Free and Public

When wealth buys health, Niramaya may be the answer by Pallavi Gupta, Health Programme Coordinator, Oxfam India

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%[1]. Two-thirds of the out-of-pocket expenditure is on medicines alone[2]. 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[3]. 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[4] 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[5]. 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!

References

[1]Global Health Observatory data repository, Health expenditure ratios, by country, 1995-2013, WHO

[2]Selvaraj S. and Mehta A., Access to Medicines, Medical Devices and Vaccines in India, India Infrastructure Report 2013-14

[3]Universal Access to Medicines in India: A Baseline Evaluation of the Rajasthan Free Medicines Scheme, WHO 2014

[4]Term used for socio-economically underdeveloped states in India.

[5]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

 

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Ebola’s lessons for Universal Health Coverage  by Mohga Kamal-Yanni, Senior health policy advisor, Oxfam

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”.

Community engagement.

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:

  • Enable CHWs to continue their role as the trusted front line workers for individuals and communities. CHWs must be an integral part of building resilient health systems;
  • Include other influential community actors – such as religious leaders, women’s groups, youth leaders and traditional healers – in outbreak control and response;
  • Make government and donor resources available to strengthen community linkages to district and national planning and implementation;
  • Implement accountability mechanisms to empower communities and civil society organisations to monitor funding for public health.

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:

  1. Adequate numbers of trained health workers, including CHWs. Oxfam calculated that training the missing 9,020 doctors and 37,059 nurses and midwives in Sierra Leone, Liberia, Guinea and neighbouring Guinea Bissau would costs $420m. Once they were trained, a total of $297m annually would be needed to pay their salaries for 10 years
  2. Low cost medical supplies (medicines, diagnostics and vaccines)
  3. Robust health information systems (HIS), including surveillance
  4. Adequate infrastructure of well-equipped health facilities, laboratories, and clean water and sanitation
  5. Adequate public financing. No country has achieved UHC without public funding. Governments should act immediately to increase their budget allocations to health. However, their ability to spend sufficient resources is blocked by an unfair global tax system that must be reformed. Donor countries must also increase their aid targeted to building country capacity in health and education
  6. A strong public sector to deliver equitable, quality service during both normal and outbreak times

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.

 

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Achieving universal health coverage in Africa: is there a role for formal for-profit providers? By Jane Doherty, School of Public Health, University of the Witwatersrand, South Africa

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:

  1. developing a sound evidence base on the nature and extent of the private sector, differentiating clearly between different components of the sector and their existing or potential impacts
  1. assembling country-based evidence on where particular arrangements have allowed private provision to be incorporated successfully in universal health coverage strategies (together with the factors explaining the strengths and weaknesses of these arrangements);
  1. exercising greater stewardship over the for-profit private sector by demonstrating the political will and leadership to regulate effectively and in the interests of national health objectives;
  1. developing an over-arching policy on the private sector’s roles and responsibilities in support of the achievement of universal health coverage;
  1. raising the awareness of Competition Commissions regarding the reasons why some behaviours of the private health sector can have an adverse impact on the health system, and necessary strategies to protect national health objectives;
  1. conscientising Ministries of Trade and Development regarding the damaging impact on public health and health systems strengthening of some of their policies that seek to attract investment into the private health sector and stimulate private health businesses;
  1. strengthening government capacity to develop, implement and monitor legislation and other regulations;
  1. making efforts to rationalise, harmonise and strengthen existing regulators;
  1. addressing important gaps in the legislation (including that relevant to health insurers, health providers, health professionals, fair competition and consumer protection);
  1. building strategic alliances with key stakeholders to counteract regulatory capture by groups with vested interests;
  1. introducing a range of price controls for services;
  1. strengthening sanctions against non-compliance with regulations;
  1. ensuring greater transparency on the part of private providers with respect to their underlying costs and quality; and
  1. monitoring and evaluating the impact of the private health sector and its regulation on the health system, including on equitable access, affordability, quality of care and efficiency.

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.

References

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.

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An odd one out or part of the same system? By Mohga Kamal-Yanni, Senior health policy advisor, Oxfam

“It was a business decision. It was about money. And screw you.” A journalist said after talking to Martin Shkreh the CEO of Turin, the US-based pharmaceutical company. The company shocked the US when it raised the price of daraprim, a 62 years old medicine by 5000% from $13.5 to $750 per tablet. The US Pharmaceutical companies association (PhRMA) was quick to tweet that “.@TuringPharma does not represent the values of @PhRMA member companies.”So is PhRMA right?

In reality Turin represents a typical symptom of the same disease: putting profit before patients. Otherwise how can we explain the escalating price of new (and sometimes old) medicines not only in Europe and US but also in low and middle income countries? Take Gilead’s medicine that cures hepatitis C as an example. Sofosbuvir (marketed as Sovaldi) was launched at $1000/pill/day. Even at the reduced price offered to some countries, the price is too high. We estimated that treating just half patients suffering with hepatitis C would have cost the Egyptian ministry of health nearly two thirds of its budget.

New cancer medicines are reaching the market at exorbitantly priced and thus unaffordable in most countries even in Europe and the US. NICE, the body that advises the UK’s NHS on medicines rejected Roche’s breast cancer medicine trastuzumab emtansine (Kadcyla) not because of ineffectiveness but because of its high price. Needless to say the price is far beyond the dreams of patients in developing countries.

Patients and advocates for access to medicines have been campaigning on access to medicines in developing countries for years. Their success is clear when the price of the anti-HIV cocktail dropped from US$ 10,000/patient/year to around US $100. Now similar actions have started in rich countries too. One of these groups sent a letter to Jeremy Hunt the UK secretary of health urging him to issue a compulsory license that enables the importation of cheaper versions of the same medicine so that women are not denied a life saving treatment.

Having “temporary” monopoly over pricing seems to be not enough for pharmaceutical companies. Pharma lobbyists carry significant influence in the corridors of power pressurising governments to design and enforce rules that exceed what is already agreed at the WTO through the TRIPS[1] agreement.

Intense lobbying to increase intellectual property rules in free trade agreements has created global public anger. Last September a cancer patient was arrested when she was accused of disrupting the negotiation of the Trans-Pacific Partnership (TPP). The recently concluded TPP negotiations were carried out over more than five years in secret and the text will only be available for elected bodies and the public when it is ready for signing.

Free trade agreements (FTAs) like the TPP are notorious for expanding corporate powers at the expense of public health and the public interest. For example, the FTAs allow corporations to sue governments over measures to promote access to medicines (such as price controls, reimbursement decisions, marketing approvals, and drug safety decisions, or stricter patentability standards). Corporations argue that such measures would damage their investments, which they insist must be protected by the FTAs. This is already happening as Eli Lily has taken the Canadian government to court over government action to make some drugs affordable.

Similar damaging FTAs are currently being negotiated –also behind closed doors- between the EU and Thailand, India and the US.

Moreover, when developing countries try to use legal tools to control or decrease prices, they are put under huge pressure from rich countries under the influence of ‘big pharma’. When Thailand issued compulsory licensing for key medicines to treat HIV and cardiovascular diseases, ‘big pharma’ launched intense pressure on the country to revoke the decision. Under the influence of ‘big pharma’, the US trade representative put Thailand on the Special 301 ‘Priority Watch list’ of countries, which subjects countries to extreme pressure from the US government. Pharma’s influence on the EC resulted in pressure from the European Commission on the Thai govt to change its decision.

Recently some Members of US congress wrote to the US administration urging it to put pressure on India to change its national intellectual property law in order to strengthen monopoly protections on pharmaceuticals. The law had previously been challenged in court by one pharmaceutical company but the court turned the claim down. Changing the Indian law by increasing intellectual property protection will deprive patients from access to needed medicines not only in India but also in the rest of the developing countries. India is considered “the pharmacy” of developing countries.

The root of the companies’ monopoly power and influence is the current model for funding for research and development (R&D) of medicines. Pharmaceutical companies justify the high prices of medicines by the need to recover the R&D costs. Yet the actual cost of R&D is kept as a big secret by the industry. In reality it is becoming increasingly clear that medicine pricing is not determined by production costs and a profit margin, but by what the market can bear.

Clearly the current R&D system is failing patients and health providers all over the world. It is high time that global leaders work for an alternative system that separates the financing of R&D from pricing the resulting medicines. It cannot be left to the pharmaceutical industry to cater only to those who can afford to pay high prices- practically deciding who lives and who dies.

 


[1] Trade Related Aspects on Intellectual Property Rights

 

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Dengue in Delhi – fighting an outbreak with the wrong numbers and an unwilling private sector by Anna Marriott, Public Services Policy Manager

A recent dengue outbreak in Delhi has once again revealed the shortcomings of the massively underfunded Indian public health system, alongside the unacceptable and illegal exclusion of poor patients by the city’s private hospitals. This blog steals the excellent analysis by my colleague Oommen Kurian from Oxfam India, recently published in the British Medical Journal, as well as the post-dengue prognosis of well known commentators, Reddy and Murphy.

Oommen Kurian’s BMJ blog outlined how the current dengue outbreak in Delhi came to international prominence following the unfortunate incident of a young couple who committed suicide after their son was rejected treatment by many prominent private sector hospitals in Delhi. Treatment was denied despite the government saying on 28 August that patients should not be denied admission to hospital on account of a lack of beds. Responding to such cases, the Government of Delhi has issued show-cause notices to five private hospitals asking them to explain why they refused to admit the boy and why their registration should not be cancelled.


Kurian’s blog focussed primarily on two major problems:  the shamefully inaccurate ‘official’ data on incidence and deaths from dengue fever, and inappropriate profiteering by Delhi’s private health sector during the Dengue outbreak. Reddy and Murthy, two prominent commentators, also argue in their post-dengue prognosis that once the media hype and finger pointing of the current dengue fever crisis passes, citizens of India are left with the same long-term problem of a chronically underfunded public health system that causes unreported tragedy on a daily basis.

The numbers

Kurian’s quick comparison of different sources of data on deaths from dengue fever show that only 29 of the 1221 deaths from dengue registered in Delhi between 2010 and 2014 entered the official system (see graph below). Official estimates of the annual incidence of dengue fever nationwide are a staggering 282 times lower than the actual number.

Dengue fever affects most of the metropolitan cities and towns in India, where the healthcare delivery systems are better than the rural areas. However, the preparedness of the system against it may be impacted by the level of massive under-reporting of cases and deaths.

Profiteering or serving?
Delhi has a large number of private hospitals, which have received free land and other subsidies from the government to provide a set percentage of their services free to poor patients. Over time, these charitable hospitals have become purely commercial entities, dishonouring the commitments made to the government.

A high level committee assigned by the Government of Delhi, headed by Justice AS Qureshi, took a bleak view of the nature of such hospitals which claim to be charitable just to lap up subsidies and have become “selfish, greedy, and exploitative” moneymaking machines. Data from 2014 show that the average total medical expenditure for treatment per case of hospitalisation is higher in Delhi than any other state in India, at Rs 34,658. The India average is Rs 18,268.

Profiteering in times of distress is nothing new to Delhi’s private health sector: even those which claim to be private “charitable” hospitals are notorious. For these very reasons, midway through the dengue outbreak, the Union Health Ministry decided to ask the Delhi government to take action against any overcharging by the private hospitals. On 16 September, Delhi’s Directorate of Health Services issued an order against private hospitals and laboratories overcharging, and implemented ceiling prices for dengue testing. Another advisory on the same day allowed the private hospitals and nursing homes to increase their bed strength by up to 20 per cent on a temporary basis for two months.

And now?

As of 21 September this year, the press has reported that while the death toll has “risen” to 22 this season, the deputy chief minister announced that the health situation is now better and the government is winning the battle against dengue. Activists do not take these numbers seriously. Advocate Ashok Agarwal, a member of a Delhi high court-appointed panel to oversee the implementation of the EWS scheme (beds reserved for patients from “economically weaker sections”) in private hospitals announced on social media that the Delhi Government’s dengue death figures are incorrect and that 23 dengue deaths have happened in one hospital alone. The director of another hospital in Delhi is on record saying that at least seven dengue deaths had taken place in his hospital alone, as of 17 September.

A look at civil registration data reveals that dengue strikes Delhi at regular intervals. With more money already put into health, the current Delhi government—only in its first year of rule—may be better placed to fight any dengue outbreak in the future. However, any effort towards containing contagion should begin with having correct numbers—of cases and deaths—and a long term plan to align the private sector in the state with the broader public health goals of society.

Once the current media hype has passed….

In their post-dengue prognosis Reddy and Murphy write that there is ‘justified outrage at the tragic deaths of children from dengue under deplorable conditions of apathy and neglect in the capital of India. But say the underlying causes of the crisis, namely chronic and long-term underfunding, poor co-ordination and planning, remain unaddressed and the daily tragedies facing citizens in the rest of the country, especially in rural areas, go unreported. They give the heartrending example of a tribal in Odisha who allegedly felt forced to sell his two-month-old son for Rs 700 to buy medicines for his sick wife. Reddy and Murphy conclude that:

Public health systems cannot function as a motley crowd of disconnected actors ad libbing their way through an unscripted play in chaotic fashion. The different actors involved require a script, coordination, direction, and need to work as a team. It is time India got its act together to create strong, well-resourced, responsive and responsible health systems. Or else, terrible things will continue to happen to innocent children, expectant mothers, poor tribals, disabled persons — and to your family and ours. We will all be responsible when such terrible wrongs happen.

 

Oommen C. Kurian is research coordinator, Oxfam India.

K Srinath Reddy is president and N R Narayana Murthy is chairman of Public Health Foundation of India

 

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Ensuring universal health coverage for the informal sector, poor and vulnerable groups

Early September, the East Mediterranean Regional Office of the WHO (EMRO) held a regional meeting on Expanding Universal Health Coverage to the informal sector, poor and vulnerable groups in September in Cairo. The meeting was one in a series of the EMRO strategy to support countries in implementing universal health coverage (UHC).

The aim of the meeting was to help countries devise national roadmaps to expand health coverage to the populations that face hardship in accessing healthcare. This aim was to be achieved via sharing global, regional and country experiences in advancing UHC, exploring political processes and structural and cultural factors involved and promoting a better understanding of UHC monitoring. This blog covers a number of key issues that were debated during the meeting.

The informal sector, poor and vulnerable groups

There was a debate about definition and identification of these populations. The region has groups such as migrant workers in the Gulf States, who may not fit with the ILO definition of the informal sector. The region also hosts millions of refugees, some of which maintained that status for decades e.g. Palestinians in Gaza, while millions of Syrian refugees are now living in Lebanon and Jordan.

Vulnerable groups are sometimes “unseen” and therefore their needs are not addressed. These include disabled people, especially those with intellectual disabilities, female and children headed households and street children. In general the informal sector population makes up the majority in most countries and therefore their health coverage has to be at the heart of any plans for UHC.

Country capacity to identify these populations is weak and the politics of targeting is complex and may have political cost. The real question is about the cost-effectiveness of governments’ focusing on identifying and registering populations in order to target services versus national funding of a basic benefit package that is available for everybody where all sectors of society can benefit.

Health financing in the region

The region is classified into three groups: group 1 comprises high-income countries e.g the Gulf States, group 2 are middle-income countries including Egypt, Iraq and Morocco. The third group of low-income countries includes Afghanistan, Somalia and Djibouti.

The percentage of government spending on health to total government expenditure in EMRO’ low and middle-income countries (LMICs) is low: on average 8% compared to the global average 11%. Out-of-pocket (OOP) spending is very high in the region even in countries that have health insurance schemes, leading to poverty and financial hardship. For example despite high insurance coverage in Iran, OOP represents 52.1% of the total health expenditure.

There is a recent interest in implementing or expanding existing social health insurance (SHI). Yet countries which have made progress towards UHC have relied on government funding. For example, Turkey introduced a Green Card to cover the informal sector, 70% of its costs is covered [1]by the government. This was accompanied with increased public expenditure on health. Turkey is merging the SHI and green card financing in order to provide a comprehensive package. The result is decreasing OOP to 17%.

Most social insurance schemes work separately and cross subsidisation is rare. Multiple schemes build inequality via different premiums and benefit packages and it is difficult to harmonise the schemes.

A number of countries and especially high-income countries choose a model of health insurance and are trying to extend premium payment and coverage to migrant workers. Private insurance is increasing in some countries such as Jordan where 25 companies provide private insurance. However there is no data on the effectiveness, efficiency and equity of the schemes.

Low-income countries are struggling to provide UHC. As aid- dependent countries there are questions about the responsibility of donors for long-term predictable financing to build strong public health sectors in these countries.

The evidence and discussions during the meeting clearly illustrated the fundamental role of government financing of health care to extend UHC to the informal sector, poor and vulnerable groups.

Delivery of healthcare

Reliance on the private sector to deliver healthcare is widely spread in the region. The range within the private sector varies from unqualified, unregulated provider to five-star hospitals – also often unregulated.

While there was near consensus at the meeting on the necessity of public financing to cover poor people, the informal sector and vulnerable groups, there was no consensus on modes of delivering the service. The role of the private sector was mentioned as “important” without defining that role. Yet evidence from successful countries such as Thailand and Sri Lanka show the importance of a strong public sector in providing UHC and the limited role of the private sector in achieving that goal.

Some commentators also suggested that separating purchasing from provision was an important part of extending coverage. However, there was a warning of the lack of evidence that such a split is more effective or more efficient in delivering health care than the direct financing and delivery within the public sector, and that indeed, often the reverse is true.

Questions were raised about governments’ capacity to manage contracts with and to regulate the private sector. Even high-income countries such as Australia face huge questions around whether the public are getting a good deal from the private sector. The South Africa experience shows the difficulties in regulating the escalating cost of the private sector. 80% of South Africans rely on the public sector. The private sector services 20% of South Africans yet consumes 60% of the total health spending[2].

Conclusion

There was general agreement during the close of the conference that country experiences point to a number of essential ingredients for expanding UHC to cover the informal sector, poor and vulnerable groups including:

  1. Strong political will: health was a political priority in countries that progressed towards UHC. Public demand (in Turkey) for healthcare was also influential in getting government’ commitment
  2. A “new” consensus that poor people, even collectively, cannot pay for their health care. UHC requires predominately public funding in a big pool (e.g. from tax). Extensive pooling leads to maximum redistribution of resources. No country has ever achieved UHC without heavy public expenditure. Even rich countries such as Japan, Germany and France increasingly rely of budget subsidy. Some commentators concluded from the World Bank study that Thailand and Mexico need to follows the example of Portugal and Spain by eliminating payroll payment and opting for tax finance. Chile has succeeded by delinking entitlement from the employment status
  3. The priority of UHC is providing services for the entire population then incrementally increase the scope of those services
  4. There are two ways to finance UHC: a) a functioning National Health Service based on tax financing, or b) public financing (budget transfer) into a national SHI to cover informal sector, poor and vulnerable groups. An important starting point is providing a standard package through all schemes whether based on insurance or public funding
  5. Financial accessibility is a necessary but not sufficient for UHC. Quality of service is of equal importance
  6. Countries’ claims of increased population coverage need to be backed up by objective assessments, in terms of: enhanced financial protection and quality and effective service coverage

 


[1] Country presentation at EMRO meeting in Cairo

[2]Country presentation at the EMRO meeting in Cairo

 

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.