to pay, Konan said. “Two out of six new cases we have now could not pay…Sustaining these activities is hard… MSF wanted us to make the treatment free but we need more money to do so.”



When IRIN visited the hospital, most of the wards had empty beds. Just one woman lay in the maternity ward. “There is generally a fall-off in patients during the harvest,” said Danané hospital director Paul Kouhon.



But user fees also keeps people away, says MSF. Just prior to withdrawing from Côte d’Ivoire in 2008 MSF's ex-head of mission Nathalie Cartier said in a communiqué: "If we don’t want to end up with empty hospitals again, it is essential that the health authorities and international donors provide the funding needed to ensure that health facilities remain functional and that care continues to be free of charge for the population."



Fight in north



User fees for the treatment of a limited number of acutely malnourished children in government clinics and hospitals were scrapped in the north following alarming acute malnutrition rates of 18 percent in the region in a 2008 survey according to NGOs.



Since then, acute malnutrition has dropped by 55 percent to 7.2 percent .



The drop is mainly due to a collective push by the Health Ministry, UN agencies and NGOs to boost supplementary foods and provide free therapeutic feeding for critically malnourished children says the survey.














Photo: Anna Jefferys/IRIN

One month before conducting the nutritional survey the National Nutrition Programme (PNN), UNICEF and WFP treated 18,458 acutely malnourished children in the north.



Now nutrition has become more integral to healthcare services in northern regions, said Raffaella Gentilini, nutrition coordinator at NGO Action Contre la Faim.



In some parts of the north health workers were not monitoring the growth of babies, she pointed out. “Now things are different. Health workers and community health volunteers know [malnutrition] is a disease and watch out for it.”



Nutrition experts caution against directly comparing 2008 and 2009 figures as a 2008 study addressed the north as a whole, while the 2009 survey analyzed five northern regions separately and expanded to the three western regions of Moyen Cavally, Bas Sassandra and 18 Montagnes. 



The public healthcare system has been deteriorating country-wide for years and is particularly weak in the north and west, where government administration is gradually resuming after years of rebel control, observers say.



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