This blog is made of short scenes because the woman’ story at the end is worth a thousand studies, statements, national or international policies.
Scene one 1986 DC
Economists do a lot of studies and extensive thinking on the critical issue of how to finance health care. They tell the world that governments cannot afford to pay for health care and that free care encourages overuse and therefore people must pay fee for services.
Scene two: October 2012 DC
Over the years mounting evidence demonstrates how user fees excludes poor people especially women from access to essential healthcare. Hundreds of NGOs send a letter to Jim Kim the president of the World Bank requesting the bank to support countries removing user fees.
Scene 3: Dec 2013 Tokyo
Jim Kim the president of the World bank says: “Even tiny out-of-pocket charges can drastically reduce [poor people’s] use of needed services. This is both unjust and un-necessary “
Scene 4: March 2016 Cameroon
Newspaper published a horrific story of a pregnant women dying at the hospital door in Cameron simply because she could not afford user fees. Her niece tried to deliver the twins but both died.
Scene 5: still to come
Governments abolish user fees. Donors including the World Bank work with the governments to fully finance essential health care for all that are free at the point of use. In Cameroon women deliver attended by trained health workers without paying for the service.
303 organisations including NGOs, academic institutions, foundations and patients groups have reacted with alarm at a last minute proposed change to the indicator used to measure financial protection for health under the Sustainable Development Goal (SDG). We understand the World Health Organisation and World Bank are similarly concerned. While maybe sounding technical or trivial, if the new indicator for Universal Health Coverage (UHC) is left unchanged it could lead to more not less exclusion of women, marginalised groups and people living in poverty from the health care they need and have a right to receive. As such, those responsible for decision making within the SDG process have an urgent responsibility to act.
The hope is that the groups responsible for finalising the indicators and associated methodologies (the UN Inter-Agency Expert Group and UN Statistics Division) will take the opportunity of a meeting taking place tomorrow and until 11th March in New York to urgently review and amend this dangerous and counter-productive newly proposed indicator. Failing to do so could mean an enormous and unprecedented opportunity to advance Universal Health Coverage globally will be lost.
How did we get here?
The SDG target for UHC is to “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.
The WHO and World Bank worked intensively for three years in consultation with the health experts in governments, academia and civil society to define and measure UHC. This work included: data to be collected, how to collect it and the feasibility of collecting standardised data that allow measures to be compared across time, populations and countries.
It was agreed after a lot of haggling with different parties that UHC could be measured using a minimum of two indicators – one for coverage of essential health services and one for financial protection. Although the indicators developed by the WHO and World Bank were not perfect, there appeared to be a consensus across the global health community to accept and support the results of their work.
It therefore came as a shock that a radical and regressive last minute change was made to the proposed indicator for financial protection by the UN Inter Agency and Expert Group on Sustainable Development Goal Indicators (IAEG) at their most recent meeting at the end of February. The proposed indicator was changed from:
“Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure”
“Number of people covered by health insurance or a public health system per 1000 population”
A letter sent last Monday 29th February by 260 organisations (and now supported by 303 and counting) to the IAEG group members called for urgent action to revoke the proposed new indicator and revert back to the original indicator agreed by the WHO and World Bank.
What’s the fuss about?
The purpose of the financial protection indicator (number 3.8.2) is simple: to find out if there is progress being made regarding people accessing health services without falling into poverty (if they are not poor), or falling into deeper poverty (if they are already poor). The indicator must also be able to fulfil the SDG commitment to measure progress across disaggregated groups, especially for those on the lowest incomes and across marginalised groups.
The proposed new indicator is not just meaningless with regard to measuring financial protection for health, it’s also dangerous. In reality it could measure as so-called ‘progress’ an actual increase rather than decrease in impoverishing and catastrophic health expenditure by households.
Problems with using health insurance coverage as an indicator include:
Problems with using coverage by a public health system per 1000 population as an indicator include:
Whilst health insurance coverage as an indicator is dangerous, the alternative – ‘coverage by a public health system’ – is simply meaningless and not objectively measurable. Citizens in many countries may have a legal entitlement to a public health system but still have to make substantial payments to access services.
A colleague from India summed up the absurdity of the proposed new indicator better than I:
“This is quite ridiculous for a country like India. The ‘number of people covered by a public health system’ in India is always 100% as per government policy and programme plans! As regards coverage by health insurance, it is assumed that if covered by insurance all expenses are taken care of. It obviously is not often the case.”
The change we hope to see in the next few days
A series of meetings will take place in New York between 8th and 11th March where the members of the UN Statistics Division and the IAEG will aim to review and finalise the status of the indicators and the methodologies to measure them. We are hopeful that given the united call of so many organisations in support of the indicators developed by the World Bank and the WHO, that the members will review and amend indicator 3.8.2. This should not be a political issue but a methodological one – we need an indicator that measures improved financial protection for health. The current proposal fails to do that.
For those organisations wishing to sign on to our joint letter calling for action to revise this dangerous indicator please add your organisational name and contact details via the following link: https://www.surveymonkey.co.uk/r/2RZGMS7
Universal Health Coverage has risen quickly to the top of the global health policy agenda, yet debates around how best to deliver healthcare to achieve UHC – and the role of the private sector -are often unhelpfully polarised.
This blog attempts at ‘setting the scene’ as discussed in a joint session by Oxfam and the Global Public Health Unit of the University of Edinburgh last year in the International Conference on Public Policy in Milan. The blog introduces key concept of Public Private Partnerships (PPP), its rising salience and the basic premise it rests on, and discusses the nature of private sector and issues relevant to achieving the UHC goals.
The rhetoric of public private mix:
Public private partnership has emerged as key priority within the framework of Universal Health Coverage (UHC), as a gateway to improved access to services -even if in its most narrow sense of expanding coverage. There has been a sharp rise in partnerships with the private sector – not only in Europe and other high income countries, but increasingly in Low and Middle income countries (LMIC) – to deliver health care infrastructure, clinical and non-clinical services, technology systems, and manage facilities.
Interactions between the public and the private sector are not new, especially in LMICs where health systems are historically characterised as pluralist and hybrid. However the ascendency of private sector in the last two decades can be attributed to the rise of the Public Private Partnerships paradigm; a post 1990s development. Such paradigm proposes a re-evaluation of the structure and function of government in relation to delivery of public services based on the assumption that hierarchical bureaucracy- the organisational form of the public delivery system is inefficient and that introduction of market mechanisms can substantially enhance its efficiency (Osborne 2000, Mills 1995).
Broadly guided by the theoretical foundations of ‘new public management’, such paradigm is concerned with injecting ‘business like practices’ into public sector agencies (Shaw 1999, 2004). Advocates for this model also argue that by increased diversity of provision, partnership initiatives secure better quality infrastructure and services at ‘optimal’ cost and risk allocation (Kwak et al 2009, Roehrich et al 2014). Overall, the literature often portrays PPPs as win-win arrangements in weak, under-resourced and deficient public systems.
However, while the partnership agenda gains currency in health (and other public) policy debates, important gaps remain in its understandings, both conceptual and empirical, and practitioner comprehension of what constitutes the private sector.
First, there is ambiguity in defining the ‘private’. Without adequate differentiation of the nature, scale and scope of the private sector engaged, evidence from one experiment involving a certain private entity on a particular health problem is used selectively to justify and legitimise involvement of ‘private’ sector at large. This is clear in the mix-up between profit making private sector and non-profit organisations.
Non-profit, non-governmental and faith based organisations including networks of people affected by particular health problems, mainly HIV, are gaining prominence. Their role in health care, especially service delivery, has significantly diversified in recent years and is no longer restricted to undertaking outreach work in family planning and reproductive health services for governments. Partnering with well-established faith based organisations in Africa or NGO managing primary health centres in India have distinct implications for health systems and governance than posed by engaging for-profit private sector such as health insurance companies.
The commercial sector on the other hand is very diverse and heterogeneous: including practitioners (of mainstream and traditional medicine), pharmacies, hospitals, pharma and medical devices companies, products manufacturers, suppliers and retailers, as well as other actors in the non-health sector such as insurance companies. On one end of the spectrum, there are informal sector, often under qualified providers offering the only source of care (or drugs) available to certain populations. On the other end there are large corporate (national or multinational) hospitals at the receiving end of substantial investments from international agencies such as the International Finance Corporation, multinational companies as well as State subsidies through arrangements involving their empanelment in national and state health insurance schemes. In the middle are small scale private enterprises such as clinics, nursing homes, drug vendors and pharmacies or larger non-health sector corporations, e.g. cement, automobile companies establishing/running anti-retroviral treatment centres (and other facilities) through partnerships with public sector under national disease control programmes.
Subsuming such widely differing arrangements under a common label of ‘public private partnerships’ obscures important distinctions between interactions and creates a false sense of novelty of the PPP approach. Engaging these diverse actors has distinct implications (and raises different concerns) for achievement of UHC goals. Distinguishing these will allow for a better assessment of their real scope and ability (or inability) to contribute to UHC goals, and explain variation in practice based on separation of ownership and risk bearing between the public and private.
Second, there is significant variation in the meaning and practice of partnerships. The term is used loosely to refer to almost any kind of arrangement (including ‘contracting in’) between the ‘private’ and the ‘public’. Partnering has extended to describe a wide range of activities involving an ever-expanding web of relationships between donors, governments, NGOs, community members, and corporate and business houses and their representatives (Kapilashrami 2010). Further, while there is a reasonably sized body of literature (empirical and conceptual) describing and evaluating global health PPPs (likes of the Global Fund to fight AIDS TB and Malaria, Roll back malaria, GAIN) and their country level interactions, a huge gap exists in understandings of PPPs at national and sub-national level.
Third, there are significant gaps in understanding the dynamics of PPP arrangements: these are not discrete models of interaction between one public, one defined private entity for example insurance companies or pharmacies. These are often complex incremental in nature and need to be seen in the changing political economy of health systems. This is evident from state partnerships that engage insurance companies and other private entities as third party administrators managing purchasing of care through provisions that engage private facilities to provide services at primary, secondary, tertiary level.
Subject to the nature of private sector agency partnered with and the design/ nature of partnership, important questions arise for achieving the goals of UHC.
Partnership with private sector is portrayed as win-win arrangements (Sanbrailo 2013). However, such projections disregard the heterogeneity in the private sector, and lack any systematic assessments of their effects, pathways through which health sector goals are influenced, and any uncertainties and in-coherences arising from their operations. Thus, careful and comprehensive assessment of the nature, scale and scope of these initiatives, alongside their underlying assumptions is an undeniable necessity for progressing the UHC agenda.
Kapilashrami A. and McPake B. (2012). Editor’s Choice:Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Health initiatives and HIV in India. Health Policy Plan. 28(6):626-635
Kapilashrami A. (2010) Public private partnerships: The discourse, the practice and the system-wide effects of the Global Fund to fight AIDS, TB and Malaria. A case of HIV management in India. PhD Thesis. Queen Margaret University, UK
Kwak, Y. H., Chih, Y., & Ibbs, C. W. (2009). Towards a comprehensive understanding of public private partnerships for infrastructure development. California Management Review, 51(2), 51-78
Osborne SP (ed). 2000. Public-Private Partnerships: Theory and Practice in International Perspective. Routledge: London
Roehrich, J., Lewis, M. K., & George, G. (2014). Are Public-Private Partnerships a Healthy Option? A Systematic Literature Review of “Constructive” Partnerships between Public and Private Actors
Oxfam (2013) Universal health Coverage: Why health insurance schemes are leaving the poor behind
Sanbrailo, J. (2013). Public-Private Partnerships: A Win-Win Solution. Blog on Huffington Post. 09/25/2013
Shaw, R. P. (2004). New Trends in Public Sector Management in Health: applications in developed and developing countries
I grew up learning that “Health is Wealth”. But today it seems that it is the other way round: one needs a substantial amount of Wealth to buy Health.
Article 14 of the Indian Constitution grants all Indians the Right to Life. Yet that right cannot become a reality when a quarter of the country’s population does not seek medical treatment because they cannot afford it and 65% do not have access to the medicines they need. India has one of the highest private out-of-pocket expenditures on healthcare at almost 70%. Two-thirds of the out-of-pocket expenditure is on medicines alone. Therefore, providing free medicines in public facilities can have a great impact on people’s healthcare costs and health outcomes.
Historically government hospitals were supposed to provide free medicines along with free consultation. Yet over the years buying medicines from private pharmacies has become almost a norm. Availability of medicines in public hospitals has been very limited over the last couple of decades. To fix this problem, many state governments have announced their own free medicines scheme and set up state owned corporations to operationalise it. Tamil Nadu set up its corporation in 1995 to ensure availability of all essential medicines in the government medical institutions throughout the State.
Other states like Kerala, Andhra Pradesh, Bihar, Madhya Pradesh, Chhattisgarh followed suit. Rajasthan was the first of the Empowered Action Group of states to roll it out successfully, thus inspiring other states in similar fiscal health. Evidence from Rajasthan illustrates that the availability of free medicines at public health facilities increases their utilization and is an important step towards strengthening the public health system.
In this pursuit, Government of Odisha increased its budget allocation for medicines to more than USD 15 million in 2012-13 and set up its state corporation for the purpose. Going a step further the government announced a specific free medicines scheme in the state called the “Niramaya Yojana” in April 2015 and increased the budget allocation to USD 32 million for the year 2014-15. The increase is comparable to Rajasthan’s spending of around USD 48 million to provide more than 400 medicines.
In November 2015, I visited the Bhubaneswar public hospital, a multi-speciality 547- bed flagship hospital of Government of Odisha as part of Oxfam India’s campaign on free medicines (“#HAQBANTAHAI:Muft Dawa, Haq Hamara”). The hospital caters to over a million people. The hospital has 5 Drug Distribution Centres (DDCs) under the Niramaya Scheme, of which only two were functional at the time of my visit because of shortage of staff. One of the two DDCs operates 24 hours all days of the week while the other is open only during the day time. Out of the 570 medicines in the state’s essential drug list, the DDCs at the Hospital had only 236 medicines as the government is still in the process of procuring and providing more medicines.
According to the Central Medicines Store officer, “free medicines have always been available at government hospitals. It is just that now they are being provided under the name of a scheme”. He felt that the main problem with any scheme is the lack of “follow-up” after it is launched. The Central Medicines Store which manages the supply of medicines within the hospital regularly updates doctors on the availability of medicines to guide their prescriptions.
Staff at the DDC which functions 24×7 said that they serve nearly 1000 patients daily. In order to ensure continuous supply of medicines, they only dispense 3 to 7 days’ supply, even if patients came from far and had a chronic illness like diabetes or hypertension. As a result, the patients either discontinue the medicines or buy them from private pharmacies at higher costs or make additional trips to get the supply which for poor people is an additional financial burden.
Despite these limitations, I was very heartened to see the well-functioning DDC where patients trust the quality of its medicines. The DDC was clean and well-kept with medicines stored in racks in an organized manner. The room was well-equipped and staff were dispensing medicines very efficiently. In fact, the DDC could well pass off as one in any big private hospital.
The example of DDCs in Bhubaneswar clearly demonstrates that people use public facilities when they are available and well equipped. However, for continued success, the scheme must be “followed-up” as the officer mentioned above: the remaining 3 DDCs are opened, the stock of medicines is increased from the current 236 to the 570 on the essential drug list; and the doctors prescribe medicines available at the DDC. The success of the scheme would add to the evidence that public facilities do function!
Global Health Observatory data repository, Health expenditure ratios, by country, 1995-2013, WHO
Selvaraj S. and Mehta A., Access to Medicines, Medical Devices and Vaccines in India, India Infrastructure Report 2013-14
Universal Access to Medicines in India: A Baseline Evaluation of the Rajasthan Free Medicines Scheme, WHO 2014
Term used for socio-economically underdeveloped states in India.
http://www.orissadiary.com/CurrentNews.asp?id=59020; Demand for Grants and Budget at a glance, government of Odisha http://www.odisha.gov.in/finance/Budgets/2015-16/Annual_Budget/DEMAND_FOR_GRANTS.pdf
This Saturday is world Universal Health Coverage (UHC) Day. The UHC day comes after a year of the international community being busy in producing numerous reports on learning from the Ebola crisis. Most of the learning from these documents has focused on mechanisms for effective global response to outbreaks.
However, more attention should be directed to learning from the role of local institutions in tackling the Ebola outbreak including how critically needed advances towards UHC can be achieved. Two key ingredients for effective epidemic prevention and response require particular focus: community engagement and health systems strengthening.
The WHO interim panel’s report on Ebola recognised that “Risk assessment was complicated by factors such as weak health systems, poor surveillance, little early awareness of population mobility, spread of the virus in urban areas, poor public messaging, lack of community engagement, hiding of cases, and continuing unsafe (e.g. burial) practices”.
As late as October 2014, 2 months after the WHO announced the Ebola outbreak as a “Public Health Emergency of International Concern”, donors were unwilling to fund large-scale social mobilization activities designed to facilitate community prevention work and treatment-seeking behaviour. There was little real understanding of community realities, beliefs and practices, or the different roles of community women and men.
Things only changed when it became clear that community engagement through trained local community health workers (CHWs) was critical for the success of the work of the treatment centres. Such work was essential for contact tracing and for encouraging people to report fevers. It also helped to change decades of unsafe burial customs that were critical for halting the spread of Ebola.
As Ebola is becoming under control it is essential that the work of building trust between communities and the authorities continues. Therefore, global and national strategies to deal with health crises must:
Resilient Health Systems
My biggest fear is that the health sector is not improved.
George Caulae, New Kru Town, Liberia, February 2015
Resilient health systems are a global public good that requires long-term commitment from national governments and international donors in order to provide universal health coverage that is free at the point of use and to respond to disease outbreaks.
The Ebola outbreak was a magnifying glass that revealed chronic under-investment in public health services. Health systems collapsed under the pressure of Ebola. Many health centres closed and people had nowhere safe to seek medical care. Maternal services came to a standstill. As a result there has been more maternal and child deaths than before Ebola.
Since then there has been a strong emphasis on developing disease surveillance and laboratory capacity. Yet for these functions to work all elements of health systems need to be built simultaneously. Resilient systems require six essential elements:
For the countries that suffered from Ebola, external funding is urgently needed. Last July (2015), donors’ pledges to the recovery efforts of the three affected countries reached US $ 5 billion. However, it is not clear what funds have been disbursed to date and what programmes will be financed. Therefore, it is critical that governments, with donors’ support, implement mechanisms for clear accountability and transparency including community and civil society participation in monitoring programme funding.
There is increasing consensus that public financing is required to achieve the financial protection from the costs of using health care that is an essential component of the concept of universal health coverage. However, the other dimension of universal health coverage is access for all to health care services that are both needed and of sufficient quality to be effective (World Health Organisation 2010).
Some donors and international agencies, such as the International Finance Corporation, argue that private, formal, for-profit providers should play some role in extending access to quality care (International Finance Corporation 2007). There are initiatives by international agencies, donors, African governments and others to expand the for-profit private sector in Africa. These include efforts to attract new local and international investors, encourage bank loans to private practitioners, and subsidise for-profit health care businesses (Doherty 2011).
Can this expansion support the principles of universal health coverage? In low- and middle-income countries, for-profit private providers, especially private hospitals, are often costly and located in more urbanised areas. For-profit services are seldom comprehensive and, while they are often perceived to offer superior and more convenient care, there is minimal public monitoring of their quality (Doherty 2015).
There is also evidence that private care is subject to incentives that distort treatment decisions (Berer 2011, Ravindran and de Pinho 2005, Hanson, Gilson et al. 2008, Doherty and McIntyre 2013). The existence of private facilities contributes to the brain drain from the public sector and aggravates the fragmentation of the health system. Further, fair competition is obstructed through unfair practices (such as collusion) as well as unregulated practices such as the ownership by single companies of health insurance companies, health care providers and pharmacies (which makes patients vulnerable to exploitation) (Shamu et al. 2010).
Lastly, powerful private sector alliances compromise governments’ ability to regulate the sector in the interests of national health objectives.
This is not to argue against the fact that some for-profit private providers make very particular contributions to the health systems in which they are located. Some patients prefer some forms of private provision, so private provision should remain an option to complement strengthened public services (Balabanova, McKee et al. 2011). However, in most health systems in developing countries, the private sector is poorly regulated and monitored. Therefore, the perceived benefits of private provision are often offset by the distortions that are introduced by the private sector overall. In particular, for-profit private provision is simply unaffordable for the vast majority of the populations in developing countries.
In the current environment of donors pushing for a strong role for the private sector, policy-makers in Africa (and in other low- and middle-income countries) need to embark on a programme of action to strengthen regulatory frameworks. Such a programme includes policies, legislation and reimbursement mechanisms that incentivize appropriate behaviours by for-profit providers (Hongoro and Kumaranayake 2000, Doherty 2015). Without these actions, investment by donors and funders in the expansion of the private sector will only serve to increase inequality in health care.
The range of actions should address the failings of the health insurance and health provision industries in tandem, as well as the interplay between them. They should include:
The length of this list underlines the extent to which extensive interventions are required to ensure that the for-profit private sector meets, rather than undermines, national health objectives, including equitable universal coverage and access to quality services. It also underlines the current weaknesses of governments in developing countries in exercising oversight of the private sector.
Accordingly, extreme caution should be exercised, by both governments and development agencies, with respect to promoting further expansion of private provision or health insurance, until solid strategies such as those proposed above can be put in place. Given the capacity constraints facing governments in Africa and other developing countries, it can be expected that progress on these interventions will be slow.
A greater priority than expanding the private sector is surely the strengthening of public sector provision, not only to meet the needs of the majority but also to provide stiffer competition with private providers. Public provision must remain the core function of the public sector.
Equally importantly, it is a priority for governments in Africa to strengthen mandatory prepayment for health care, especially through general taxation but also, where appropriate, through earmarked taxes, including payroll-based payments. The leverage provided by this instrument in incentivizing providers to comply with quality controls and contain costs is arguably far greater than through legislation alone.
Balabanova D, McKee M, Mills A (eds). 2011. ‘Good health at low cost’ 25 years on: what makes a successful health system? London: London School of Hygiene and Tropical Medicine.
Berer M. 2011. Privatisation in health systems in developing countries: what’s in a name? Reprod Health Matters; 19(37): 4-9.
Doherty J. 2011. Expansion of the private health sector in East and Southern Africa. EQUINET Discussion Paper 87. Harare: EQUINET.
Doherty J, McIntyre D. 2013. Addressing the failings of public health systems: should the private sector be an instrument of choice? In: Surender D, Walker R. Social policy in a developing world. Cheltenham, UK: Edward Elgar: 101-124.
Doherty J. 2015. Regulating the for-profit private health sector: lessons from East and Southern Africa. Health Policy and Planning; 30: i93-i102.
Hanson K, Gilson L, Goodman C, Mills A, Smith R, Feachem R, Feachem N, Koehlmoos T, Kinlaw H. 2008. Is private health care the answer to the health problems of the world’s poor? PLOS Medicine; 5(11): e233
Hongoro C, Kumaranayake L. 2000. Do they work? Regulating for-profit providers in Zimbabwe. Health Policy and Planning; 15(4): 368-377.
International Finance Corporation. 2007. The business of health in Africa: partnering with the private sector to improve people’s lives. Washington, D.C.: International Finance Corporation, the World Bank Group.
Marriott A. 2009. Blind Optimism: Challenging the myths about private health care in poor countries. Briefing Paper 125. Oxfam International.
Ravindran T, de Pinho H. 2005. The Right Reforms? Health Sector Reforms and Sexual and Reproductive Health. Johannesburg: Women’s Health Project, School of Public Health, University of the Witwatersrand.
Shamu S, Loewenson R, Machemedze R, Mabika A. 2010. Capital flows through medical aid societies in Zimbabwe’s health sector. EQUINET Discussion Paper 82 Serie. Harare: Training and Research Support Centre, SEATINI, Rhodes University, EQUINET.
World Health Organisation. 2010. World Health Report. Health systems financing: the path to universal coverage. Geneva: World Health Organisation.