Thursday, June 4, 2009

The Ban against Health Service Advertising and Access to Quality Medical Service in the Malaria Epidemic: A Case of Middle Class Kampala Residents.










Abstract
This paper reports findings of a study which explored the impact of the ban on health service advertising on the malaria epidemic. The ban on health service advertising is based on the Hippocratic oath that all medical personnel swear in effect that they treatment of patients should not be motivated by profit. The oath as prescribed by Hippocrates the first medical trainer-in ancient Greece- binds all health workers to work on patients without profit. This paper explores whether this oath is outdated given the contemporary reality of a market economy. To explore this viability of the Hippocratic Oath, the paper contextualises it in the malaria management reality in Uganda.

With a significant potion of the population having the means an inclination to seek and receive quality treatment of malaria, the paper inquires whether the government’s interventions through the ban on the justifications of poverty, equity and the range of market failures is tenable. The fact that the government is constrained for resources and manpower in the fight against malaria, the question that purely private delivery and financing of malaria control interventions would lead to inefficient outcomes from society’s point of view. The view taken by this paper is a lift of the ban on health service advertising generally and in the field of malaria control in particular would go a long way in optimising of the resources in the fight. Using the survey method, the paper reports the findings of middle class Kampala residents and private health service providers on the issue of the ban against health service advertising. It concludes that it would be prudent on the government’s part to repeal the ban on health service advertising.

Given the fact that most of middle class resident of Kampala get treatment for malaria from private health providers, the argument of equity does not stand. The other issue to consider is that since private health service providers are businesses, advertising would improve their revenue, which revenue the state would tax to supplement resources in the provision of better malaria and other health services to the poor.
Introduction
Sarah Boseley (2008:1) observes that: “The health and life expectancy of Ugandans is amongst the worst in the world.” This is because its healthcare performance is ranked by the World Health Organisation as 186th out of 191 nations. The WHO attributes this state of affairs to its past of wars and political instability. All health indicators are on the low side. Life expectancy in Uganda is 48 years for men and 51 for women, which is below the average for sub-Saharan Africa of 52. Infant mortality is high and is estimated at 97 deaths per 1,000 births and so is maternal mortality. One woman dies in every 200 births. Around one million people are living with HIV and there are 91,000 Aids-related deaths a year.
Even in such a context, Uganda has scored highly on its combat against HIV which has generated praise from different parts of the world. To this effect, it has become a role model across the global in the fight against HIV/AIDS. Sarah Boseley (2008:1) notes that: “Yet in one important respect, its tackling of the HIV/Aids epidemic, Uganda won a global reputation and was held up, especially by President Bush, as an example to the rest of Africa.” That it managed to successfully combat HIV/AIDS would imply that the Ministry of Health would prove effective in dealing with the other severe challenges that Uganda faces, such as child mortality and malaria.
But the country struggles to make progress in this area. According to Malaria Today (2005:7) “Malaria remains a leading cause of morbidity and mortality world-wide, especially in pregnant women and children, and particularly in tropical Africa, where at least 90% of the malaria deaths occur.” At position 186 out of 191, it is true that Uganda is badly affected by malaria epidemic. This clearly shows that malaria is a serious health problem in Africa in general and Uganda in particular. The same document holds that malaria is not only a health problem but also an economic problem. Malaria Today (2005:8) states that: “The economic burden of malaria to the country, the family and the individual is immense. It has been estimated that it causes a reduction of 1.3% in the annual per capita economic growth rate of malaria endemic countries and the long term impact of this is a reduction of the GNP by more than a half.” Malaria does not only affect the productivity of the country but also has an impact on the number of days that students can attend school, the income spent on the treatment not to mention the time foregone when the people are sick or those who look after them.

Given the gravity of malaria, it would be correct to presuppose that the government, the non-governmental organizations, the society and the donor community, would be focused on the management of malaria. The fact is that malaria is easy to treat. Malaria Today (2005:7) states that: “Yet malaria is a curable disease and not an inevitable burden. Effective medicines and preventive measures are available.” The problem, though, is that these effective and relatively inexpensive interventions reach only a small proportion of the populations in need, mainly because of insufficient financial resources on one hand and inadequate information on the other hand.

Malaria Today (2005) argues that during the last decade, new medicines and approaches have been developed for malaria case management, for selective vector control and for epidemic detection and control. It further states that malaria has become integrated into other health programmes and partnerships have been increased both internationally and nationally by the Roll Back Malaria (RBM) Initiative instigated by WHO's Director General in 1998. These developments have led to increased global awareness of malaria, and in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) started operations. By mid-2004, the GFATM had allocated nearly 2 billion US$ for malaria control over a five-year period such funding for malaria control is making it possible to reduce the global burden.

The fact that research has improved on the nature of treatment, considerable resources have been made available in the fight against malaria and the economic cost of the disease especially in development world, it would be a fair assumption that everything is being done to combat the disease. However, the reverse is true. Sarah Boseley (2008:3) notes that: “In 2003, there were more than 12 million malaria cases and 8,450 deaths…Malaria accounts for 40 percent of out-patient visits to hospital and 14 per cent of deaths.” This means the progress on the fight against malaria has been poor, even though the disease is a major killer of Ugandan children and an obstacle to economic development.
The question that this paper seeks to answer is why in spite of its success in the combating of HIV/AIDS and the various interventions by the government and the international community, malaria is still a health and economical problem in the Uganda. The paper hypothesizes that the provision of information about the cause of and how to prevent infection by HIV/AIDS was crucial in the fight against the disease. It is logical, then, to argue that information is crucial in the war against malaria. However, where behaviour change communication was effective in HIV/AIDS, the same can not be applied to malaria given its complicated nature. This means that two kinds of information are required the preventive and that provides access to treatment. Therefore, the ban on health advertising is an important impediment in the fight against malaria.
Theoretical Framework
The main question that this article seeks to answer is why despite the various interventions, malaria is still a health and economical problem in the developing world. Therefore, the theory(ies) that can establish useful insights in line with the questions above are the theories of persuasion.

According to Dillard, P&Pfau, M (2002:2), persuasion “is a symbolic transaction, which uses reason and/or emotional appeals in an attempt to alter behaviour…Thus persuasive communication seeks to change behaviour without direct force.” In the case of this paper, the behaviour targeted for change by the health service provider sending out the message is the access to malaria treatment from a specific location or the use of a particular drug in the treatment of malaria to the public.
Miller G. R. (2002) notes that there are: “three distinct behavioural outcomes that can be the ultimate goal of a persuasive communication: response shaping, response reinforcing, and response changing.” Response shaping persuasion is the type that aims at establishing behaviour that did not existed before. Response changing is the concept that this article explores in relation to health service advertising.
The study holds that health service advertisements would have one end to achieve. This would be to shape the responses of the public to health service advertising. This could be through the use of fear appeal, which holds that messages that appeal to fear are likely to lead to change of attitudes and behaviour among the audience. This works at three levels-that is to say the message should be horrible or project a scenario that is likely to happen or not or if it is believable. Given the medical and economic cost of malaria, it is plausible to argue that these are enough fear appeals that could be used effectively in health service advertisements. This could be achieved through the employment of the language expectation theory. Brooks (1970:155) argues that:
The possibility of contrast effects should be considered. This principle assumes that we carry stereotypes into such social situations as public speech. There, the speaker’s behaviour may be discrepant with stereotyped expectations. If the discrepant stimuli can be assimilated or ignored, they are likely to be exaggerated in a listener’s perceptions… one explanation is this: unfavourable (or favourable) speakers may be perceived more (or less) not because their behaviour is intrinsically persuasive (or dissuasive) but because it contrasts with stereotyped expectations which audiences hold.
The key assumption in the above quotation is that the effectiveness or lack of effectiveness of the persuasive message depends on the expectations of the audiences. This means that any persuasive message is responded to from the social expectation of the audience to the communicator and the linguistic tools that he uses. These linguistic tools should be those that are expected of him as an individual or as a social group. Burgoon, Denning& Roberts (2002: 120) refer to the linguistic tools in the macro-sociological expectation and preferences of the language to define language expectation theory as:
Language expectation theory assumes that language is rule-governed system and that people develop macro-sociological expectations…usually cultural values and societal standards or ideals for what is competent communication performance.
The above observation is specific about speech; however it is applicable to all persuasive messages such as advertising. In effect an effective advertisement is that message that is structured using cultural and societal standards and ideals for competent communication performance.
Language expectation theoretical propositions that inform this article include the following:
• Highly credible communicators have the freedom (wide bandwidth) to select varied language strategies and compliance-gaining techniques in developing persuasive messages, while low credible communicators must conform to more limited language options if they wish to be effective.
• Fear arousal that is irrelevant to the content of the message of the harmful consequence of failure to comply with the advocated position mediates receptivity to different levels of language intensity and compliance-gaining strategies varying in instrumental verbal aggression. Receivers aroused by the induction of irrelevant fear or suffering from specific anxiety are most receptive to persuasive messages using low intensity and verbally unaggressive compliance-gaining attempts but are unreceptive to intense appeals or verbally aggressive sausory strategies.
Basing on the assumption that the pain of the fever, the economic loss as a result of the fever and the existence of highly credible communicators in the form of pharmacy owners and doctors in clinics would make the patients receptive to the messages carried in advertisement, this paper argues that advertisements would provide timely information to the population about the treatment of malaria. Such information will reduce the burden of malaria at both the household and national levels because the people will through advertisements get information on where or with what to treat malaria if and when they get an attack. This make sense especially to the Ugandan middle class that is relatively well off and would be willing to get quality drugs and treatment if such information was available.

Advertising
Nicosia (1974:2) defines advertising as, “…to give notice, to inform, to notify or to make known. This means that when the health service providers advertise they are informing, giving notice, or notifying the public of their existence, the products and the services that they offer. Nicosia’s definition is echoed by Dunn& Barban (1986:2) who define advertising as, “…a paid, non-personal message from an identifiable source, delivered through the mass mediated channel that is designed to persuade.” Therefore, there are expectations of a return on the money spent by the health service providers in sponsoring the advertisements in the media. The return is through the awareness created of the health service provider, its products and services. These translate into the public taking on their services and products. This would mean that both the public and health service providers benefit. The public by accessing information on where and with what to treat malaria, and the health service providers-since-they are businesses first and foremost a profit and consequently a return on their investments in the health sector

It would seem that health service advertising would employ this paradigm. They provide a service and for investors in these institutions it is crucial to inform the public about the existence of the service that their institutions offer. The process of communicating the existence of this service is paid for by the health service provider and the motive is to attract potential customers in this case the customers to get treatment for malaria. This is the cardinal principle that survival and growth of the health service provider’s business depends on how effectively the business communicates to its potential clientele to create awareness of the service that it offers.

This means that more often than not, advertising serves marketing, educational, informational, persuasive and economic functions purposely to improve the income and standing of the firm in the industry. Nicosia (1974) suggests that there are three components of successful advertising. These are information, reasoning/emphasis and the uniqueness of what is being advertised. The target population of this paper is the middle class. This means that unlike the majority of Ugandans who depend on the state to provide them with the treatment of malaria, they have the means and economic resource to get better treatment. If according to Hausmann Muela S, Muela Ribera J. (2000:2) lack of: “…purchasing power is a fundamental constraint to effective malaria control interventions for much of the population. The burden of disease can have important economic costs for very poor households…”, the middle class can not be constrained by these factors. The question, then, is what constrains the middle class from accessing quality treatment against malaria? The answer is obviously information about quality health service providers and drugs to use in the treatment of malaria. Health service advertising would ultimate provide such information to this class of people. This is would be in line with Rapath’s (1966:173) assertion that: “…advertising conveys to the consumers the desirability of certain products.” In the case of the health service providers, the Rapathain product are the treatment and drugs that they would provide to the public.
Overview of Malaria Management in Uganda
The malaria management regime in Uganda is informed by the general health policy as laid down by the Ministry of Health. The core assumption of this policy is the pledge to provide “health-for-all, with special consideration for the welfare of the poor, the most vulnerable and the disadvantaged.” The Ministry envisages achieving this commitment through state-private sector partnership. The private sector in Uganda consists of NGOs (facility and non-facility-based), private practitioners, the traditional health care system of traditional healers and midwives, and an expanding private pharmaceutical sector. The state’s partnership with the private sector in the provision of health services generally and malaria control specifically arises from the recognition of that fact that this sector is collectively responsible for a significant proportion of health care in the country. Each one of these constituent sub-sectors has specific comparative advantages, which must be recognised if they are to be fully harnessed.

To make the partnership operational, the Ministry has proposed the establishment of appropriate instruments to facilitate and regulate the private sector in line with existing national laws and regulations and offer incentives that would attract private health services to all parts of the country as well as providing assistance to private providers in areas not effectively served by public facilities, so as to achieve wider coverage of the population, in preference to setting up competing public services.

In spite of the good intentions of the policy to the private sector, the ban of health service advertising is a disservice to private sector-especially the business oriented service providers. If these units are set up as businesses, advertising would be beneficial to both the state and the entities themselves. In the first place, the entities would become viable commercial entities. In the second place when these entities cater for the health problems of especially the middle class, then resources of the state would be channelled to the disadvantaged sections of the society.

This is made worse by the insistence of the policy to adhereance to medical ethics in the running of private health entities. The policy states that “…to guide the planning, financing and implementation of all aspects of this policy at all times, and in all circumstances by emphasising the basic principles of equity, fair play, justice and other considerations of ethical importance in the health profession.” It is the contradictions in the health policy that accounts for the poor state of malaria management in Uganda. Hausmann Muela S, Muela Ribera J. (2000:2) observes that: “Treatment in both the public and private sectors is hampered by three key weaknesses: low quality of care, inefficiency in service delivery and low utilization of adequate care.” In the case of state health entities, the main reason is the inadequate funding that the health services receive from the state. In the case of the private health service providers, it is the lack of motivation. This is because the policy forces them to behave like institutions of the state. The argument that this papers makes is that the hypodermic provisions in relation to advertising should be lifted. If the private health service providers are to advertise and behave like other business entities, they would be in a strong position to provide information and quality service to that section of the public that can afford and at the same time release the state from the obligation of providing health services to all and concentrate on the disadvantaged members of society.

Methodology
This study is a quantitative study that seeks to use the survey method of research to collect people’s view about the ban of health service advertising and its impact on malaria treatment and management. The scope of the study is limited to the middle class in one Kampala suburb for two reasons. These are this class can afford to pay for the treatment of malaria but are hampered by lack of information because of the absence of advertising and given the inadequacy of resources, the state would then turn the attention to the disadvantaged sections of the population.
Study area
The study was done in the Ntinda-Wandegeya area, targeting the private clinics and pharmacies that provide services to the resident of the Middle class neighbourhood of Ntinda-Naalya-Kiwatule-Kisaasi.

Study population and sample size
The total population of the study were 85 respondents. These included 60 patients that were randomly selected in three hospitals/clinics and three pharmacies in the area of the study. 30 respondents were the doctors/health service providers in the six selected hospitals/clinics and 5 were officials in the Ministry of Health in the malaria control programme.

Sample composition and selection procedure
The sample composed of respondents from three levels (clients of pharmacies and clinics, the management of the pharmacies and clinics and officials in the malaria control programme in Ministry of Health). To get the number of respondents of each category different formulas were used. For clients of pharmacies and clinics random selection was employed-every nth client where n was the 10th patient. In the case of the management of the pharmacies and clinics and officials in the malaria control programme in Ministry of Health the selection was stratified random formula where five pharmacies and clinics were selected.

Sampling at all the three levels was purposive for three main reasons. The first reason was to ensure that all strata in malaria treatment-the policy makers, the service providers and the patients were equally represented in the sample. Second, to enable the paper gather specific relevant information on issues of treatment and access to information to treatment that were being investigated, and, third, to enable the paper get only knowledgeable and confident respondents to generate the required data.

Methods of Data Collection
A self-administered questionnaire was used as the main method of data collection from the selected patients and service providers for two main reasons. First, it was convenient in administering for both the researcher and the intended respondents since they are all reasonably educated. Secondly, it enabled the respondents to read the questions, critically think and thereafter respond freely and willingly. Besides, the self administered questionnaire guaranteed anonymity of respondents, and as such, their responses were presented in their original and authentic form.

In addition to the self-administered questionnaire, telephone interviews were used to collect data from Ministry of Health staff who did not have time on their schedules to either respond to a questionnaire or hold an interview. Responses generated through telephone interviews supplemented those obtained through the self-administered questionnaire, and as such, improved the reliability, validity, quantity, and quality of answers.

Data Quality Control
For purposes of reliability of the findings, the researcher used the triangulation method i.e. the researcher used several data collection methods, which included a self-administered questionnaire, telephone interviews, and informal discussions. All these were used to ensure that data collected were consistent. For purposes of validity of findings, the researcher used the respondents’ validation method i.e. after collecting, analysing and interpreting data, the researcher went back to some of the respondents in the clinics and pharmacies and inquired from them on whether their responses tallied with the interpretations and conclusions made by the researcher.
Data Processing and Analysis
Data processing went through four stages. First, interview and informal discussion responses were noted and then organised. Second, the self-administered questionnaire responses were thoroughly checked for detection and elimination of errors, and ensuring accuracy and completeness. Similar findings were put in one category while dissimilar data were put in another Data analysis involved coding of close-ended questions whereby responses were grouped into categories in order to give exact figures of how many respondents cited or chose a particular category; this was mainly done through the tally method. Percentages and tables were also used among other statistical methods.
Findings
Discussion of Findings

Recommendations
The following are recommendations for resolving concerns raised by respondents in the study.






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