Even before the devastating Ebola epidemic in West Africa, development agencies were highlighting that health indicators in this region were lagging the rest of the continent. In a 2013 report UNICEF noted:
“West and Central Africa in particular requires a special focus for child survival, as it is lagging behind all other regions, including Eastern and Southern Africa, and has seen virtually no reduction in its annual number of child deaths since 1990.”
But as Ebola has overwhelmed some countries and threatened many others, questions are being asked about the role of international agencies in undermining health systems in West Africa. Specifically, fingers have been pointed at the 1980s structural adjustment policies of the World Bank and IMF for forcing poor African countries to cut public spending on health. These policies also shifted the financing burden of health services onto poor populations by charging them user fees. Interestingly at the time one of the leading critics of this policy was none other than the current President of the World Bank.
Other health policies promoted at the same time were also damaging to poor people’s access to health care. The Bamako Initiative (BI) launched in 1987, was prompted by UNICEF and WHO as community management of “revolving drug funds”. However, BI institutionalized user fees for essential medicines in some of the poorest countries in the world. Not surprisingly, with most households unable to pay these fees, utilization of health services in the countries concerned slumped, with the poor most likely not to seek care. In West Africa where the BI became established, typical utilization of curative services at the start of the millennium was around one visit per person every three years!
Thankfully a huge volume of research evidence over the last 20 years has conclusively proved the folly of this approach. User fees have been shown to be ineffective in raising health revenues, inefficient in incurring high administration costs and inequitable in excluding the poor. They have also resulted in outrageous human rights abuses where poor people (often women and babies) have been detained in hospitals because they can’t pay their bills. Sadly this practice continues to this day.
As a result of these findings many prominent aid agencies have radically changed their health financing policies, including the World Bank whose President has referred to user fees as “unnecessary and unjust”. Even one of the architects of the World Bank’s previous pro-user fees policy has publicly stated his change of position on user fees although he did not admit that it was a mistake then.
However, not all agencies have been so clear in making a break with the past. As recently as 2008 in its State of the World’s Children Report, UNICEF was still championing the Bamako Initiative and openly criticizing NGOs that were advocating the removal of user fees Indeed one of the countries singled out for praise in implementing the BI was Guinea, from where the current Ebola epidemic has spread
It is true that the international agencies involved in promoting the BI have gradually shifted their positions on health financing and are now rallying behind the goal of universal health coverage. However, the agencies that promoted the BI need to acknowledge their past mistakes rather than assuming that the Bamako Initiative never happened.
This is problematic because whereas other development agencies are aware of the changing consensus on health financing, this may not be the case in many countries. Some governments are still laboring under the illusion that the BI is working and thus user fees policies are still implemented. Thankfully, some countries in the region are now replacing user fees with public financing, for at least some of the population, most notably in Liberia, Ghana, Senegal, Niger and Sierra Leone. The latter’s free health services initiative for pregnant women and children under 5 has been a particularly good example of the impact of removing user fees.
However in West and Central Africa, out-of-pocket payments including user fees remain by far the biggest health financing mechanism. With the Ebola virus not beaten yet in the region, the lack of effective healthcare coverage doesn’t only threaten the health of the population in the region but also poses a threat to global health too.
Therefore, as the international community begins to support countries in West Africa to develop more resilient health systems, there is one immediate action they should take as a top priority. This action would cost practically nothing but its impact could be profound in helping put countries on a path towards equitable universal health coverage. After a twenty-eight year failed experiment, it’s time that agencies including UNICEF and WHO formally and publicly end the Bamako Initiative.
 UNICEF 2013 Committing to Child Survival, a Promise Renewed, Progress Report 2013 Available at: http://www.unicef.org/publications/files/APR_Progress_Report_2013_9_Sept_2013.pdf
 IDS Practice Paper in Brief 2015 Ebola and Lessons for Development Available at: http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/5849/ID557%20Online.pdf
 Kim JY et al editors 2000 Dying for Growth Global Inequality and the Health of the Poor. Common Courage Pres
 UNICEF 2009 Maternal and Child Health the Social Protection Dividend: West and Central Africa
 Yates R 2009 Universal Health Care and the Removal of User Fees The Lancet 373: 2078–81 Available at http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60258-0.pdf
 Kippenberg J Burundi A High Price to Pay Detention of Poor Patients in Hospitals 2006 Human Rights Watch Volume 18 No 8(A) New York, USA
 See https://www.youtube.com/watch?v=RNfzXh4I-Pw
 Kim JK Poverty Health and the Human Future [Speech] World Health Assembly, Geneva, Switzerland 21 May 2013 Available from: http://www.worldbank.org/en/news/speech/2013/05/21/world-bank-group-president-jim-yong-kim-speech-at-world-health-assembly
 Boseley S (2012) From user fees to universal healthcare – a 30-year journey. The Guardian
 UNICEF 2008 State of the World’s Children: Child Survival available at: http://www.unicef.org/sowc08/docs/sowc08.pdf
Because imitation is the best form of flattery, here’s my version of Duncan Green’s ‘From Poverty to Power’ “links I liked”:
A report on the contribution of the BRICS countries (Brazil, Russia, India, China and South Africa) on global health and development notes their overseas development aid has grown 10 times faster than the traditional G7 donors in the past 5 years. Despite their own domestic development problems, the BRICS are increasingly becoming a significant global force for financing development in poorer countries.
In recognition of the importance of government subsidies for achieving universal coverage, the federal government of Nigeria is to start paying the premium contributions of pregnant women and children under 5 years under the country’s National Health Insurance system.
The India government is rolling out a pilot scheme for a universal health package. The pilot will provide access to free generic drugs in at least one district in every State in the country. This move is expected to provide a huge relief to millions of poor people in India who spend a larger share of their meager income on medicine.
The Kenyan government plans to add outpatient services to the NHIF benefit package. Strangely, this move is aimed at reducing fraud and cost rather than improving access. Questions remain if current capacity of health service can support such expansion, and whether this will make any real improvements in access for the people given its objectives. In a related development, the NHIF has adopted capitation payment system, and has also raised contribution rates (premiums) paid by scheme members.
The Swedish government has appointed an Ambassador (Dr. Anders Nordström) to champion its work on helping poorer countries achieve MDG goals 4, 5 and 6 (child mortality, maternal health, and HIVAIDS and malaria. The appointment is in recognition of the importance global health on Swedish overseas development agenda and the need to strengthen efforts at achieving the health related MDGs as the deadline looms very large.
Meanwhile the Spanish government is to cut about 10% of its budget for health as part of broader measures to reduce the country’s budget deficit.
These are exciting times for health care reform in India. Last year in his Independence Day Address the Prime Minister declared that health would be accorded the highest priority. Going a step further, the government outlined plans to increase public financing of health from 1.2% of India’s GDP to 2.5% and there have been many recent press statements on this. Of course actions will speak louder than words.
In November 2011 the High Level Expert Group submitted its report to the National Planning Commission, describing a vision where every citizen should be entitled to essential healthcare services that will be guaranteed by the Central government. The report shows how it is feasible for India to establish a UHC system within the next ten years. In response the PM has let it be known that he wants the Planning Commission to take steps to help the government offer free universal health care, as proposed by the group. Very welcome plans are already apparently in motion to provide free medicine for all through Public Health Facilities under the National Rural Health Mission.
The Public Health Foundation of India has just launched a dedicated website to drive forward progress on Universal Health Coverage (UHC) in India. The website showcases the recent groundbreaking report of the Planning Commission’s High Level Expert Group on Universal Health Coverage. It features background documents, commentary, and expert interviews and serves as an interactive space for UHC publications as well as national and global events.
The High Level Expert Group report includes the following key recommendations:
The UHC India website could not have been launched at a more appropriate moment. This month the National Advisory Council, led by Sonia Gandhi, will consider the recommendations of the High Level Expert Group, which is indicative of a key milestone in the push for a system where all Indian citizens, regardless of their economic, social or cultural backgrounds will have the right to affordable, accountable and appropriate health services.
For UHC to succeed political and financial commitment will be essential and much hard work is needed. This new website is an excellent resource for anyone committed to making this aspiration a reality.
Jayati Ghosh is Professor of Economics at Jawaharlal Nehru University in New Delhi, India, and delivered the Lancet Lecture 2011 at University College London on the subject of “Economic growth and women’s health outcomes: A deepening divide?” Here Ghosh gives some highlights of her lecture for Global Health Check, with a focus on the deepening divide between economic growth and women’s health in India:
Even though economic growth and human development do not always move together, GDP growth is still expected to be associated with better health conditions, for various reasons. Rising per capita incomes typically involve an improvement in food and nutrition standards among the poor, which is obviously an essential precondition for better health. Deterioration in nutrition due to poor eating habits is more likely to occur after incomes cross a certain level. Increasing national income also puts more absolute resources in the hands of governments to spend on essential public health. Even if the proportion of public health spending to GDP remains unchanged, rising per capita GDP means rising per capita public spending on health. And governments may get greater fiscal space to even increase their health expenditure as a share of GDP. Either way, this can mean greater spread and better quality of basic public health services such as clinics, hospitals, doctors, nurses and subsidised medicines. It can also allow governments to spend on infrastructure that has a direct bearing on health, such as better housing, transport and communications that reach health facilities to poor or remote areas, safe drinking water and sanitation.
So how has recent growth in one of the most dynamic parts of the global economy – India – impacted on health? In particular, how has India fared relative to other countries that are at similar levels of per capita income or are even poorer? Consider India in relation to Sri Lanka, Vietnam and Bangladesh. Of these, Sri Lanka has the highest per capita income (in US $ terms) but India has had the fastest rate of growth in the past two decades.
Despite this, India’s health indicators are either worse than or show slower improvement, than these other countries. It is useful to consider health outcome indicators for women and girls in particular, since these may be taken as the “floor” conditions of health in the society. Since gender discrimination continues to operate to reduce the access of women and girls to health services of various kinds, female health indicators are the most effective way of assessing the general progress of health conditions. Consider two basic indicators: the female infant mortality rate (IMR – number of female deaths below the age of 1 year per thousand live births of females) and the maternal mortality rate (MMR – number of women dying because of childbirth-related complications per 100,000 live births).
The female IMR In India is more than double that in Vietnam, at 51 per thousand, and it declined by only 40 per cent over the two decades – one of the slowest rates of improvement in the region. The MMR at 230 per hundred thousand in 2008 was nearly 5 times that in Vietnam and nearly 6 times that in Sri Lanka. What is even more shocking is the slow improvement – even Bangladesh has outperformed India in terms of decline in IMR, though it is a poorer country with slower GDP growth.
By contrast, Vietnam and Sri Lanka have both achieved indicators that are close to those of developed countries (female IMRs of 11 and 10 respectively in 2009 and MMRs of 39 and 48 in 2008). So obviously it is possible to get better women’s health outcomes even without reaching higher per capita income levels.
What explains the paradox of high growth and relatively poor health outcomes in India in particular? Of course India is also very regionally diverse, with some states like Kerala showing excellent health outcomes for women, similar to those in Vietnam. And three states have also shown much improved health indicators in the past two decades: Tamil Nadu, West Bengal and Maharashtra. But in the bulk of the country, female IMR and MMR are still very high and have declined very slowly.
One important reason for this is under-nutrition, which has actually worsened in recent times according to indicators like calorie consumption. Rising prices of food are making this problem worse as women and girls in poor households take the brunt of food scarcity. The declines in per capita food grain availability in the country as a whole, already show the problem, but they do not reveal the disproportionate impact on poor and more vulnerable groups.
Related to this is the distributional issue: income growth has been concentrated among the top ten per cent of the population, whose health indicators were already more like those in rich countries, and there is little improvement of consumption patterns in the bottom half. Another reason is poor sanitation, reflecting low governmental priority to critical concerns like clean drinking water and toilets. A third cause is lack of good and affordable health services for women especially in the reproductive age group. Nearly three quarters of all health spending is by households out of their own pockets, which contributes to many families falling into indebtedness and poverty.
All of these factors are crucially determined by government policy. Despite much publicly expressed concern on all these issues, the Government of India has simply not put its money where its mouth is. Public spending as a share of GDP has not increased, and per capita spending on some essential activities like immunisation and primary health centres has actually gone down.
Instead, the government has sought to provide essential health services on the cheap, using the underpaid labour of local women working for much less than the minimum wage, and not properly trained regular public employees with adequate facilities.
So the apparently growing divide between economic growth and women’s health outcomes in India is really the result of the wrong orientation of public policy. This is not inevitable: the experience of other Asian countries shows that a more positive synergy can be created. This requires a shift in economic approach, since it can be argued that it is not just that health spending has been neglected by the government. Rather, it is an outcome of an economic strategy based on corporate profitability as the main driver of growth, which in turn is associated with reduced government spending. This is because the focus on incentivising private investment reduces the capacity to tax and therefore spend public revenues, with consequent fiscal constraints; and also because the state then stays away from or even moves out of activities that may generate private profits, including medical services.
The point is that with sufficient political will, this can be changed. Health spending needs to be valued not just for its own sake, but as an essential element in an overall macroeconomic and growth framework oriented to better conditions of human life (rather than just GDP expansion). This would be part of a wage- and employment-led strategy of ecologically sustainable growth, with a focus on improving human development.