Free and Public

My duck is not the only one

Ducks“The neighbours called us the duck and her ducklings” . Pearl Van-Dyck shares the story of her mother’s struggle to stay alive.

Today would have been her birthday. I remember the afternoon when my mother told me that the hospital result showed that the lump on her arm was cancer. My life changed that afternoon. I couldn’t imagine our lives without her. We were so close that the neighbours called us “the duck and its ducklings”. .

She was desperate to stay alive “I just need 3 more years to allow Jo finish school” she often said. (Jo is my younger sister) .Then my mother began the very expensive treatment at the Korle Bu Teaching Hospital in Accra.

Hospital Accra

The Korle Bu Teaching Hospital

Watching her enduring the treatment but worrying about the exorbitant cost of the treatment was very difficult indeed. Both my parents were professionals with regular earnings. Yet, the treatment became unaffordable on their incomes alone. There were times when she missed treatment due to shortage of money. I often ask myself: what if she could have had all the treatment sessions? What if cancer treatment were not so expensive? Would she still be here to see my children?

My mum is one of many- according to the WHO, cancer is one of the leading causes of death in developing countries. Most affected people are simply unable to afford the cost of treatment.

The outrageous cost of cancer treatment is not limited to developing countries. Last year, NICE decided that Kadycla, a medicine to treat breast cancer, is not to be prescribed by the NHS due to its high cost. The outrageous cost of Kadcyla -£90,000 annually per patient- led a coalition of public health advocates to send a letter to Jeremy Hunt requesting that he issues a compulsory licensing to break the patent and enable generic production of affordable versions. Needless to say, that the UK will not do so.

Yet if the British government can’t afford the price of medicines, what chances have the governments of poor countries got to provide such drugs for their citizens? And how rich should a person be in order to be able to afford cancer medicines?

But pharmaceutical companies hide behind the lack of health care in developing countries as a justification of ignoring the plight of people living with cancer there. Recently the CEO of Astra ZDuckeneca claimed that free cancer medicines are not beneficial for Africans. If he looked back he might have remembered similar claims about HIV medicines when it was said that Africans cannot handle ARVs. Yet thanks to civil society campaigns and generic medicines, now 15 million people are on treatment.

Clearly African governments need to invest in health systems in order to achieve their commitment to Universal Health Coverage and provide the much needed services to their citizens. This has to go hand in hand with global efforts to decrease the prices of medicines.

Sadly my mum didn’t get the three years she wished for and I miss her dearly. But I really hope for the time when people won’t lose their loved ones just because they couldn’t afford the medicines they need. I am awaiting the report of the High Level Panel, set up by the UN Secretary General to address the imbalance between human rights, trade and Intellectual Property and access to medicines. It is critical that the HLP makes clear recommendations to the UN leaders on how to ensure that the global system for R&D results in health technologies being affordable to all patients.

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No health security without health systems by Mohga Kamal-Yanni, Senior Health Advisor, Oxfam GB

The Ebola outbreak has shocked the entire world of global health. Even while Ebola lingers in West Africa the future of health security and the organisation of health systems are being debated.

There have been many conferences held and reports published to provide “lessons learned from the Ebola crisis. A thread running through all of these events has been an agreement on the need to build resilient health systems. Yet building such a system requires planning, investment and serious long term commitment. Short term investment does not produce the necessary workforce needed for a functioning health system. Dhillon and Yates identified 5 key areas that require immediate attention in order to rebuild health systems: community based systems; access to generic medicines; restoring preventive measures; integrating surveillance into health systems and strengthening management.

An Oxfam paper identifies six critical foundations for resilient health systems. I can visualise these foundations as a chair with 4 legs. If you keep one leg short and invest in another leg, the balance is tipped and the chair falls. Meantime if you ignore the base or the back of the chair, it moves from the seating area to the recycling bin!

A Graph showing the trend of healthcare utilisation in Province Orientale (Source: IRC position paper. www.rescue.org) image001

 An adequate number of trained health workers, including non-clinical staff and Community Health Workers (CHWs)

The urgency of allocating resources over a ten year period cannot be better expressed than by Bernadette Samura, a health worker from Pamaronkoh, Sierra Leone:

“Because many nurses have died, it is time for the government now to train more nurses’.

Based on the WHO’s minimum standards of 2.3 doctors, nurses and midwives /10,000 people, Oxfam calculated the gap in these workers and the cost of training and paying them. Liberia, Sierra Leone, Guinea and Guinea-Bissau require $420m to train 9,020 medical doctors and 37,059 nurses and midwives. Once they were trained, a total of $297m annually would be needed to pay their salaries for 10 years. It is worth remembering that at the height of the outbreak, all humanitarian agencies were desperately seeking program managers, logisticians, financial officers, epidemiologists, community mobilizers, and others in addition to clinical staff. Yet these cadres hardly feature in global talks or statistics about the necessary composition of an adequate health workforce.

  1. Available medical supplies, including medicines, diagnostics and vaccines

The lack of vaccines and medicines for Ebola shone a spotlight on the failure of the global research and development (R&D) system. The current system relies on monopoly created by intellectual property rules which leads to pharmaceutical companies conducting R&D in diseases that are expected to produce high profits. In order to get the balance in favour of public health, the public sector has to have a hold over sitting the health priorities and financing of R&D.

  1. Robust health information systems (HIS), including surveillance

The Ebola outbreak highlighted the critical role of HIS in disease control. However, surveillance, which is now being highlighted as critical to disease control, needs to be an integral (not parallel) part of HIS and the overall health system. Epidemiologists alone will not be able to produce useful and reliable data. Effective surveillance requires doctors and nurses to diagnose the diseases, and community workers who gain community trust to report cases. All these workers are needed to act appropriately in their respective roles to prevent the spread of and treat those affected by these diseases.

  1. An adequate number of well-equipped health facilities (infrastructure), including access to clean water and sanitation

There are 0.8 hospital beds per 10,000 people in Liberia and 0.3 in Guinea compared to an average of 50 beds in OECD[1] Countries. Scaling up the number of well-equipped health posts and district hospitals, especially in underserved areas, is critical not only to address health needs but also to build community trust in health systems.

  1. Adequate financing

Countries’ experience clearly indicates that long term sustainable, reliable and equitable financing has to be based on public financing. The annual funding gap that must be covered in order to achieve universal primary health care is approximately $419m for Sierra Leone, $279m for Liberia, $882m for Guinea and $132m for Guinea-Bissau[2]. Although the sums specified are large it is possible to raise the necessary resources by relying on various forms of tax funding, innovative financing and donors’ support. For example, in 2012, tax incentives awarded to six foreign companies in Sierra Leone were estimated to be worth eight times the national health budget.

  1. A strong public sector to deliver equitable, quality service

Evidence shows that countries that achieved or made progress to achieve UHC relied on a strong public sector. Relying on private provision risks creating a two tier system, whereby poor people pay for a dubious quality of service from drug peddlers and others, while wealthy people enjoy the services of 5-star hospitals.

Building resilient systems that protect people’s health and deal with outbreaks has to address all the six elements of the system simultaneously and systematically. Achieving better health outcomes for all and protecting the world from emerging diseases requires a long term global commitment for building health systems. This must start now.

Footnotes

[1]Organisation for Economic Co-operation and Development

[2]Calculated from the estimated figure to reach UHC (the agreed $86/person per year multiplied by the population number) and the current public spending on health

 

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The race has begun to select the new WHO Director General By Mohga Kamal-Yanni

The WHO has announced that the election process for the new Director General (DG) is now open. The election comes at a critical time in the organisation’s history. WHO was criticised by many for failing to respond to Ebola sufficiently quickly, while the fact that Member States had de-prioritised WHO’s emergency work and cut WHO funding was not widely acknowledged.

WHO has been facing serious financial difficulties for more than 6 years. The crisis prompted Margaret Chan to launch a reform process in 2010.  Implied in the reform plan was a correction of the imbalance in the WHO budget whereby ear-marked project funds outweighed flexible core funding in a ratio of 80/20. Six years later and the financial imbalance has not improved. It is also not clear what different member states require from the reform. WHO is in danger of becoming a ‘pay-as-you-go’ service organisation, far from its constitutional mandate.

The results of underfunding its core budget are not only limited to decreased WHO ability to perform its functions, but it also threatens its independence. Countries rely on WHO’ guidance on the assumption that advice is independent from commercial and political interests and is based on science and evidence.

Previous elections lacked transparency and failed to allow public scrutiny of the process. The global health community did not know the “manifestos” of the candidates or how they would prioritise and deal with global health problems.

The prestigious medical journal The Lancet has attempted to fill the manifesto gap by inviting candidates to share their visions. The journal also did its own ranking of the candidates according to the key competences needed for the job.

In the new recruitment processes, the WHO has announced some changes aimed at enhancing transparency. These include a forum for Member States to interact with the candidates, and allowing the WHA to choose from three candidates – instead of simply approving one.

The new DG will have to face huge challenges in terms of the impact of years of financial stringency on core functions and on moral and mandate as well the difficulties facing the role of the WHO in the complex global health field. Given the critical importance of the DG role and the challenges he/she will face, we recommend that mechanisms be put in place to enable public scrutiny of the candidate’s vision for the WHO. In order to enable this public engagement we propose:

  1. Each candidate publicly presents his/her manifesto including:
  • Their vision for what WHO would look like at the end of his/her term
  • Their key priority reform issues
  • How they will secure WHO’s independence while enhancing its financing
  • How to prioritise work areas across the complexity of global health issues and the various requirements of member states
  • Their aspiring legacy
  1. Open public debates with stakeholders to discuss the candidates’ manifestos. This can be done as a webcast to allow participants from all countries with a moderator to organise the debate

As countries begin to nominate their candidates, the global health community is entitled to know where candidates stand on key health questions as well as on the fundamental challenges and issues facing the WHO.

 

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User fees kill

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.

https://www.oxfam.org/sites/www.oxfam.org/files/worldbank-cso-platform-on-health-open-letter.pdf

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.

https://www.naij.com/763152-doctors-refused-help-pregnant-lady-babies-cut-knife.html?utm_source=facebook&utm_medium=social&utm_group=free

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.

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Last minute change to the UHC indicator for the SDGs is raising alarm bells! by Anna Marriott and Mohga Kamal-Yanni

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”

to:

“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:

  • Health insurance has no universal meaning or definition and therefore doesn’t work for cross-country comparisons;
  • Insurance is not a measure or guarantee of financial risk protection – in a number of countries the introduction of insurance schemes has not reduced out of pocket payments or provided protection against catastrophic health expenditure
  • What package of services is covered under an insurance scheme can vary enormously thereby potentially not protecting households against costs associated with a wide range of diagnosis, treatment and care services
  • There are numerous examples where insurance can widen inequalities (e.g. voluntary insurance that excludes people with pre-existing conditions or those unable to pay or social health insurance when only for the formal sector, thereby excluding the majority of people in low and middle income countries who work in the informal sector);
  • Dangerously the proposed indicator risks promoting voluntary insurance schemes against a large body of significant and robust academic evidence that such schemes do not advance UHC
  • Data disaggregation by income groups or other forms is not universally possible

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

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Private sector heterogeneity and Universal Health Coverage By Dr. Anuj Kapilashrami, Lecturer in Global Public Health, University of Edinburgh

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.

These include:

  • Increased competition and dual system of ‘free’ and ‘paid’ services as observed in private sector partnerships in disease control programmes whereby corporate centres charged for services (HIV testing, laboratory tests and CD4 counts) offered free in public hospitals (Kapilashrami and McPake 2012). This affects affordability and access, and leads to opportunistic behaviour and reduced accountability of providers.
  • Problems of quality among untrained and unregulated informal providers and regulatory infringements by drug vendors and pharmacies; irrational prescriptions and unnecessary investigations and surgical procedures (Garg et al 2014, Duggal et al. 2013)
  • Concerns around affordability resulting from cost escalation and diversion of costs from primary level care which have negative implications for women as service users and carers (Oxfam 2013)
  • Changes in governance and customary relationships between institutions, providers and users as State becomes financier and guarantor of services purchased from third parties. Such complex arrangement undermines traditional accountability systems and obscures users understanding of their entitlements to care.

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.

References

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

https://www.oxfam.org/sites/www.oxfam.org/files/bp176-universal-health-coverage-091013-en_.pdf

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

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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.