As world leaders prepare to gather for the 66th World Health Assembly on May 20, social movements are questioning the market-friendly version of universal health coverage (UHC) it is promoting.
One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12th Five Year Plan, which uncritically endorses the private medical sector and focuses on health insurance schemes. In a recent paper – JSA proposes an alternative UHC model.
Public financing for whom?
In the past five years there has been an impressive roll out of government-funded insurance schemes in India that are supposed to improve the country’s public health system. In theory, treatment covered under these schemes can be provided by any accredited facility. But in practice the majority of providers are found in the largely unregulated private sector which already accounts for 80% of outpatient and 60% of in-patient care according to the National Sample Survey Organisation (NSSO), making India one of the most privatized systems in the world. India’s healthcare system is increasingly dominated by big hospitals chains (e.g. Apollo Hospitals) with an infamous track record of expensive services and unethical practices. As it is, health insurance schemes mostly channel public monies for private profit. For example, from 2007 to 2013 the state of Andhra Pradesh allocated a total Rs.47.23 billion to facilities accredited under the Arogyasri scheme, of which Rs.36.52 billion went to private facilities.
Getting it right
Health is a right, and priorities should be based on citizens’ needs. What the majority of Indians lack is comprehensive primary care, but current health insurance “packages” only insure beneficiaries for ailments that require hospitalization. They cover a very small portion of the burden of disease, excluding out-patient treatments for tuberculosis, diabetes, hypertension, heart conditions, and cancer among others. Evidence from the first such scheme in India – Arogyasri – suggests that it consumed 25% of the state’s health budget but addressed only 2% of the burden of disease.
Who inverted the pyramid?
This situation ends up distorting the very structure of the health system by starving primary care facilities to the benefit of more profitable secondary and tertiary care. In 2009-2010, direct national government expenditure on tertiary care was slightly over 20% of total health expenditure, but if one adds spending on the insurance schemes the total would be closer to 37%. In Andhra Pradesh, following the implementation of Arogyasri, the proportion of funds allocated for primary care fell by 14%.
A good health system is like a pyramid: the largest numbers should be treated at the primary level where people live and work. We need to flip the inverted pyramid that has been created and offer a new roadmap predicated on public funding and provisioning of a public system that reprioritizes primary health care, and is comprehensive, integrated and accessible to all.
The health insurance schemes in place fail to address another key issue: access to medicines. Paradoxically, India is the largest producer of drugs in the developing world and at the same time the country where the WHO estimates the greatest number can’t afford the medicines they need. Since the Patent Act was amended in 2005, domestic pharmaceutical companies can’t produce cheaper versions of new drugs, which are now sold by multinationals at prices well beyond the reach of most patients. Poor regulations also means more than 50% of the average family spending on medicines is on irrational or unnecessary drugs and diagnostic tests according to the NSSO. Clearly, the pharmaceutical sector must be reigned in, and all essential drugs should be made available, free of cost, at all public facilities.
Addressing public health gaps
The task of achieving health for all in India will not be easy. Current public health services are marked by poor access, low quality and limited choice. Besides rampant corruption, poor management results in mismatches between demand and supply of services: facilities aren’t distributed optimally; equipment and funds fall short of requirements and don’t flow efficiently. Labour shortages can be partly explained by disinvestment in medical education and flawed deployment mechanisms. Although programs such as the National Rural Health Mission have made some inroads to improve services, much remains to be done. The problem is largely one of unresponsiveness to citizens coupled with unreliable technical estimates of costs and disease burden, leading to ill-informed prioritization.
It is necessary to recast the UHC debate and propose alternatives to strengthen the public health systemto address these problems and to build integrated, comprehensive services with strong mechanisms of accountability. Key to these changes are the following:
Over the short term, we also need to explore alternate ways of harnessing private resources for public health goals. Given the sheer size of the private sector, it is not possible to entirely ignore it while planning for equitable access to public services. It’s not a monolithic entity either; some segments such as charitable, faith-based and other not-for-profit healthcare facilities that work in less developed parts of the country can fill certain critical gaps in the public system. Under clear terms and conditions, other private providers such as general practitioners or small and medium-sized hospitals could be in-sourced to complement available public health services. Importantly, there should be no transfer of assets and resources into private hands and kickback statutes should be put in place to ensure there are no referrals with conflict of interests.
All the possible mechanisms for harnessing the private sector should be seen as supplementary (and often interim) measures, and not as a substitute for very significant scaling up and strengthening of the public system both in terms of quality and accessibility.
There is a need to reclaim public systems, to strengthen and expand them. Moving toward health for all requires major transformations in health care, but also in a wide range of social determinants of health – food security and nutrition, water supply, sanitation, working conditions, housing, environment, education and more. We need to build broad-based alliances for social change to redefine the relationship between people and their public systems.
Amit Sengupta is a Research Associate with the Municipal Services Project and Associate Global Co-ordinator with the People’s Health Movement, a global network of 18 national chapters that includes India’s Jan Swasthya Abhiyanfor which he acts as National Co-convenor.
Madeleine Bélanger Dumontier is Communications Manager for the Municipal Services Project, a global research initiative that explores alternatives to the privatization and commercialization of service provision in the electricity, health, water and sanitation sectors.
Photo: Rajeev Chaudhury
On 1st April patients in India celebrated a victory in the battle for affordable medicines. The Indian Supreme Court rejected a patent on B crystalline form of Imatinib Mesylate (Glivec®/Gleevec®), a cancer treatment developed by the pharmaceutical company Novartis. This decision enables patients suffering chronic myeloid leukaemia to access generic versions of Glivec at $175 per month – nearly fifteen times less than the $2,600 charged by Novartis. As the court handed down their verdict, it became clear that India chose to prioritise protecting the health of citizens above the commercial interest of pharmaceutical companies.
Novartis has been trying to challenge the Indian Intellectual Property law since 2006 when its patent application for Glivec was first rejected. Novartis claimed that Indian Patent Law did not conform to the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). It is worth noting that no other company or country has ever sought to make this claim against India to the World Trade Organisation – the body responsible for settling such disputes. After much debate, the court turned down the Novartis case.
The case rests on the way the India intellectual property law makes use of many of the flexibilities of the TRIPS agreement, including how the patentability criterion defines innovation. Section 3D of the Indian law, which is condemned by Novartis and other pharmaceutical companies, prevents patents on new forms, uses, doses, formulations and combinations of known medicines or substances. Instead, to be granted a patent, the revised medicine must show significantly enhanced therapeutic efficacy.
In the Novartis case, although the company provided evidence of improved physical features of the medicine, it did not demonstrate improved therapeutic efficacy. Novartis presented some late evidence of increased bio-availability of the revised medicine but even that was based on comparison with the original molecule of imatinib which is actually no longer marketed as treatment. Moreover, increased bio-availability does not automatically mean enhanced therapeutic efficacy.
The claim by pharmaceutical companies that Indian patent law will stop innovation is without foundation. On the contrary, Section 3D encourages innovation (incremental or otherwise) by preventing companies like Novartis securing patent extensions for making trivial changes to their products – a practice known as ‘Evergreening’. Allowing companies to secure patents, and therefore profits, by making trivial changes to existing products acts as a disincentive for much needed R&D investment in new products to treat and prevent diseases.
Novartis, along with other companies are also claiming the court ruling will put an end to R&D investment by companies in India. They argue that the unlikelihood of securing patents removes any incentive for R&D investment. The reality is that other scientific and economic factors have proven much more important for R&D investment including the availability of a strong science base in a country, appropriate infrastructure and an industry-friendly tax system.
In short the court resolution means that more people suffering chronic myeloid leukaemia can be treated now. Novartis says that its patent on Glivec is protected in 40 countries. That means the rest of the world can now use generic versions of Glivec without worrying about patent issues. Developing countries need to learn from India in promoting the use of high-quality generic medicines so that patients can access treatment at affordable prices.
The story highlights the urgent need to review the dysfunctional intellectual property system and find new ways of stimulating R&D to produce new medicines that have real therapeutic value. In the interim, pharmaceutical companies should stop spending millions of dollars on litigation in their effort to secure patents for evergreening their products. Instead they should invest in R&D for new products that could make a real difference to people’s lives.
Mohga Kamal-Yanni is a Senior Health and HIV Policy Adviser at Oxfam GB
In 2009 Oxfam published “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” to help redress what we saw as an international health discourse increasingly dominated by unchallenged private sector advocates. Some of those same advocates accused Oxfam of being purposefully selective with the evidence.
The health team at Oxfam were therefore very pleased to see the recent publication of a thorough and balanced independent appraisal of peer-reviewed evidence on this topic in PloS Medicine. The study supports many (not all) of our conclusions about both the public and private sector.
In their research Basu et al. assess the comparative performance of the private and public sectors in health across a range of health system performance areas. They are clear that comparative evidence is often lacking and that distinctions between what is public and private are often difficult (for example when public facilities act more like commercial operators by charging fees). With these limitations acknowledged, the authors’ own conclusion states:
‘Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients’.
Like Oxfam, the authors of this comparative study make special note of the World Bank as an influential advocate of public-private partnerships in health, but one whose claims are often unsubstantiated by their own data. The authors raise concerns about a conflict of interest for the World Bank that may undermine the validity of their research and analysis on this topic.
Some highlights from the paper are listed below (though I recommend reading this important article in full – especially for interesting country examples):
Access and responsiveness
Accountability, transparency and regulation
Fairness and equity
Other important findings
And on the World Bank….
The evidence from this study shows that while public health systems are often weak and under-resourced they still deliver better quality of care, more equitably and with greater efficiency than the private sector. The study highlights the tendencies of private providers to serve higher socio-economic groups, have higher risk of low-quality care, create perverse incentives for unnecessary testing and treatment, and suffer from weak regulation. It also suggests there are a number of ways public health systems can do better. They must be more responsive to patients and more accountable to citizens, improve systems for distributing essential inputs like medicines, and address financial barriers to accessing care (such as formal and informal fees).
These are legitimate challenges that deserve thoughtful attention and action, but they should not be used as evidence of the superiority of private sector approaches. Instead, the policy response to these findings should be very clear: far more effort and resources must be mobilized to maximize the clear advantages of public health systems, rather than further starving them of the resources and support they need to deliver equitable and quality health care for all.
The question of how to raise domestic revenue for health is something that policymakers across Africa continue to grapple with. In recent decades different options have been tried and tested –user fees, small-scale community based health insurance, private insurance schemes, and taxation. Today Kenya, like many countries in the region, is left with a complicated patchwork of different schemes offering different levels of coverage to different population groups. Merging these into a single national risk pool which uses public financing to provide for all citizens will improve access to healthcare and reduce administrative costs.
One way of raising more money for health would be to introduce an earmarked tax on diaspora remittances. “According to the Central Bank of Kenya, money remitted by the diaspora is growing monthly,” says Dr Jane Chuma, a health economist and senior research scientist at Kenya Medical Research Institute in Kilifi. “Last year, over $1 billion (Sh85 billion), higher than the revenue earned from coffee or tourism, was remitted to the country. Putting a little levy on foreign transactions could raise significant money for health. In 2009, Gabon raised $30 million (Sh2.6 billion) from diaspora remittance tax, which they put into health care.”
Another option is to merge existing funds to create a single National Social Health Insurance Fund which pools all the resources that are currently available for health into one pot and stop the duplication of effort. “Tax funds allocated to health, NHIF contributions, community health insurance schemes and donor money, if pooled together, can create a large enough single pool. This will ensure that both the rich and the poor are covered while reducing administration costs. As there will only be one organisation buying services, it will have bargaining power.”
During the NARC government when Charity Ngilu was the Minister for Health, there was some discussion about starting a National Social Health Insurance Fund in Kenya. It was passed by Parliament but the president did not sign it. ‘The big boys’ as Hon. Raila Odinga said in Kenya’s first presidential debate on February 11, ‘shot it down’. These ‘big boys’ included private health insurance schemes and private hospitals.
“What Kenya needs are leaders who are willing to put the private sector to task. That they either be part of these reforms or lose altogether by not working together with the public system under universal health care. There are many innovative ways of using private doctors to provide health care in public facilities. What we lack is political will and leadership,” says Dr Chuma.
Whatever the means of raising money, people need to be confident that the money will not be misused. The history of National Health Insurance Fund is plagued with corruption and there is little trust in the public that they will deliver should they take on the role of National Social Health Insurance Fund. “A new institution would need to be in place to swallow NHIF. It would require re-branding, with a new board and new staff. It shall require a lot of work to build trust in the public health care system where beneficiaries will be expected to seek services,” says Dr Chuma.
Public health facilities need to be closer to the people, be well equipped and charge no fees. In this way, each citizen in the country will be able to walk into any health facility, get whatever treatment is required and walk out without paying a shilling. However, removing charges alone will not be enough to keep patients coming. The public health facilities have to be fully staffed and well stocked with medicines. It is not enough, for example, to say that giving birth at a maternity ward is free and then expect mothers to buy gloves, cotton wool and drugs because there are none available at the facility.
A commonly-held fear of a ‘walk in, walk out’ health facility is that providers will be overwhelmed by people who may not need the service but take advantage of its availability because it is free. This is an unfounded fear because there are other costs related to seeking care like costs of transport or the cost of losing a day’s work to go to a health facility. Few therefore, will come to the facility when they really do not need services.
To reduce costs of payments for treatments, the government will need to invest heavily on preventative measures to reduce the heavy burden of infectious diseases. At the moment more money is going to curative rather than preventative health care. The greatest weapon against infectious communicable disease is good hygiene. This will require the government to provide safe water and improve waste disposal. The second greatest weapon is provision of essential vaccines followed by use of insecticide-treated bed nets. To reduce costs on the National Social Health Insurance Fund, the government will need to invest in these simple tools or face an unnecessary dent on the health fund.
As we usher in a new government in a few weeks, our hopes are high. The President-elect, Uhuru Kenyatta, through his coalition’s manifesto, has promised free primary health care for all Kenyans as well as raising government health financing from 6 percent to 15 percent. Politicians make appealing promises during the campaign period but we will have to wait to see if they will be brave enough to fight for this agenda. The situation is urgent, as annually, about 1.5 million Kenyans are pushed below the national poverty line due to health payments.
Tabitha Mwangi is a freelance science journalist based in Kenya. Her articles have appeared in The Daily Nation and The East African. She has a PhD in epidemiology and worked in the Kenya Medical Research Institute for 10 years before becoming a writer.
While reading the outcome statement and background document of the joint World Bank/WHO ministerial level meeting on Universal Health Coverage (UHC) held last week, two clear issues emerge: The first one is getting political commitment to UHC at the highest government level; the second one is that “fiscal realities (in poor countries in particular) greatly constrain the ability to rely predominantly on public funding. Still, countries do not need to be rich to make progress towards UHC, experience suggest that political commitment is essential.”
The papers seem to suggest that fiscal reality is cast in stone and that within this fiscal reality countries have the political space to move forward to UHC. This approach, in essence, tells us something about the sad situation we have come to live in. A reality in which the financial oligarchy have taken over country democracies, according to Simon Johnson’s The Quiet Coup. A reality in which economic inequalities have an enormous negative impact on health equity and social wellbeing. Untaxed private wealth hinders many countries to finance strong public systems to reach or maintain Universal Health Coverage.
It is not only a problem of poorer countries. We have the same within the European Union. For instance 23.400 “mailbox” companies are registered in the Netherlands, with its infamous tax heaven industry. It lead for instance to Portuguese and Spanish multinationals to avoid paying tax in their respective countries. Both Spain and Portugal have to severely cut their public spending on health expenditures and privatize part of their health services, as required by austerity measures set by the European Union. Even the G20 starts to recognize that the tax avoidance by big business is a big problem for the social development of societies.
These examples merely indicate that the issue of fiscal space and progress on UHC are closely interlinked. The Lancet Article ‘Political and economic aspects of the transition to universal health coverage’ explains it as follows: “UHC will only be achieved if public policies ensure that a large share of this increased spending is pooled through a mechanism that promotes equitable and efficient utilization of care. The exact mechanisms for pooling will depend on social processes and political action that establish the parameters for an acceptable public role in health care. In some cases, the result will be a government that primarily regulates the health-care sector, in other cases a government that finances or directly provides care.” In many emerging economies, such as South-Africa, Indonesia; but also in European countries with traditional generous social security systems, there is strong political pressure to remain attractive for international (financial) investors. In parallel there is similar pressure to reduce public spending on health care and create space for health insurance companies in the market of (mandatory) social insurance packages. Authors have coined this process of tax competition “a race to the bottom in slow motion”, with specific policies becoming less generous without disappearing, or creating a public debt that will eventually force their termination.
The authors also suggest a mechanism to mitigate this race to the bottom, the so called social protection floor. The idea underpinning this initiative is that all states would commit to agreed minimum levels of social protection tailored for their respective country. The UN General Assembly resolution concerning universal health coverage acknowledges the link between universal health coverage and social protection mechanism, and urges member states to give priority to these links within their national social programs and policies.
The contradiction is obvious: There is a strong drive to have Universal Health Coverage included in the post 2015 development agenda and for countries to advance UHC at national level. At the same time these countries are dealing with (global) tax competition, tax evasion and a deregulated financial sector that is playing with casino capital at a global level. It is a good first step that WHO and World Bank work with member states to increase capacity and undertake steps towards universal health coverage. Actors working on advancing UHC inevitably will come to the issue of claiming national policy and fiscal space as a basic macro-economic condition for a country to advance its coverage of social protection and health services. Good examples in these include Brazil and Thailand.
The question is whether all the countries that are now supporting the cause of UHC are willing to make progress on further regulation of the financial sector and reform of their fiscal policies. Are these countries able to agree on global redistribution mechanisms and regulatory mechanism to curb the massive amount of untaxed wealth and casino capital, and hence free considerable resources to fund the national social protection floors? Will countries be able to develop true “progressive” taxation schemes, not merely income or VAT based, but rather on wealth and CO2 emission? Or do we want rather global philanthropy to provide the complimentary funds for advances in UHC and social security?
Bottom line: Universal Health coverage is in essence linked to political demands, choices and inherent power relations, both at the national and global level. If we all agree to have UHC included in the post 2015 agenda, then we should be willing to be truly involved in the political and ideological battle that will enfold over the coming period.
Remco van de Pas is a Senior Health Policy Advocate at Wemos
This post was first published as an editorial in MMI Network news, 26 February 2013. Reposted here with permission.
A new documentary film opening in UK and Irish cinemas this week tells the story of what its makers call “the Crime of the Century” – how available low-cost antiretroviral medicine was blocked from reaching Africa and other parts of the global south in the years after 1996. The film signals the dangers of the increasingly-perilous outlook for access to essential medicine in developing countries.
Fresh from its much-talked-about premiere at the Sundance Film Festival in Park City, Utah, last month, Fire in the Blood opens at the Irish Film Institute (IFI) in Dublin and the Prince Charles Cinema in London later this week. The film will be released in cinemas across the UK on Monday 25th February. The film tells a harrowing story of inhumanity and heroism, with a highly compelling cast of characters. It details how it could come to pass that millions upon millions of people, primarily in Africa, were left to die horrible, painful deaths, while the drugs which could have saved them were being safely and cheaply produced and distributed just a short airplane ride away.
“I was curious to see what the reaction in the US would be”, says writer-director Dylan Mohan Gray. “So much indoctrination about the necessity of high drug prices has gone on there that the Big Pharma Research & Development (R&D) defence is very much a sacred cow… even those with profound reservations about how the industry behaves tend to grudgingly accept its validity. This is very easy for me to understand, since I was more or less that way myself when I began digging into all this.” Gray was, however, gratified to discover that the American audiences who waited in line to attend six sold-out screenings at Sundance had much the same reaction after seeing the film that he had had when he began to work on the story. “There is a very strong sense of betrayal when people find out what their governments have done in their name… and a very powerful conviction that the prevailing system of developing and commercialising medicine has to change”.
As the film points out, drug companies actually do very little basic research for drug discovery. “84% of drug discovery research is funded by government and public sources”, says Gray, citing the landmark work of Professor Donald Light, “Pharmaceutical companies fund just 12% of such research, while the lion’s share of their spending goes into marketing and administration.” These facts will come as little surprise to those familiar with the industry, but many have never really contemplated the repercussions of pricing essential medicines at levels only a tiny sliver of the world’s population can afford.
While the film tells the story of how multinational drug companies and the Western governments collaborated to keep low-cost generic AIDS drugs out of the hardest-hit countries at the height of the HIV/AIDS pandemic – at a cost of ten million or more lives – it also tells the fascinating story of the unlikely group of people which came together in order to try and break this blockade. Among this number were front-line doctors, HIV-positive activists, generic drugmakers, intellectual property specialists and individuals of global stature such as Desmond Tutu and Bill Clinton (both interviewed in the film). “That’s what really set this story apart for me”, says Gray. “It was a real-life David versus Goliath tale, full of incredibly interesting, daring, courageous mavericks who took on the world’s most powerful companies and governments to do what virtually everyone else at the time said was impossible (i.e. mass treatment of HIV/AIDS in Africa), and against all odds they won…”
While the inspirational story of how low-cost generic AIDS drugs, first and foremost from India, came to save millions upon millions of lives in Africa (and beyond) is at the heart of FIRE IN THE BLOOD, the film concludes on a distinctly alarming note. “The story this film tells was on the verge of being forgotten, something we can’t afford to let happen”, says Gray. The film details the tireless efforts of Western governments, working on behalf of industry, to impede and cut off supplies of affordable generic medicine from countries like India and Thailand to other parts of the global south, primarily by means of bi- and multilateral trade agreements which low- and middle-income countries are placed under enormous pressure to sign.
“The drug industry is stagnant, its pipeline is anemic and it has pinned all its future hopes on China and India”, notes Gray. “Almost all these companies are publicly-traded, which means their bosses have to keep turning profits quarter-by-quarter if they want to try and keep their jobs… as they see it, they simply can’t afford to take a humanitarian view on issues of access.” With the World Health Organisation having estimated that one-third of all deaths worldwide are attributable to treatable and preventable diseases, largely due to lack of access to medicine, the stakes could not be higher.
Meanwhile, for all its insistence that high prices are the only practical trade-off for an industry that spends so much money on R&D to find new and innovative medicines, Gray noted with a wry smile that the who’s who of senior pharma executives will be gathering in London for the industry’s can’t-miss event, the Pharma Summit, just a few days after FIRE IN THE BLOOD opens theatrically in the UK. “I was amused, but not surprised, to read that the theme of this year’s summit is Should pharma cut its losses and get out of R&D?”.
Araddhya Mehtta is a global heath campaigner for Oxfam GB.