Private for profit and UHC: a panel discussion at the International Conference on Public Policy, Milan 1-3 July 2015
In 2012, the UN General Assembly unanimously adopted a resolution to encourage governments to transition towards universal access to affordable and quality health-care services. In 2013, the WHO Director-General described UHC as “the single most powerful concept that public health has to offer”.
A range of financing and delivery mechanisms have since been implemented in diverse international contexts, with limited empirical evaluation of their potential to achieve equitable access to universal health coverage. Financing health care will be negotiated as part of the Financing for Development conference in Addis Ababa in July 2015.
There is strong evidence that no country has achieved or made big strides towards achieving UHC without a strong public health system, yet the position of the private-for-profit sector in UHC reforms remains a subject of wide debate.
At the International Conference on Public Policy in Milan (1-4 July 2015), Oxfam and the University of Edinburgh are co-hosting panel discussion that seeks to examine new and existing evidence on the role of the private sector in health – and the paradigm of public- private partnerships. The session aims to enhance understanding and knowledge of the nature and scope of public-private interactions in health, and to critically evaluate the role of the private for-profit sector in health in the context of achieving UHC in low- and middle-income countries. The session will do this by:
The session will have a strong focus on low- and middle-income country experiences, perspectives and debates, but will also welcome relevant evidence and experience from high-income countries.
Five papers will be presented covering the following:
The papers will be discussed by Dr. Mark Hellowell, University of Edinburgh and Professor Rama Baru from Jawaharlal Nehru University.
The session will be co-chaired by Anuj Kapilashrami from the University of Edinburgh and Mohga Kamal-Yanni from Oxfam. Chairs and discussants will also engage the audience through ‘question and answer sessions where panellists will reflect on substantive issues raised by the presentations, panellists’ own research and interjection from the audience.
Readers are invited to participate in the session via sending comments and questions via twitter. Please follow @MohgaKamalYanni @Akapilashrami
Look out for a follow up blog on the conclusions of the session and links to the presentations.
The research papers are available here.
In its seminal World Health Report of 2010, WHO argued that all countries can make progress towards Universal Health Coverage (UHC) by expanding the number of people covered by effective health services and giving them financial protection from the costs of these services. The report also highlighted the pivotal role of equitable health financing reforms in achieving this objective. These processes ought to be easier in wealthy countries, but even in the world’s biggest economy, due to an inequitable financing system, tens of millions of people still lack effective health coverage.
In Malawi (with a GDP per capita 1/226 of the United States) the health financing situation is particularly challenging. This is especially the case following the suspension of considerable sums of aid financing after the “Cashgate” corruption scandal that brought down the former government. So, faced with a high burden of unmet health needs, a heavily constrained government budget and uncertain levels of external funding, how should Malawi take its next steps towards UHC?
With the public financing situation looking bleak, a knee-jerk reaction might be to look for alternative financing sources and in particular to raise health funds directly from the population – in the form of user fees. But evidence from across the continent over the last thirty years shows that this would be a mistake. Charging patient fees would raise very little revenue, would incur high administration costs and most worryingly would exclude millions of poor Malawians from receiving healthcare. Also with the world looking to build resilient health systems in the aftermath of the Ebola epidemic it would be extremely unwise to suddenly create new access barriers to essential health services.
While concerns around fee-paying wards and bypass fees remain, fortunately, the government recently made clear statements to the effect that the majority of services will remain free at the point of delivery.. Not only is this good news for the health and welfare of the population, it is a smart political move by the Government, who may have remembered the last time they introduced health fees following advice from ex-pat advisers. This was soon after independence when new health charges were met with extensive hostility from the population. This triggered a political crisis and resulted in some ministers losing their jobs. Following this lesson of people power, Malawi was one of the few African countries not to bow to donor pressure to introduce fees in the 1980s, when it continued to provide universal free health care. This undoubtedly contributed to Malawi outperforming some of its neighbours in making progress towards the health-related MDGs. With many other African countries now learning that they too should remove user fees, it would be a tragedy for Malawi to move in the opposite direction.
But if user fees aren’t the answer and with private voluntary insurance also proving an ineffective route to UHC, what steps could the Government of Malawi (GoM) take towards reforming its health financing system? As the 2010 World Health Report and subsequent influential reports have shown, the key to achieving UHC lies in public financing reforms. In particular, it requires increasing levels of pooled public financing and in maximizing the efficiency and equitable allocation of these funds. In terms of raising higher amounts of domestic funding, broader public financing reforms could increase the size of the overall government’ budget and a political choice could be made to increase the health share from 8.6 % towards the Abuja target of 15%. Also, it is to be hoped that aid financing will increase again in the near future because external assistance will be essential for Malawi for at least the medium term if it is to reach adequate levels of public health financing.
But to secure this additional funding, perhaps the best strategy for the health sector will to demonstrate to its domestic and external financing sources that it can deliver rapid results with incremental allocations in funding. This will involve investing additional funds in cost-effective interventions that extend health coverage to more people in Malawi – and especially to the poor and vulnerable.
One immediate “quick-win” along these lines, could be to ensure that people relying on NGO facilities in remote areas also receive free services. This would require increasing government grants to these facilities. In fact this is already a policy priority for the new Government. Fast-tracking this reform would bring health and economic benefits to the communities concerned and political benefits to the government. Looking at UHC success stories in other countries, the government of Malawi and donor partners could also achieve rapid progress by implementing extensive supply-side reforms. For example Rwanda and Ethiopia have made spectacular progress in extending coverage through scaling up services provided through publicly-funded community health workers. Also implementing extensive reforms of medicines supply systems to ensure the provision of free generic medicines and health commodities has proved a very effective way to increase coverage of essential services. Furthermore these types of pro-poor initiatives could prove an attractive proposition for donors wanting to re-engage in Malawi’s health system.
Therefore even though the health financing situation may appear daunting in Malawi, this doesn’t mean that a completely new strategy based on private financing will be the solution. International evidence shows that this would probably result in a deterioration in health coverage – particularly for the poor. Instead Malawi would be better advised to learn from its own history and re-invigorate its publicly financed health system, which as the world has learnt is the proven route to achieve universal health coverage.
Levy J 2015 In U.S., Uninsured Rate Dips to 11.9% in First Quarter Gallup 13 April 2015 Available at http://www.gallup.com/poll/182348/uninsured-rate-dips-first-quarter.aspx Accessed 23 June 2015
List of countries by GDP (nominal) per capita Wikipedia Available at: https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nominal)_per_capita Accessed 23 June 2015
Tran M 2014 Malawi aid freeze could hit health and education sectors The Guardian 14 January 2014 Available at http://www.theguardian.com/global-development/2014/jan/14/malawi-aid-freeze-health-education Accessed 23 June 2015
Yates R 2009 Universal health care and the removal of user fees The Lancet Volume 373, No 9680 pages 2078 to 2081 available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60258-0/abstract Accessed 23 June 2015
Heymann D L et al 2015 Global health security: the wider lessons from the west African Ebola virus disease epidemic The Lancet, Volume 385 , Issue 9980 , 1884 – 1901 available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60858-3/fulltext Accessed 23 June 2015
Chauwa A 2015 Malawi govt backtracks on hospital user fees Nyasa Times April 5 2015 Available at http://www.nyasatimes.com/2015/04/06/malawi-govt-backtracks-on-hospital-user-fees/ Accessed 23 June 2015
Messac L 2014 Moral hazards and Moral Economies: The Combustible Politics of Healthcare User Fees in Malawian History South African Historical Journal Volume 66 Issue 2 Available at http://www.tandfonline.com/doi/abs/10.1080/02582473.2014.903292?journalCode=rshj20#.VYmGt1xa_ww Accessed 23 June 2015
Cortez R et al 2014 Achieving MDGs 4 & 5: Malawi’s progress on maternal and child health The World Bank Knowledge Brief 92548 Available at http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/11/11/000406484_20141111141118/Rendered/PDF/925480BRI0Box30August0201400PUBLIC0.pdf Accessed 23 June 2015
Chuma J, Mulupi S, McIntyre D Providing Financial Protection and Funding Health Service Benefits for the Informal Sector Evidence from Sub-Saharan Africa RESYST Working paper 2 April 2013
Evans DB et al 2010 The World Health Report Health Systems Financing – The Path to Universal Coverage The World Health Organization
Mogombo K 2015 Gondwe unveils MK901.6 billion 2015/2016 Budget Mana online 25 May 2015 Available at http://www.manaonline.gov.mw/index.php/business/item/3011-gondwe-unveils-mk9016-billion-20152016-budget Accessed 23 June 2015
Crowe S 2013 In Ethiopia, a far-reaching health worker programme has helped reduce child mortality across the country UNICEF Available at http://www.unicef.org/infobycountry/ethiopia_70372.html Accessed 23 June 2015
Joychen P J 2013 Free medicine scheme makes a big splash in Rajasthan Deccan Herald 8 February 2013 Available at http://www.deccanherald.com/content/310818/free-medicine-scheme-makes-big.html Accessed 23 June 2015
In recent weeks, two separate reports have been released which critique the trend by DFID to increasingly involve the private sector in development, including the provision of health and education.
The first report by Global Justice Now maps a variety of initiatives supported by DFID to open up health and education markets to private firms – from a £25 million project with Adam Smith International aiming to enrol 50,000 more children in private schools in Kenya, to a £7million partnership with Coca-Cola on girls’ education and training in Nigeria. This latter scheme is part of a broader DFID-Coca-Cola collaboration which openly benefits the company’s sales plans, the report reveals. DFID’s support of HANSHEP – or ‘Harnessing Non State Actors for Better Health for the Poor’ – gets a particular profile too, including through their £35 million contribution to a Public-Private Partnerships advisory facility. DFID’s influence is shown to extend beyond the financial commitments it makes, through its advice to governments as they develop private sector-friendly policies for the delivery of services.
The second report by the UK Government’s aid watchdog, Independent Commission for Aid Impact (ICAI), reviews how DFID is working with the private sector to achieve its mandate to tackle poverty around the world. Worryingly it states that ‘DFID should reassess how it appraises, monitors and evaluates its engagements with business to ensure fitness for purpose and a sharper focus on the poor’ and that ‘In some cases… we are not confident that DFID’s support is additional to what businesses would have done anyway’.
For Oxfam, the dangers of the promotion of privatisation of health and education services, especially in relation to the rising tide of global inequality, are clear. Private services benefit the richest first and foremost, leaving people in poverty behind[i]. When health care is sold through the private sector for example, quality care and medicines are often available only to those who can afford it, while poor people may be forced to rely on low-quality or unqualified care like drug hawkers and grocery shops selling medicines[ii].
Indeed ICAI’s report notes that a survey undertaken of a HANSHEP programme operating in Ghana, Kenya and Nigeria – the African Health Markets for Equity – found ‘that less than 1% of people using facilities supported by AHME were from the bottom income quintile in Ghana and other participating countries’.
Prioritising the private sector can see public services eroded as scarce financial and human resources are diverted from the public to the private system, through an internal ‘brain drain’ and expensive public-private contracts. Oxfam’s exposé of a Public-Private Partnership (PPP) hospital in Lesotho, found that the hospital was costing at least three times the amount of the old public hospital it was built to replace for example, amounting to 51% of the total health budget for the entire country[iii]. The International Finance Corporation (IFC) – manager of the DFID-supported PPP advisory facility mentioned above – advised on this PPP arrangement, reaping a $720,000 ‘success fee’ for its work[iv].
When richer people opt out of public systems for health care and education, they also have minimal interest in promoting spending on public services or demanding better quality, as well as less incentive to pay taxes. Thus a downward spiral of deteriorating quality can be set in motion[v]. The result is a 3 tiered system of five star services for the richest people, and a mixture of deteriorated public and unqualified private providers for the poorest. Inequality and poverty thrive.
The same tiered system also develops in education, where children of rich families often attend elite private schools and universities, while poor and lower-middle class children may have a choice between poor quality private education or deteriorating public schools. DFID, as well as other donors such as the World Bank, has been heavily promoting for-profit “low-cost private schools” for delivering better learning outcomes. However, the evidence on quality in these schools is weak. They rely on untrained teachers, standardization and scripted lessons to keep costs down. Moreover, we know that any kind of school fees – as well as other related costs like uniforms and transportation – will block access to schooling for children from the poorest families. Relying on fee-charging schools to deliver education will mean that too many of the world’s future Einsteins and Beethovens will be lost – shut out from accessing a quality education because of their poverty.
Profit-making companies also have clear interests in pushing for their own increased role in social sectors. In South Africa, private health insurance firms have been accused of lobbying against a new National Health Insurance Scheme that promises to provide essential health care for all.[vi] In the USA alone, the pharmaceutical and healthcare sectors spent more than $487m on lobbying in 2013, more than was spent by any other sector[vii].
Debates on the role of public and private actors in health and education are increasingly relevant as the development community prepares for this summer’s Financing for Development (FFD) summit, where mechanisms for financing the new post-2015 development goals will be discussed. A submission led by the International Chamber of Commerce (ICC) responding to the draft negotiating text for the Summit, pushes the insertion of new language to promote ‘blended finance’ (public and private) and a bigger role for private finance, including ‘using limited public finance to mobilize private’. In one shocking suggestion, the submission also advocates for the commitment to ‘move away from harmful, unsustainable [private sector investments]’ to be deleted too.
It is critical that any public funds used to leverage private investment, and private finance generally, comply with development effectiveness principles and be subject to robust environmental and social safeguards, be fully transparent and accountable, and be equitable in risk and benefit sharing between governments, donors and private investors. Public Private Partnerships (PPPs) should be considered only where evidence of effectiveness is abundant and where alternative delivery options are not. Sustainable development criteria for PPPs should be adopted and endorsed by the private sector and by governments. Such criteria should also include the PPP design and implementation process being fully owned by the ostensible beneficiaries, full transparency of contracts and terms, and assessment in terms of equitable and affordable access to infrastructure and services. Oxfam, together with other agencies, have developed a series of sustainable development principles to guide how public-backed private finance is used.
DFID should learn from past experiences and revise its support for private sector financing and delivery of these critical services, prioritising instead investments in strong public services that can deliver universal health coverage and education for all.
[i] Basu et al found that the private sector in health care tends to serve higher socio-economic groups for example. Basu et al (2012) ‘Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review’, PLoS Medicine, Vol. 9., Issue 6. http://www.plosmedicine.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pmed.1001244&representation=PDF
[ii] Oxfam (2009) ‘Blind Optimism. Challenging the myths about private health care in poor countries’, pp.10-12, http://policy-practice.oxfam.org.uk/publications/blind-optimism-challenging-the-myths-about-private-health-care-in-poor-countries-114093
[iii] Oxfam (2014) ‘A Dangerous Diversion. Will the IFC’s flagship health PPP bankrupt Lesotho’s Ministry of Health?’ http://policy-practice.oxfam.org.uk/publications/a-dangerous-diversion-will-the-ifcs-flagship-health-ppp-bankrupt-lesothos-minis-315183
[v] T. Smeeding (2005) ‘Public Policy, Economic Inequality, and Poverty: The United States in Comparative Perspective’, Social Science Quarterly, Vol. 86 (suppl): 955-83.
[vii] Oxfam (2015) ‘Wealth: Having It All and Wanting More’. https://www.oxfam.org/en/research/wealth-having-it-all-and-wanting-more
The Ebola crisis exposed the weaknesses of healthcare systems in low- and middle-income countries created mainly by insufficient funding. Given the global community’s commitment to universal health coverage (UHC), the Ebola outbreak has prompted serious reflection among health policy decision-makers. One of the central features of this debate is financing: how can relatively poor countries find the money to pay for universal health coverage? To date, low- and middle-income countries have been growing toward UHC through social health insurance systems funded through employment. Yet, progress has been slow and uneven leaving people in the informal sector, who are the majority of the population, out was insurance schemes. Rather than seeking innovative solutions to this old problem, what is needed is a renewed commitment to an old solution: tax-based financing.
Taxation has sometimes been overlooked in debates around financing UHC. The Lancet’s recent Global Health 2035 commission only discussed taxation in the context of specific consumption taxes on risky behaviours, such as tobacco and alcohol. These so-called “sin taxes” are important public health measures but they are unlikely to generate sufficient revenue to finance UHC. Instead, low- and middle-income countries should look to translate economic growth into healthcare spending through general taxation.
Using data from low- and middle-income countries my colleagues and I examined the association between tax revenues and health spending. We found that tax revenue was a major statistical determinant of progress towards UHC. Each $10 per-capita increase in tax revenue was associated with an additional $1 of public health spending per capita. Whereas each $10 increase in GDP per capita was associated with an increase of $0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax financing is an efficient way of translating economic growth into health spending.
Countries with more tax revenues have also made more progress on other indicators of UHC, even after adjusting for economic activity in the country. Among tax poor countries, greater tax revenues are associated with more women being attended by a skilled healthcare worker during pregnancy and greater access to healthcare for all people.
How taxes are collected is also important. Governments can choose how they collect tax revenues. The IMF and World Bank traditionally split these modes of taxation into three types: 1) Taxes on income, profits, and capital gains, which tend to be progressive because the poor pay a smaller proportion of their income; 2) Taxes on goods and services, which tend to be regressive because the poor pay a larger share of their income; and 3) Other taxes, such as property taxes. In recent years, low- and middle-income countries have tended to rely more heavily on taxes on goods and services because they are easier to collect. However, they can also increase the cost of staple foods and healthcare, unless these specific goods and services are exempt from such taxation. Because taxes on goods and services can increase the cost of food and healthcare they may also reduce access to these necessities among economically deprived households and communities.
With the same tax data described above, we examined whether changes in taxation within a country over time was associated with changes in infant mortality. The results were clear. Where taxes on goods and services increase (thereby increasing the cost of food and healthcare) infant mortality also increased. However, where taxes on income, profits, and capital gains increase (progressive taxation) we do not find this same relationship.
Expanding the tax base in low- and middle-income countries can be difficult, especially if governments are going to rely on income, profits, and capital gains. This is because there is a very large informal economy in many of these countries, tax revenues from income can be unstable. Yet, the UK government has shown how some countries can increase revenues through reducing corporate tax evasion. Under the direction of DFID, tax accountants worked with two developing countries (Ethiopia and Tanzania) to reduce tax evasion, increasing tax revenues by 40% in 3 years. This type of intervention is especially important because before the Ebola outbreak in Sierra Leone, only one in five leading mining companies had paid any corporate income tax. If they had been adopted sooner, such interventions could have strengthened the health systems in Sierra Leona and other Ebola-hit countries.
Tax is not sexy. Tax is not necessarily innovative. But, tax is the cornerstone on which we can achieve UHC.
This post is based on: Reeves A., Gourtsoyannis Y., Basu S., McCoy D., McKee M., Stuckler D., 2015, Financing universal health coverage: effects of alternative tax structures on public health systems in 89 low- and middle-income countries. The Lancet, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60574-8/abstract
Significant advances towards Universal Health Coverage (UHC) in a number of low and middle income countries have fostered an enthusiasm for UHC amongst governments and civil society organisations (CSOs). This is a welcome shift yet the progress remains fragile. An Oxfam programme delivered in Ghana, India and Egypt with funding from the Rockefeller Foundation has highlighted a number of lessons on how to increase demand for UHC and help governments make concrete steps towards achieving it.
Examples of programme activities
The CSOs participating in the project have engaged in national level policies on health with specific focus on UHC. They acted as conveners for stakeholders and provided platforms at key moments such as the national budget and policy processes. Blogs and policy briefs were used to promote UHC as a national priority.
Oxfam provided technical support to the CSOs via organising webinars on topics such as financing UHC, sharing experiences of Ghana and India’s insurance systems and via sharing advocacy tools as well as mentoring in project planning. Platforms were created for linking and learning, technical backstopping and training and an online archive of products and materials for future advocacy work by partners and Oxfam staff was established.
UHC public awareness was increased through activities such as mobile clinics and a discussion camp in Egypt, marches in Ghana and translation of a UHC cartoon to a local language in India.
To crown it all, partners participated in the first UHC day (12 December 2014). In India, Oxfam collaborated with the World Health Organisation, Public Health Foundation of India and the Rockefeller Foundation to commemorate the UHC day. The celebrations included a panel discussion on “UHC in India: Opportunities and Challenges” and sharing Oxfam India’s draft discussion paper, “Financing Healthcare for all in India: Towards a Common Goal”.
The CSOs participating in the project identified the following learning lessons:
Low level of awareness and understanding of UHC and the post 2015 development framework consultations among the legislature, executive, the media and the civil society was a challenge. The project aimed to address this challenge via its activities in different country contexts and via the use of global resources such as informative briefing papers. In Ghana, discussions were held with the Ministry of Health on the need to build the capacity of parliament on UHC and the post 2015 development framework consultation and process. Over the longer term, the Ghana UHC campaign is hoping to build the capacity of Ghanaian civil society on UHC. In Egypt, CSOs used both traditional and social media as well as direct contact with communities to raise awareness.
Influencing governments on UHC financing is a major challenge because of the low level of public funding of health services and the rising trend towards privatisation of healthcare. Advocating for a pro-poor strong public health system has been a difficult task. In order to address this challenge, the use of research evidence such as those published by Oxfam and others has given credibility to support for public financing. The web portal on the social regulation of private sector was developed in India, which provides information and invites citizens to share their experiences of seeking care at private health facilities..
The limited time for the project (only one year), while providing a base for CSOs activities, did not allow the organisations sufficient time to develop the work to a level where real impact can be seen. With the current focus on long-term planning and financing of UHC, it is important that donors also extend funding for NGOs the necessary time to achieve tangible results.
This project has formed a firm foundation on which further work on UHC can be built. The lessons learnt from the project can be used to inform and improve the outcomes of similar projects.
Even before the devastating Ebola epidemic in West Africa, development agencies were highlighting that health indicators in this region were lagging the rest of the continent. In a 2013 report UNICEF noted:
“West and Central Africa in particular requires a special focus for child survival, as it is lagging behind all other regions, including Eastern and Southern Africa, and has seen virtually no reduction in its annual number of child deaths since 1990.”
But as Ebola has overwhelmed some countries and threatened many others, questions are being asked about the role of international agencies in undermining health systems in West Africa. Specifically, fingers have been pointed at the 1980s structural adjustment policies of the World Bank and IMF for forcing poor African countries to cut public spending on health. These policies also shifted the financing burden of health services onto poor populations by charging them user fees. Interestingly at the time one of the leading critics of this policy was none other than the current President of the World Bank.
Other health policies promoted at the same time were also damaging to poor people’s access to health care. The Bamako Initiative (BI) launched in 1987, was prompted by UNICEF and WHO as community management of “revolving drug funds”. However, BI institutionalized user fees for essential medicines in some of the poorest countries in the world. Not surprisingly, with most households unable to pay these fees, utilization of health services in the countries concerned slumped, with the poor most likely not to seek care. In West Africa where the BI became established, typical utilization of curative services at the start of the millennium was around one visit per person every three years!
Thankfully a huge volume of research evidence over the last 20 years has conclusively proved the folly of this approach. User fees have been shown to be ineffective in raising health revenues, inefficient in incurring high administration costs and inequitable in excluding the poor. They have also resulted in outrageous human rights abuses where poor people (often women and babies) have been detained in hospitals because they can’t pay their bills. Sadly this practice continues to this day.
As a result of these findings many prominent aid agencies have radically changed their health financing policies, including the World Bank whose President has referred to user fees as “unnecessary and unjust”. Even one of the architects of the World Bank’s previous pro-user fees policy has publicly stated his change of position on user fees although he did not admit that it was a mistake then.
However, not all agencies have been so clear in making a break with the past. As recently as 2008 in its State of the World’s Children Report, UNICEF was still championing the Bamako Initiative and openly criticizing NGOs that were advocating the removal of user fees Indeed one of the countries singled out for praise in implementing the BI was Guinea, from where the current Ebola epidemic has spread
It is true that the international agencies involved in promoting the BI have gradually shifted their positions on health financing and are now rallying behind the goal of universal health coverage. However, the agencies that promoted the BI need to acknowledge their past mistakes rather than assuming that the Bamako Initiative never happened.
This is problematic because whereas other development agencies are aware of the changing consensus on health financing, this may not be the case in many countries. Some governments are still laboring under the illusion that the BI is working and thus user fees policies are still implemented. Thankfully, some countries in the region are now replacing user fees with public financing, for at least some of the population, most notably in Liberia, Ghana, Senegal, Niger and Sierra Leone. The latter’s free health services initiative for pregnant women and children under 5 has been a particularly good example of the impact of removing user fees.
However in West and Central Africa, out-of-pocket payments including user fees remain by far the biggest health financing mechanism. With the Ebola virus not beaten yet in the region, the lack of effective healthcare coverage doesn’t only threaten the health of the population in the region but also poses a threat to global health too.
Therefore, as the international community begins to support countries in West Africa to develop more resilient health systems, there is one immediate action they should take as a top priority. This action would cost practically nothing but its impact could be profound in helping put countries on a path towards equitable universal health coverage. After a twenty-eight year failed experiment, it’s time that agencies including UNICEF and WHO formally and publicly end the Bamako Initiative.
 UNICEF 2013 Committing to Child Survival, a Promise Renewed, Progress Report 2013 Available at: http://www.unicef.org/publications/files/APR_Progress_Report_2013_9_Sept_2013.pdf
 IDS Practice Paper in Brief 2015 Ebola and Lessons for Development Available at: http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/5849/ID557%20Online.pdf
 Kim JY et al editors 2000 Dying for Growth Global Inequality and the Health of the Poor. Common Courage Pres
 UNICEF 2009 Maternal and Child Health the Social Protection Dividend: West and Central Africa
 Yates R 2009 Universal Health Care and the Removal of User Fees The Lancet 373: 2078–81 Available at http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60258-0.pdf
 Kippenberg J Burundi A High Price to Pay Detention of Poor Patients in Hospitals 2006 Human Rights Watch Volume 18 No 8(A) New York, USA
 See https://www.youtube.com/watch?v=RNfzXh4I-Pw
 Kim JK Poverty Health and the Human Future [Speech] World Health Assembly, Geneva, Switzerland 21 May 2013 Available from: http://www.worldbank.org/en/news/speech/2013/05/21/world-bank-group-president-jim-yong-kim-speech-at-world-health-assembly
 Boseley S (2012) From user fees to universal healthcare – a 30-year journey. The Guardian
 UNICEF 2008 State of the World’s Children: Child Survival available at: http://www.unicef.org/sowc08/docs/sowc08.pdf