Free and Public
Currently Browsing: Health financing

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

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

 

Share

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.

Share

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.

 

Share

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

 

Share

« Previous Entries

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.