Free and Public
Currently Browsing: SDGs

Critical issues in the prevention and control of non communicable diseases

There is now worldwide recognition of the global health and economic impact of non- communicable diseases (NCDs). The health goal of the Sustainable Development Goals (SDGs) has a specific target to “reduce by one third the level of premature mortality from NCDs”. However, progress towards achieving the target has been poor.

The WHO set up a special Commission to make actionable recommendations for governments to act on in order to respond to the crisis of NCDs. The commission outlined six recommendations, including the critical importance of strong political will to ensure that NCDs prevention and treatment are top national and international priorities.

These recommendations will contribute to the third UN High Level Meeting on NCDs to be held in September. If NCDs are to be prevented and controlled, governments and international institutions need to address the following issues to curb the resulting health and economic impact:

  1. Women

Women bear the brunt of chronic diseases as the most likely unpaid carers of sick family members. Women’s unpaid health care work has been valued at 3.09% of the global gross domestic product – a hidden subsidy to countries’ health budgets. Lack of access to treatment for any member of the family adds to women’s unpaid care work. Moreover, some of the NCDs carry stigma for women. For example, a young women may never get married if it is known that she is diabetic, and the cost of treatment is a factor in her rejection. The costs of treating cancer and the stigma attached to the disease, especially breast cancer, may lead to women being rejected by husbands without financial or other support.

Just two weeks ago, the WHO called for the elimination of cervical cancer given that vaccination and screening programmes are feasible. It is critical that governments expand awareness and delivery programs for early detection, diagnosis and treatment of breast and cervical cancer, as well as other NCDs. These programmes are critical not only for health but also for removing stigma against affected women.

  1. Access to medicines

High prices are a major barrier for patients’ use of medicines that save lives, significantly improve the quality of life and decrease suffering. Globally there is stark inequality in access to medicines for NCDs, which is reflected in the higher morbidity and mortality rates in poorer populations and poorer countries.

Cancer is the second cause of mortality worldwide. Early detection of cancer without affordable treatment could feel as a death sentence for patients. Anecdotal data shows the serious impact of high prices of medicines on patients’ lives.

The UN and its member states must find sustainable solutions to the crisis in medicines if they are to tackle NCDs in a meaningful way. Prevention alone is not the answer for the millions who already suffer NCDs, nor for their families who suffer the economic and emotional impact of ill health and of lack of treatment. The UN High-Level Panel on Access to Medicines proposed actionable recommendations for governments and relevant international agencies that pave the way to improving access to medicines and innovation. These must be urgently implemented. By doing so, governments would adopt strategies that make medicines affordable to payers.

It is also time that the WHO lead in developing an R&D convention that ‘de-links’ financing R&D from the price of medicines so that research is driven by public health needs, not financial incentives, and thus produce medicines at low prices.

  1. Health in trade

Free Trade Agreements (FTAs) usually include conditions that have negative implications on the health of the population in the signatory countries, especially in relation to NCDs. Firstly, FTAs usually include further protection of intellectual property rules beyond the TRIPS[1] agreement, and therefore increase the potential of high prices for new medicines.

Secondly, Investor-state dispute settlement clauses (ISDS) prevent governments from implementing policies that aim to protect public health. There are recent examples of this impact in the case of a Lily pharmaceutical company using ISDS to stop the Canadian government from adopting policies to cut the price of a medicine for treating Attention Deficit Hyperactivity Disorder. Another example is Philip Morris tobacco company taking legal action against the governments of Uruguay and Australia for including warnings against smoking on cigarette packets. In three cases the companies used ISDS clauses in an FTAs that considered governments’ actions not as protection of population’s health, but as cutting companies’ profit. Although the companies lost their cases, threat of arbitration can be a deterrent to developing countries preventing the adoption of policies to respond to NCDs.

Therefore, before signing an FTA, governments must conduct impact assessments of the potential impact of the agreement on health policies and access to medicines with meaningful engagement of civil society, parliament and media. WTO needs to monitor and condemn pressure from countries and companies on those governments who intend to use the flexibilities enshrined in the TRIPS agreement to decrease the price of medicines.

  1. Universal Health Coverage

Sustainable investment in healthcare is critical to creating resilient public health systems that can prevent and treat NCDs.  Strategies that tier services according to ability to pay, result in increased societal inequality and ill health in addition to being inefficient. No country has achieved or made progress towards achieving UHC without the majority of financing coming from the public purse. Lack of government spending and delivery of health care results in more unpaid caring work for women and high impoverishing out of pocket spending. Most countries face a health work force crisis, which requires long term investment in training and remunerating workers.

Governments need to increase investment in public healthcare systems in order to reach a minimum of 15% of public expenditure or 5% of GDP. Public investment has to prioritise financing of healthcare through progressive taxation, and avoid regressive and unaffordable insurance schemes, which tend to exclude the poorest and most vulnerable people at scale in countries with large informal sectors. Health services should be free at the point of use to ensure equity of access to healthcare. Public investment in comprehensive primary health care should be prioritised including the training and remuneration of Community Health Workers, especially women workers to enhance reaching women in rural and remote areas.

Donor countries must support developing countries to invest in building resilient public healthcare systems; including training and remuneration of health workers, through aid.

  1. Private sector’s engagement

Clearly the private sector has a role to play in responding to NCDs. However, commercial determinants of health present huge risks given that profit motives of tobacco, processed food and beverage companies, are directly at odds with public health goals. It is highly unlikely that “voluntary” actions by companies would result in cutting the negative impact of those products, given that cuts in sales act directly against companies’ commercial interest.

State-led initiatives and strong regulation are critical to tackling the NCDs crisis. “Sin taxes” on sugar products, tobacco and alcohol have been heavily opposed by those industries, despite the clear evidence of the positive impact of tax on lowering consumption of those harmful products and generating revenue for public spending on health.

Yet governments’ engagement with the private sector has been heavily promoted without emphasis on these crucial safeguards. Engagement with commercial actors should be driven by public health concerns not by economic interest.

  1. Promoting mental health

According to WHO, depression is a leading cause of disability in the world. Yet there is a lack of political support for the promotion of mental health and for investing in the diagnosis and treatment of mental health problems. Governments need to invest in evidence based training, to develop appropriate and adequate services for those suffering from mental health problems. Furthermore, integration of mental health awareness, diagnosis and treatment is needed in primary health care. National awareness campaigns in collaboration with civil society and the media are also critical to remove stigma associated with mental health, especially for adolescents who usually suffer in silence.

Conclusion

The forthcoming UN HLM on NCDs is an opportunity for world leaders to commit to protecting their citizens, by turning rhetoric into reality through serious political will and adequate financial commitments. Actions at national and international levels are necessary and feasible to prevent and control the pandemic of NCDs.

[1]Trade Related Aspects on Intellectual Property Rights, which countries automatically sign when they join the WTO

Share

World AIDS Day: Lessons for reversing inequality by Mark Goldring, Oxfam UK Executive Director

img_20161130_171228979_hdr

Today is World AIDS Day, a day to celebrate the many lives saved and to remember the many lost to the HIV virus. Importantly it is a day to reflect on what we have learnt from working to address the inequality challenges of the HIV epidemic. This is particularly critical for civil society, and others, working to reverse inequality. I will focus here on 4 lessons:

Lesson one: Inequality kills. Millions have died because they were too poor to pay the exorbitant prices of medicines & hospital fees. Investing in public health systems to offer free service as the point of use and in affordable medicines are essential to save lives and tackle inequality – both health inequalities and crucially, economic inequality.

We must remember that it was civil society movements that put pressure on pharmaceutical companies and created the environment for Indian companies to compete and thus slash the price of HIV medicines from $10,000 to around $ 100/ person /year leading to the over 18 million people on treatment now. Inequality in access to medicines affects millions all over the world. A big cause of this inequality is the global system of biomedical research and pricing, which leaves critical decisions on medicines- basically the decision on who lives and who dies – in the hands of pharmaceutical companies. This system needs re-thinking to ensure availability of the medicines we need at affordable prices.

Therefore, the recommendations of the UN Secretary General high level panel on medicines published just a couple of months ago are a great step in the right direction to ensure that the research and development (R&D) system produces affordable medicines for people who need them. We hope for the UK leadership in implementing these recommendations. We see interdependence between progress on the issue of anti-microbial resistance (on which we have seen magnificent leadership from the UK government) and delivery on the UN panel recommendations to transform the R&D system for accessing medicines.

 

 

 

 

 

The second lesson is related to a critical dimension of inequality, which is accessing health services. A big lesson from HIV is that its services are fundamentally free and thus saving the lives of the 18 million people who are on treatment. This must extend to all health services. Paying for health care pushes 100 million people into poverty each year. One billion people are denied health care because they can’t afford to pay. Health services free at the point of use are critical to prevent this situation and to enable people to stay healthy and productive – thus improving livelihoods and economic growth. Women bear the brunt of paying for health care as they have to care for sick family members and they are the last to access paying services. Recently the UN statistical group mandated to frame the indicators to measure the Sustainable Development Goals, agreed on the indicator that measures the financial protection arm of Universal Health Coverage. The indicator 3.8.2 will measure what really matters: the out of pocket expenditure on healthcare. Again, civil society has been instrumental in establishing this indicator.

ِِِِAccess to HIV treatment could not happen without securing adequate financing. This is the third lesson. Thanks to domestic and donors funding like the Global Fund, poor and marginalised people can access the services.

Building resilient health systems that provide services needed for HIV, other diseases including non communicable diseases and emerging infections, requires adequate and sustainable financing. Public financing is critical – there is now consensus across the global health community that all governments must push forward urgently on achieving universal health coverage. At the core of the consensus is an understanding that an increase in public financing for health is a non negotiable ingredient for success.

Oxfam campaigns on tax reforms as a fundamental solution to raising additional needed revenue and at the same time redressing extreme economic inequality. However, few low and lower middle income countries have sufficient resources, even with significant tax reform, to pay for health care for all. Aid should be provided in the right way – supporting the expansion and improvement of public health systems, the removal of fees and the scale up of the health work force

It’s a worrying trend that the marginalised and vulnerable in middle income countries are being left behind as a direct result of the trend of withdrawing development assistance from these countries. This is clearly illustrated in the negative impact on HIV programmes that is supporting marginalised groups and civil society advocacy. Donors have a responsibility to transform their support in a way that addresses the needs of marginalised groups.

Last but not least, active citizenship – people’ involvement in decision making has been a great driving force to overcome discrimination and the marginalisation of women, sexual minorities and other marginalised groups. This is at the heart of the success in the response to HIV and is at the heart of our inequality campaign

These four factors require the world to make long term commitments to investment in R&D, in free public services and in enabling community and civil society participation in decision making and in monitoring the commitments of governments, donors and international agencies. This is critical if the world leaders are serious about leaving no one behind.

Share

A victory today for Universal Health Coverage- Statement from Oxfam

We are delighted to announce a victory for the drive for universal health coverage.  We will now be able to count the cost of paying for healthcare for  households around the world. It is truly exciting that in a couple of years we could have sound global data on what kinds of health financing mechanisms are most effective for leaving no one behind in healthcare. Armed with this, we can call for policy changes to achieve more equity in health and prevent the 100 million people currently being pushed into poverty each year paying for health care.

Today, the group of experts tasked with developing the indicator framework to measure progress towards the Sustainable Development Goals (SDGs), have agreed to measure financial risk protection of universal health coverage by ‘’proportion of the population with large household expenditures on health as a share of total household expenditure or income”. This signals a great shift in from the previous dangerous indicator that would just measure population with access to health insurance or a public health system.

The previous indicator was flawed because it did not measure whether or not people were actually financially protected against potentially catastrophic costs for health care. It would have also failed to measure progress across different income groups or by gender. It was also dangerous as it sent a signal to governments around the world that health insurance was the route to achieving Universal Health Coverage despite robust and scientific evidence that many voluntary health insurance schemes have exacerbated inequality.
A global campaign was mobilized to replace the dangerous indicator with one which ‘measures what matters’.

In a campaign largely coordinated by Oxfam, civil society organisations, academics, development agencies and statistical authorities expressed their deep concerns with letters, lobbying and public statements. Now we can celebrate a step closer to universal health coverage that leads to everyone accessing the quality health services they need without being pushed, or pushed further, into poverty.

Share

Will the SDG indicator group make Universal Health Coverage indicator fit-for-purpose? by Anna Marriott, Public Services Policy Manager, Oxfam

raju-case-study

In March this year we posted a blog on global health check about a dangerous and surprising last minute change to the indicator measuring financial risk protection for Universal Health Coverage (UHC), being developed by the Inter-Agency Expert Group on the Sustainable Development Goals (IAEG-SDGs). The IAEG is meeting in Geneva this week and aims to conclude discussions on this indicator (3.8.2), along with some of the other contentious indicators they have identified within the SDGs global indicator framework.

Since we reported on the danger of the nonsensical indicator undermining the highly valued SDG target on achieving UHC (that gives everyone access to quality health services, without causing impoverishment), the global health community has mobilized in large numbers to call for the reinstatement of the original indicator or a revised version of it, as proposed by the World Health Organisation (WHO) and World Bank (WB). Here are a few highlights of the actions from a range of constituent communities with a stake in this issue over the past few months:

  • As an immediate reaction to the changed indicator, over 300 NGOs wrote to the IAEG-SDGs last February calling for the new indicator 3.8.2 to be immediately revoked and replaced
  • Executive Director of Oxfam International Winnie Byanyima made this statement also in support of the WHO/WB proposed indicator
  • In the IAEG’s own open consultation in September 2016 on the possible refinement of global indicators, significantly more responses [144] were received on indicator 3.8.2 than the next most popular indicator [92] and 70% of respondents favoured the WHO/WB proposed indicator. Importantly, 62% of these respondents were explicit that the WHO/WB indicator should replace and not be in addition to the current flawed indicator.
  • In the run up to this week’s IAEG-SDGs meeting, another CSO letter signed by 98 organisations called for the current immediate replacement of 3.8.2 with the WHO/WB proposed indicator
  • This week 351 health academics and researchers from 62 countries have written directly to the members of the IAEG-SDGs expressing their concerns with the current indicator and calling for its replacement with the WHO/WB supported indicator. This letter is published in the Lancet.

The motivation for all this is to warn against keeping the current indicator whether on its own or in combination with the WHO/WB refined indicator. The current – flawed – indicator to measure financial risk protection for UHC reads:

    ‘coverage by health insurance or a public health system per 1,000      population.

The reasons this is not fit for purpose are manifold:

  • -Coverage by health insurance or a public health system does not equate to financial protection
  • -There is no universal meaning or definition of health insurance.
  • -Numerous schemes have actually widened inequalities e.g. voluntary insurance for only those who can pay
  • -It risks promoting voluntary insurance schemes against a large body of significant and robust evidence that such schemes do not advance UHC. This is not the job of the IAEG-SDGs
  • -Every citizen is theoretically covered by a public health system rendering the data meaningless

As an illustration of these flaws see the stories of Ranu and Esther.

esther-case-study

Thankfully the IAEG is considering the alternative WHO/WB proposed indicator – one that is based on a global consensus following extensive consultation over a 3 year period. This alternative reads:

“Proportion of the population with large household expenditures on health, as a total share of household expenditure or consumption.”

This is relevant to the UHC target, as it directly measures the financial impact on households of the costs of health services. It is methodologically sound and grounded in an internationally agreed standard definition which is scientifically robust and policy neutral. Information and data is readily available from routine household surveys conducted by national statistical offices (e.g. Budget Surveys, Income and Expenditure Surveys, Living Standards Measurement Surveys) to support calculations. Furthermore, it is amenable to disaggregation on income, gender and geographical location.

A risk remains that in an attempt to reach agreement the IAEG members will include the WHO/WB proposed indicator as an addition rather than replacement to the flawed indicator. This is unacceptable for all the reasons above but also because countries are already straining with the weight of the SDG measurement framework and it would be a waste of their precious resources. Any data issued by governments using this indicator as a measure will be useless and thus easily ignored by health and statistical experts such as the 351 signatories who signed the health academics letter, the 100s of NGOs who’ve signed letters on this, and the 22 statistical authorities who submitted to the online submission. It would work to counter the hard won global consensus and huge momentum on UHC. And the losers would be all those currently left behind by their own national health systems – those like Raju and Esther who face the stark consequences of paying out of pocket for their health care.

To avoid this danger, the current indicator must be taken off the table completely. Instead of keeping this wasteful indicator, let’s measure what really matters: the impact of health spending on households.

 

Share

The race to UHC – How Malawi has outperformed most in Africa but risks going off course by Robert Yates

In September 2015, all countries committed themselves to a new set of sustainable development goals (SDGs). One of the targets to achieve the health SDG is Universal Health Coverage (UHC), whereby everybody receives the health services they need without suffering financial hardship[i]. Across the world, countries are recognizing that achieving UHC requires a publicly financed health system to ensure risk pooling where healthy and wealthy members of society subsidize services for the sick and the poor[ii]. Conversely, a privately-financed, free market in health services has proven that it will never achieve UHC – a fact which has now been recognized by experts and agencies who previously promoted private health financing[iii].

Countries such as Thailand, Sri Lanka and Costa Rica have demonstrated that the key to achieving UHC is to replace private voluntary health financing (user fees and private insurance) with compulsory public financing (in particular tax financing). This not only improves people’s access to health services it also reduces the impoverishing burden of out-of-pocket (OOP) health expenditure[iv].

A country which learnt this lesson before many of its peers is Malawi. Despite only having a GDP per capita of around $350, Malawi was one of the few African countries to achieve MDG 4 in reducing child mortality. This achievement was celebrated in a Lancet Global Health paper[v] which highlighted Malawi’s success in increasing the utilization  of a number of effective health interventions  by children– for example immunizations and treatments for infectious diseases.

However, this analysis didn’t mention a key feature of Malawi’s health system which has made it unique within the continent of Africa: Malawi has been the only country in Sub-Saharan Africa to provide universal free health services throughout its public health system and never charge user fees – with the exception of some recent worrying user fee experiments I have written about here[1]. Having not put in place this demand side barrier, utilization of services has been higher in Malawi which has enabled the country to make faster progress towards the MDGs and UHC[vi].

This is illustrated vividly in the following graph, from WHO Afro Region. The graph illustrates that with a relatively high level of public financing of 5.8% GDP (which includes aid financing) and a no user-fees policy in place in public facilities, Malawi records only a 12% share of total health expenditure in the form of out-of-pocket financing. This is a good proxy measure for the level of financial protection offered by the Malawian health system and it is at a level significantly below the 20% maximum level recommended by WHO.

Picture2

 

 

 

 

Conversely in Nigeria, which only spends 0.9% of its GDP in the form of public health financing and where user fees are charged at all levels, private out-of-pocket health financing accounts for 72% of total health expenditure – one of the highest rates in the world. At these levels of OOP payments not only are millions of Nigerians being impoverished by health care costs or prevented from accessing vital healthcare altogether, considerable human rights violations are also resulting where many people are detained in health units because they can’t pay their hospital bills[vii]. This latter phenomenon is unheard of in Malawian public hospitals.

But perhaps the most stark illustration of the difference in performance between these two countries at the opposite ends of this curve, is that whereas Nigeria is 8 times richer than Malawi, Nigeria’s child mortality rate (109 deaths per 1000 live births) is 70% higher than Malawi ’s (64 deaths).

In reviewing these records, the obvious policy recommendation for Nigeria is that it too should increase its public health spending and abolish user fees in its public health system. And for Malawi, the lesson should be to build on this success and use further increases in public financing to improve the availability and quality of free services.

The Government of Malawi’s recent policy announcement to implement service level agreements which will fund selected CHAM[2] facilities to provide free services will be an excellent way to fulfill this objective. Needless to say, if Malawi wants to stay ahead of the pack, it should scrap the hospital bypass fees that have been introduced recently, and certainly ignore the siren calls to introduce user fees more broadly in the public health system. This would simply take the country up the curve to join those where poor people don’t access health services because they can’t afford them, and where more children die before their fifth birthday.

References

[1] And a very brief period in 1964, when a misguided expatriate advisor persuaded the government to introduce fees. However, following extensive public demonstrations President Banda soon reversed this policy to restore universal free services

[2] Christian Health Association of Malawi

[i] United Nations Sustainable Development Goal 3.8  Sustainable Development Knowledge Platform website available at: https://sustainabledevelopment.un.org/sdg3 accessed 28 July 2016

[ii] Yates R Universal Health Coverage: progressive taxes are key

The Lancet , Volume 386 , Issue 9990 , 227 – 229 Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60868-6/abstract accessed 28 July 2016

[iii] Lane R 2013 Dean Jamison – Putting economics at the heart of global health The Lancet Vol. 382, No. 9908 Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62613-6/fulltext?rss=yes Accesed 28 July 2016

[iv] Evans TG et al Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010). Nonthaburi, Thailand: Health Insurance System

[v] Kanyuka, Mercy et al. Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study The Lancet Global Health , Volume 4 , Issue 3 , e201 – e214 Available at: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00294-6/abstract Accessed 28 July 2016

[vi] Yates R, Child mortality in Malawi The Lancet Global Health , Volume 4 , Issue 7 , e444 Available at http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30083-3/abstract Accessed 28 July 2016

[vii] Agbonkhese J FG urged to end detention of women in hospitals nationwide Vanguard online 2 February 2015 Available at http://www.vanguardngr.com/2015/02/fg-urged-end-detention-women-hospitals-nationwide/ Accessed 28 July 2016

Share

« Previous Entries

Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni