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3 December 2024
Dr Manal Etemadi is a Research Fellow in our Health Economics team. Originally from Iran, she has dedicated her working life to medical poverty and financial protection in the Iranian health insurance system. Here she blogs about this fascinating work.
A contemporary famous Persian poem said: ‘My pains / Although they are not like the pains of the people / They are the pains of the people’. Spending all my teenagerhood drowning in poetry made me more sensitive to the pain of people, especially the vulnerable ones.
It’s been 10 years since I found my research question, amongst the hundreds of policy problems a health system in a developing country might face. What can we do to protect the poor against health expenditure and intergenerational poverty?
Every time somebody asks me why I focus on poverty in my research, I remember the many long, saddening stories of people I met who suffered medical poverty in silence.
Being born in a low- and middle-income country means you are potentially exposed to a variety of risks to develop disease, both physical and mental. In the trade-off between access to health services or food, work, or thinking about family members’ material needs, health is always the last thing on the list. That’s exactly why people living in poverty should be the first group to focus on.
People living in poverty are more susceptible to both communicable and non-communicable diseases. Unhealthy lifestyles, low levels of literacy and education, lack of access to healthy and sufficient food, especially during childhood, crowded living spaces lacking basic facilities, predispose them to early and more severe disease, especially debilitating diseases.
This poor health, alongside poverty, doubles the challenges of accessing health services. Poverty can result in the death or disability of the family’s provider, reducing the household’s income, ending children’s education, creating intergenerational poverty and facing catastrophic health expenditure.
Poor people in low- and middle-income countries can’t afford to be sick. Generally, the for-profit private sector plays a significant role in service provision. This leads to out-of-pocket payment, especially for poor people who need health services and have nowhere else to turn.
People who don’t have a permanent job don’t have sick leave. When it comes to following up for treatment, each penny for health means less food for the family. This is the reality: parents won’t pay for their health if the cost is their kids’ hunger.
The time it takes to get to the health centre, waiting to be seen by a health professional, means losing the opportunity to do a poorly paid job. This means not being able to afford food at the end of the day. The interval between diagnosis and starting treatment is typically longer amongst people living in poverty. Low health literacy and fear of serious disease play a part. This wait imposes a severe cost burden on families and loses the opportunity of daily income.
I have met so many people like this during my career, either at the hospital or in the health insurance system. The single mother in the most deprived region of the country with three paralysed young children, who can’t afford to pay for their nappies, let alone their medical check-ups. The blind diabetic man with failing kidney and liver, unable to work while his wife, a full-time carer living with social assistance cash subsidy, struggles to access the medicines they need. The 20-year-old man with a spinal cord injury, whose retired dad spent all his savings on failed rehabilitation for his only child, leaving the entire family in extreme poverty.
Ill health can mean using the household’s emergency reserve (assuming it exists), getting help from relatives, reducing consumption of essential goods like food, and selling assets. If the family can survive the financial shock of one illness, the next illness will trap them in poverty.
The situation is even more tragic for refugees and undocumented migrants, who are poor, have lived in conflict and been forced to leave their country. But the neighbouring host country is another developing country, struggling to support the general population, let alone migrants.
Poverty in low- and middle-income countries is the shadow of health. This is why I made an oath to spend my life advocating for equitable health financing. We must break the vicious cycle of poverty and poor health.