Getting sick represents a risk of falling into poverty for millions of people around the world. The cost of health care put millions of people in the position to choose between buying food, sending children to school or paying to get healthcare. Yet this is not inevitable because solutions exist: Universal Health Coverage (UHC) makes it possible for people to access health care without sacrificing other basic needs.
Universal Health Coverage (UHC): Senegal example
Two years ago, the United Nations General Assembly unanimously adopted a Resolution urging Governments, civil society and international organizations to promote UHC, in order for people to use the health services they need without suffering financial hardship. More than 70 countries worldwide, including 30 of the poorest, have passed laws for UHC and have already started to reap the benefits of healthier communities with potential for stronger economies.
Health care coverage is low in developing countries. In Africa only 10% of the population has health coverage. In Senegal, 60% of the population lives with less than 2 dollars per day and only 20% has health coverage. In 2013 the government of Senegal set a target of covering 75% of its population by 2017.
UHC is an ambitious society project which, first and foremost requires a strong political will for building equitable societies. Political will must be translated into concrete action by building an equitable health system that covers the most vulnerable populations, mobilizing adequate financial resources from both domestic funding and donors’ assistance.
Civil society plays a key role in informing citizens about their health rights and ensuring that the principles of equity, including gender equity, and universality are fully respected. For example, supporting government’s efforts in Senegal means advocating to expand free services beyond the current groups (children under 5 years of age and the elderly) and beyond the current covered diseases. That is why the Pan-African Institute for Citizenship, consumers and Development (CICODEV) has launched the “Access to Health and the Universal Health Coverage” campaign.
Financing UHC: The responsibility of states and donors:
Far from reaching the 15% Abuja Commitment (2001), health expenditure accounted for only 5% of the Senegalese national budget in 2012 according to WHO Global Health Observatory. CICODEV is concerned that the 2015 Senegalese budget plan allocates only 5 billion CFA francs (€7, 6 million) to health whereas more than 25 billion CFA francs (€38 million) are needed to achieve the government goal on UHC. Discussions are underway in Senegal to mobilize additional resources, through innovative funding.
Meanwhile, official development assistance (ODA) represents 19% of Senegal’s health expenditure and hence it plays a significant role in financing health services. However, establishing a progressive taxation system for both individuals and corporations is an essential strategy to mobilize domestic resources to finance UHC in a sustainable way.
UHC post Ebola
The current Ebola crisis in West Africa highlighted the importance of sustainable investment in UHC. Today, the European Union Ministers in charge of Development Cooperation are meeting in Brussels to discuss the short and medium-term EU’s response to Ebola outbreak. They will also review the ongoing process to define the next 15 years global Sustainable Development Goals. They must seize this opportunity to defend the public re-distributive policies such as using ODA to finance UHC in order to support countries committed to making the right to health a reality for their population.
When the Ebola crisis eventually begins to diminish, and the journalists and camera crews withdraw, public interest fades and political pressure on leaders subsides, the people of Sierra Leone, Liberia and Guinea will be left to rebuild their lives, their communities and their countries. Understanding the problems that led to the escalation of the Ebola crisis is essential in order for these countries to emerge safely from it and to prevent another crisis in the future.
The ability of a country to contain an outbreak of an infectious disease like Ebola is largely dependent on the strength of its healthcare system and on having enough staff working within it to cope with the crisis. Clearly the healthcare systems in the affected countries were too weak to control the outbreak. For example, Sierra Leone had 119 doctors serving a population of nearly six million people. This meant that for every 50,000 people in Sierra Leone, there was one doctor compared to a 100 in the UK. That ratio in Sierra Leone falls well below the WHO’s recommended minimum of at least 23 doctors, nurses and midwives per 10,000 of the population.
In Liberia and Guinea, the shortage of healthcare workers is even worse. In these countries, there is only one doctor for every 100,000 people. In addition to the severe shortage of health workers, there are also problems in terms of the number of health facilities accessible to citizens and insufficient medical supplies. For example, in Liberia, there are only 3,352 hospital beds for a population of nearly 4.5 million. Guinea has a similar number of beds (3,435) for a population of nearly 11.5 million. It is hardly surprising then that these countries have struggled to contain the Ebola virus.
Inequality and the rich country drain on health workers
The health worker shortage in Africa is a stark example of global inequality. According to WHO research, Africa has the highest burden of disease of any continent, but has only 3% of the world’s health workers, and less than 1% of the world’s financial resources. While the continent continues to grapple with infectious diseases, such as HIV, malaria, cholera, tuberculosis and child pneumonia, as well as problems with maternal health, there has also been a rise in noncommunicable diseases. But the number of health workers to respond to these challenges remains remarkably few.
In order to address the unequal distribution of healthcare workers, we need to understand the labour market dynamics that affect the training, recruitment, deployment and performance of global and local health workforces. There is a global shortage of healthcare workers, affecting high-, middle-, and low-income countries, from the USA and Germany to India and Uganda. The difference between high-income countries and low- and middle-income countries lies in their ability to address these health workforce shortages, and to invest in the recruitment and training of medical staff and managers. Too often, richer countries simply recruit staff from poorer ones. It is estimated that 10% of Sierra Leone’s trained nurses are working in the UK health system.
There are many issues that lead health workers to seek employment outside their country of origin, including low salaries, inadequate health facilities and a lack of training and career development. Serious investment in these areas is needed in order to avoid the damage to local health services that is caused through the loss of healthcare workers. When significant numbers of doctors and nurses leave the countries that financed their education, there is a huge loss of public investment which makes it more difficult to deliver services and to offer education and training to people who wish to enter the health profession in the future. While workers should enjoy freedom of movement, mechanisms should be in place to support their retention, such as improving working conditions, and remuneration and career development. In Zambia, for example, healthcare workers receive an extra 25% recruitment and retention allowance on top of their basic salary, which has been effective in decreasing the migration of nurses.
Ensuring countries have the human resources tackle health crises
Wealthier nations are more able to make these kinds of investments, not only within their own borders, but internationally through providing aid and sharing expertise. A recent Global Forum on Human Resources for Health recommended that each country with severe healthcare personnel shortages should be supported to develop and implement a budgeted plan to strengthen its health workforce, as part of a broader national health strategy. This should include a special focus on the most poor and marginalised sections of society, as well as strategies to train skilled health workers and maximise their performance.
The Ebola crisis has undermined the economic progress that Sierra Leone, Liberia and Guinea were making, thereby limiting the ability of these governments to make much-needed investments in their public services. It has, however, also succeeded in focusing attention on the shockingly unequal distribution of healthcare workers, which stands in the way of achieving key public health priorities, such as reducing child mortality, improving maternal health, increasing vaccine coverage, and combating HIV/AIDS, malaria and other diseases.
The international community must invest in human resources for health for all. Health workers are the basis of a functioning healthcare system, which in turn helps to drive economic growth, save lives and improve the quality of life for millions of people around the world.
In 2001, I stood in the UN building in front of a huge picture of a woman dying with somebody next to her holding her hand. The writing under the poster read: “you mustn’t die alone”. I wanted to shout: “she mustn’t die full stop”. At that time the new antiretroviral medicines had started to work miracles, bringing people from their deathbeds back to life. Yet as a Ugandan doctor truly said: ‘the medicine is in the North but the disease is in the South’. The pharmaceutical industry was happy to sell the medicines at very high prices in rich countries while turning a blind eye to the rest of the world.
It was largely thanks to a huge global mobilisation of civil society led by people living with HIV that leaders and pharmaceutical companies started to feel embarrassed about denying access to life-saving medicines to millions of people. But it was only after generic competition kicked in that access to medicines became something policymakers talked about. An offer by an Indian company to sell a cocktail of the three basic medicines for one dollar a day slashed the prices of antiretrovirals, meaning that today over 9 million people are on treatment,, including over 7 million in Africa.
Generic competition was possible because India had not at that time implemented the Trade Related Aspects on Intellectual Property Rights (TRIPS) and thus was able to manufacture the medicines. Since adopting TRIPS, India’s ability to produce medicines has been limited. Yet the country has been under immense pressure from multinational pharmaceutical companies, the US and the EU to tighten its IP rules even further and thus to limit access to medicines to those who need them.
It seems that the world is obsessed by granting more and more monopoly power to pharmaceutical companies rather than by investment in research and development (R&D) for medicines and vaccines that are needed for public health.
For this reason Ebola is the other side of the coin to HIV as the intellectual property rights system allows the market to shape R&D priorities, rather than public health needs. That same system allows companies to charge high prices that are unaffordable in developing countries as the HIV crisis taught us.
The fear of Ebola crossing borders and affecting people in the US and Europe has changed the situation – clearly there is now a market for travelers, but more importantly the threat of a global epidemic means that donors may be willing to pay for products that contain the spread of Ebola and other hemorrhagic fevers.
The most promising vaccines that are now being rushed through clinical trials have been developed with public money, mainly from the governments of the US, Canada and the UK.
It is not ethical, sustainable nor safe to leave commercial interests decisions and financing for R&D for products, capable of modifying global health threats, to be dictated by the commercial interests of pharmaceutical companies.
Governments, under pressure from multinational companies, have agreed to a profit -based system (TRIPS) instead of looking for more innovative ways of financing R&D.
Throughout the history of medicine’s development, public funding has played an essential role in developing breakthrough medicines, including for the treatment of HIV and now prevention of Ebola. We need to change the present monopoly ownership system to allow public funds their proper place in stimulating accessible and affordable technologies that make our world a safer and more humane place.
‘We must do more, and do it faster,’ said Tony Banbury, the UN Secretary General’s Special Representative on Ebola, and Head of the UN Mission for Ebola Emergency Response (UNMEER), last week. We need ‘more staff to be deployed to the districts where the disease is. We need more Ebola treatment facilities, more community care centres, more partners on the ground to staff these centres, we need greater mobility. And we need money to pay for it all.’
So it was not much to ask that the world’s most powerful leaders would seize the opportunity of the G20 Summit in Australia (15-16 November) to address the acute global health and humanitarian crisis of Ebola.
Some governments have already made generous pledges of finance and medical staff since the WHO declared this Ebola outbreak a ‘Public Health Emergency of Global Concern’ in August this year. Yet instead of ambitious new commitments to help implement the UN plan, the G20 issued a statement on Ebola that was more talk than action.
Yes, G20 countries want to ‘extinguish’ the outbreak, and will ‘do the necessary,’ but no new cash or human resources were pledged. Their statement seemed to back away from specific commitments from governments; it could only ‘invite’ other governments to respond, whereas it ‘urges’ the pharmaceutical sector, the World Bank and IMF to do so.
There is one apparently new commitment in the statement: a further $300m from the IMF, with an unspecified split between concessional loans, debt relief, and grants. This is in the context, however, of the combined debt of Sierra Leone, Liberia and Guinea being $3.6bn, which is already costing them $100m in debt service in 2014, and will be more next year. Considering the devastating impact of Ebola, these countries need grants and debt cancellation, not new debt.
To be fair, the G20 statement is a little better on solutions for the longer-term. The G20 recommitted to implementing the WHO’s International Health Regulations (which they are legally obliged to have already completed by 2012), that focus on disease surveillance and response capacities. The statement flagged that some G20 countries have initiatives to support countries in West Africa and elsewhere to implement the regulations too.
The World Bank re-announced its idea to develop a contingency fund for health crises, which would provide ready cash in the event of a future outbreak. The fund is supposed to provide a financial incentive for pharmaceutical companies to invest in vaccines and treatments for diseases afflicting developing countries, by assuring them that any vaccine or drug that they produce be paid for (out of this fund) if another epidemic hits. Clearly global financing for rapid response to outbreaks could be a useful vehicle for global actions. However, such solutions must also enhance local capacity to respond to outbreaks, and rapidly mobilise sufficient human and financial resources to help the countries in need.
The Ebola crisis highlights the failure of the current research and development (R&D) system which relies on market incentives for developing vaccines and medicines for public health needs. Financing R&D for vaccines and medicines for Ebola and similar outbreaks needs to happen now. R&D cannot wait till an outbreak is declared a global emergency. Instead the vaccines and medicines must be developed, and be ready for production and distribution at that time.
We will await the details of those proposals. The immediate priority must be focusing on the current outbreak, where there is still a need for greater international response. The UN has set itself a target to get a hold on the epidemic by 1 December – which would require treating 70 per cent of patients, and ensuring that 70 per cent of all burials are done safely. We are now 13 days away from this deadline, and the G20 had an opportunity to push the international response towards this goal. Unfortunately, it didn’t take it.
There is still a long way to go to turn this epidemic around, to reduce suffering and to save lives. This crisis cannot be summarised by numbers of cases and deaths – it is reaching into the heart of these countries, spreading fear and social breakdown. Oxfam is working with people who have lost five members of their family in a single week to Ebola. This kind of devastation is not easily overcome.
The impact also goes far beyond Ebola cases. A major collapse of health services means that deaths and illnesses from other diseases are going unchecked. It is difficult to imagine what can happen to women who have difficult labours when no health service is available for them, or for children that can’t get treated for malaria or pneumonia.
We urge G20 countries to rapidly deliver the promised financial and medical support to the affected countries in order to help bring an end to the suffering of their citizens.
The G20 has missed an important opportunity in the fight against Ebola. Now they have 13 days to prove they can still be world leaders.
Written by Toru Honda, MD, Chairperson, SHARE
On September 1, 2011, the Lancet featured Japan’s 50th anniversary of Universal Health Coverage (UHC). In 1961, Japan formally kick-started its national health insurance system. The system comprised two main components; an employee-based insurance ‘Shaho’ and a community-based insurance ‘Kokuho’.
Now Japan is lauded by WHO and OECD as one of the best countries in the world when it comes to healthy longevity of its population with relatively low medical expenditures. How was this possible? One key factor is the Japanese ‘Peace Constitution’ which underpinned universality and accessibility in health care services. Article 25 of the constitution stipulates that:
“All people shall have the right to maintain the minimum standards of wholesome and cultured living. In all spheres of life, the State shall use its endeavors for the promotion and extension of social welfare and security, and of public health”.
The Lancet articles presented fair analyses and lessons learnt from the Japanese experiences, especially regarding public policy and health system formation. However there is one important factor that was missed in the Lancet articles- namely the Primary Health Care (PHC) approaches. Japanese forerunners struggled to supplement the health system’s failures and shortcomings at the community levels by PHC.
This bottom-up approach has been tremendously important and instrumental than the mention in the Lancet articles. For the war-battered Japanese society, especially in rural areas where doctors have always been a rare commodity, PHC played a critical role.
I will describe the example of two persons who were role models for PHC:
Dr. Toshikazu Wakatsuki, a medical doctor and Mr. Masako Fukazawa, the mayor of Sawaguchi-mura village, who were great pioneers in setting up Community-health and UHC in Post-war Japan.
Dr. Wakatsuki was dispatched to the remote Saku region in Nagano prefecture to work in a forlorn hospital in March 1945 – just a few months before the surrender of Japanese Imperial Army to the Allied Forces. Although he was a gifted surgeon, he got deeply involved from the start in health promotion and preventive activities in the poor and mountainous communities. Since late 1940s, he had helped organize outreach health teams and community health volunteers and jointly started health counseling sessions for poor villagers using role plays pertinent to their everyday health issues and tried to raise health awareness among rural population. By 1980s, thanks to Wakatsuki and local people’s joint efforts, Nagano prefecture saw the incidence of stroke and TB, the two major killer diseases at that time, drastically lowered and medical cost to the population considerably reduced. Even to this day, Nagano stays at the top level among the 47 prefectures and city governments in terms of both male and female longevity.
In 1957, Mr. Fukazawa of Sawauchi-mura village, in the Iwate prefecture, was elected as mayor. The village is in northern Japan and is mostly immersed in snow with bad roads and no doctors. He first introduced state-of-the-art bulldozers into the village to remove deep snow from the roads and thus facilitated the transportation of the villagers to clinics, schools and shops during winter. He also started prenatal counseling and toddlers’ regular health checkups free of charge. In early 1960s Fukazawa introduced free medical consultation for infants under 1 year old and elderly persons above 60. His do-it-alone measure was severely criticized by the then central and prefectural governments because the national health insurance law did not allow such a policy. But Fukazawa proudly declared “Although I know what I did for the infants and the elderly was against the health law, I know it is in accordance with our Constitution, article 25.”
In five years’ time, villagers as well as policy makers were astonished to know that the infant mortality rate in Sawauchi was brought down from 69.6 per thousand to zero!. This marvelous achievement was accompanied by less medical costs compared to neighboring villages in the same prefecture. Eventually the Central Government adopted the same policy. Like Dr. Wakatsuki in Saku, Mr. Fukazawa was also eager to strengthen health promotion and preventive activities. He set up a village health committee and asked the villagers for active participation. For him, UHC was not only about making medical services free but also creating a sustainable and participatory mechanism in the community.
As physician and public health researcher, Julian Hart correctly pointed out in his famous article:
“The availability of good medical care tends to vary inversely with the need for it in the population served. This law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
This law is still valid to remind us of the fundamental factors that undermine the availability of health service. It emphasise that optimistic reliance on market forces must be challenged when establishing UHC both in the community, national and global contexts.
As a member of global society we must contribute to realizing better health for peoples in the developing nations. Our past experiences in UHC could offer important lesson for other countries and UN agencies that governments role in shaping the national health policies is without a doubt of paramount importance. Yet our experiences also shows that grass-roots level initiatives can also make a huge difference to improving the quality of UHC.
A new report published by Oxfam last week calls on governments to reduce inequality by changing the rules and systems that have led to extreme inequality, and by prioritising policies that redistribute money and power. ‘Even It Up: Time to End Extreme Inequality’ firmly presents universal public services – including health and education – as part of the solution to out-of-control inequality.
Health is both a human right and a building block to tackling poverty and reducing inequality. The provision of good quality health care for all – free at the point of use – can mitigate the impact of skewed income and wealth distribution, by closing the gap in life chances between the rich and the rest. Moreover, universal free health care (UHC) with other public services, especially education, puts ‘virtual income’ into the hands of ordinary people, further helping to level the playing field. Between 2000 and 2007, the ‘virtual income’ provided by public services reduced income inequality by an average of 20 percent across OECD countries for example.
In addition, quality health care and education can transform societies, by giving people the tools and ability to challenge unfair rules that perpetuate economic inequality. For example, healthy and well-nourished children are more likely to spend more years at school and to have better cognitive skills that help learning.
But the extent to which public services are able to achieve their inequality-busting potential is heavily dependent on how these systems are designed, financed and delivered. Low levels of public spending and a continued reliance on out-of-pocket payments to fund health services are disproportionately harming poor and marginalised women and men. User fees and other forms of out of pocket payments can push struggling families further into poverty and prevent people from getting the treatment they need.
“I went for a cataract operation. They told me it costs 7,000 Egyptian pounds. All I had in my pocket was seven so I decided to go blind” – a 60-year old woman in a remote village in Egypt”
When health care is not free, poor people are excluded from service or are forced to sell assets and borrow money; leading to debt and thus further perpetuating existing economic hardships. This happens even in rich countries; in the USA, medical debt contributed to 62 percent of personal bankruptcies in 2007.
All too often the amount of money available for governments to spend on public services is limited. Taxation is critical to ensure sufficient public funds can be invested in delivering free healthcare for all. However, the exploitation of tax loopholes, unfair tax rules and tax dodging results in governments’ loss of millions of dollars each year. For example, in 2008/09 the Rwandan government authorized tax exemptions that could have been used to double the health and education spending.
Decent investments in public health services that are free at point of delivery will boost the rights and opportunities of poor people. The growing momentum for UHC – under which all people should get the healthcare they need without suffering financial hardship – has the potential to vastly improve access to healthcare, and drive down inequality.