As world leaders prepare to gather for the 66th World Health Assembly on May 20, social movements are questioning the market-friendly version of universal health coverage (UHC) it is promoting.
One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12th Five Year Plan, which uncritically endorses the private medical sector and focuses on health insurance schemes. In a recent paper – JSA proposes an alternative UHC model.
Public financing for whom?
In the past five years there has been an impressive roll out of government-funded insurance schemes in India that are supposed to improve the country’s public health system. In theory, treatment covered under these schemes can be provided by any accredited facility. But in practice the majority of providers are found in the largely unregulated private sector which already accounts for 80% of outpatient and 60% of in-patient care according to the National Sample Survey Organisation (NSSO), making India one of the most privatized systems in the world. India’s healthcare system is increasingly dominated by big hospitals chains (e.g. Apollo Hospitals) with an infamous track record of expensive services and unethical practices. As it is, health insurance schemes mostly channel public monies for private profit. For example, from 2007 to 2013 the state of Andhra Pradesh allocated a total Rs.47.23 billion to facilities accredited under the Arogyasri scheme, of which Rs.36.52 billion went to private facilities.
Getting it right
Health is a right, and priorities should be based on citizens’ needs. What the majority of Indians lack is comprehensive primary care, but current health insurance “packages” only insure beneficiaries for ailments that require hospitalization. They cover a very small portion of the burden of disease, excluding out-patient treatments for tuberculosis, diabetes, hypertension, heart conditions, and cancer among others. Evidence from the first such scheme in India – Arogyasri – suggests that it consumed 25% of the state’s health budget but addressed only 2% of the burden of disease.
Who inverted the pyramid?
This situation ends up distorting the very structure of the health system by starving primary care facilities to the benefit of more profitable secondary and tertiary care. In 2009-2010, direct national government expenditure on tertiary care was slightly over 20% of total health expenditure, but if one adds spending on the insurance schemes the total would be closer to 37%. In Andhra Pradesh, following the implementation of Arogyasri, the proportion of funds allocated for primary care fell by 14%.
A good health system is like a pyramid: the largest numbers should be treated at the primary level where people live and work. We need to flip the inverted pyramid that has been created and offer a new roadmap predicated on public funding and provisioning of a public system that reprioritizes primary health care, and is comprehensive, integrated and accessible to all.
The health insurance schemes in place fail to address another key issue: access to medicines. Paradoxically, India is the largest producer of drugs in the developing world and at the same time the country where the WHO estimates the greatest number can’t afford the medicines they need. Since the Patent Act was amended in 2005, domestic pharmaceutical companies can’t produce cheaper versions of new drugs, which are now sold by multinationals at prices well beyond the reach of most patients. Poor regulations also means more than 50% of the average family spending on medicines is on irrational or unnecessary drugs and diagnostic tests according to the NSSO. Clearly, the pharmaceutical sector must be reigned in, and all essential drugs should be made available, free of cost, at all public facilities.
Addressing public health gaps
The task of achieving health for all in India will not be easy. Current public health services are marked by poor access, low quality and limited choice. Besides rampant corruption, poor management results in mismatches between demand and supply of services: facilities aren’t distributed optimally; equipment and funds fall short of requirements and don’t flow efficiently. Labour shortages can be partly explained by disinvestment in medical education and flawed deployment mechanisms. Although programs such as the National Rural Health Mission have made some inroads to improve services, much remains to be done. The problem is largely one of unresponsiveness to citizens coupled with unreliable technical estimates of costs and disease burden, leading to ill-informed prioritization.
It is necessary to recast the UHC debate and propose alternatives to strengthen the public health systemto address these problems and to build integrated, comprehensive services with strong mechanisms of accountability. Key to these changes are the following:
Over the short term, we also need to explore alternate ways of harnessing private resources for public health goals. Given the sheer size of the private sector, it is not possible to entirely ignore it while planning for equitable access to public services. It’s not a monolithic entity either; some segments such as charitable, faith-based and other not-for-profit healthcare facilities that work in less developed parts of the country can fill certain critical gaps in the public system. Under clear terms and conditions, other private providers such as general practitioners or small and medium-sized hospitals could be in-sourced to complement available public health services. Importantly, there should be no transfer of assets and resources into private hands and kickback statutes should be put in place to ensure there are no referrals with conflict of interests.
All the possible mechanisms for harnessing the private sector should be seen as supplementary (and often interim) measures, and not as a substitute for very significant scaling up and strengthening of the public system both in terms of quality and accessibility.
There is a need to reclaim public systems, to strengthen and expand them. Moving toward health for all requires major transformations in health care, but also in a wide range of social determinants of health – food security and nutrition, water supply, sanitation, working conditions, housing, environment, education and more. We need to build broad-based alliances for social change to redefine the relationship between people and their public systems.
Amit Sengupta is a Research Associate with the Municipal Services Project and Associate Global Co-ordinator with the People’s Health Movement, a global network of 18 national chapters that includes India’s Jan Swasthya Abhiyanfor which he acts as National Co-convenor.
Madeleine Bélanger Dumontier is Communications Manager for the Municipal Services Project, a global research initiative that explores alternatives to the privatization and commercialization of service provision in the electricity, health, water and sanitation sectors.
Photo: Rajeev Chaudhury
The question of how to raise domestic revenue for health is something that policymakers across Africa continue to grapple with. In recent decades different options have been tried and tested –user fees, small-scale community based health insurance, private insurance schemes, and taxation. Today Kenya, like many countries in the region, is left with a complicated patchwork of different schemes offering different levels of coverage to different population groups. Merging these into a single national risk pool which uses public financing to provide for all citizens will improve access to healthcare and reduce administrative costs.
One way of raising more money for health would be to introduce an earmarked tax on diaspora remittances. “According to the Central Bank of Kenya, money remitted by the diaspora is growing monthly,” says Dr Jane Chuma, a health economist and senior research scientist at Kenya Medical Research Institute in Kilifi. “Last year, over $1 billion (Sh85 billion), higher than the revenue earned from coffee or tourism, was remitted to the country. Putting a little levy on foreign transactions could raise significant money for health. In 2009, Gabon raised $30 million (Sh2.6 billion) from diaspora remittance tax, which they put into health care.”
Another option is to merge existing funds to create a single National Social Health Insurance Fund which pools all the resources that are currently available for health into one pot and stop the duplication of effort. “Tax funds allocated to health, NHIF contributions, community health insurance schemes and donor money, if pooled together, can create a large enough single pool. This will ensure that both the rich and the poor are covered while reducing administration costs. As there will only be one organisation buying services, it will have bargaining power.”
During the NARC government when Charity Ngilu was the Minister for Health, there was some discussion about starting a National Social Health Insurance Fund in Kenya. It was passed by Parliament but the president did not sign it. ‘The big boys’ as Hon. Raila Odinga said in Kenya’s first presidential debate on February 11, ‘shot it down’. These ‘big boys’ included private health insurance schemes and private hospitals.
“What Kenya needs are leaders who are willing to put the private sector to task. That they either be part of these reforms or lose altogether by not working together with the public system under universal health care. There are many innovative ways of using private doctors to provide health care in public facilities. What we lack is political will and leadership,” says Dr Chuma.
Whatever the means of raising money, people need to be confident that the money will not be misused. The history of National Health Insurance Fund is plagued with corruption and there is little trust in the public that they will deliver should they take on the role of National Social Health Insurance Fund. “A new institution would need to be in place to swallow NHIF. It would require re-branding, with a new board and new staff. It shall require a lot of work to build trust in the public health care system where beneficiaries will be expected to seek services,” says Dr Chuma.
Public health facilities need to be closer to the people, be well equipped and charge no fees. In this way, each citizen in the country will be able to walk into any health facility, get whatever treatment is required and walk out without paying a shilling. However, removing charges alone will not be enough to keep patients coming. The public health facilities have to be fully staffed and well stocked with medicines. It is not enough, for example, to say that giving birth at a maternity ward is free and then expect mothers to buy gloves, cotton wool and drugs because there are none available at the facility.
A commonly-held fear of a ‘walk in, walk out’ health facility is that providers will be overwhelmed by people who may not need the service but take advantage of its availability because it is free. This is an unfounded fear because there are other costs related to seeking care like costs of transport or the cost of losing a day’s work to go to a health facility. Few therefore, will come to the facility when they really do not need services.
To reduce costs of payments for treatments, the government will need to invest heavily on preventative measures to reduce the heavy burden of infectious diseases. At the moment more money is going to curative rather than preventative health care. The greatest weapon against infectious communicable disease is good hygiene. This will require the government to provide safe water and improve waste disposal. The second greatest weapon is provision of essential vaccines followed by use of insecticide-treated bed nets. To reduce costs on the National Social Health Insurance Fund, the government will need to invest in these simple tools or face an unnecessary dent on the health fund.
As we usher in a new government in a few weeks, our hopes are high. The President-elect, Uhuru Kenyatta, through his coalition’s manifesto, has promised free primary health care for all Kenyans as well as raising government health financing from 6 percent to 15 percent. Politicians make appealing promises during the campaign period but we will have to wait to see if they will be brave enough to fight for this agenda. The situation is urgent, as annually, about 1.5 million Kenyans are pushed below the national poverty line due to health payments.
Tabitha Mwangi is a freelance science journalist based in Kenya. Her articles have appeared in The Daily Nation and The East African. She has a PhD in epidemiology and worked in the Kenya Medical Research Institute for 10 years before becoming a writer.
While reading the outcome statement and background document of the joint World Bank/WHO ministerial level meeting on Universal Health Coverage (UHC) held last week, two clear issues emerge: The first one is getting political commitment to UHC at the highest government level; the second one is that “fiscal realities (in poor countries in particular) greatly constrain the ability to rely predominantly on public funding. Still, countries do not need to be rich to make progress towards UHC, experience suggest that political commitment is essential.”
The papers seem to suggest that fiscal reality is cast in stone and that within this fiscal reality countries have the political space to move forward to UHC. This approach, in essence, tells us something about the sad situation we have come to live in. A reality in which the financial oligarchy have taken over country democracies, according to Simon Johnson’s The Quiet Coup. A reality in which economic inequalities have an enormous negative impact on health equity and social wellbeing. Untaxed private wealth hinders many countries to finance strong public systems to reach or maintain Universal Health Coverage.
It is not only a problem of poorer countries. We have the same within the European Union. For instance 23.400 “mailbox” companies are registered in the Netherlands, with its infamous tax heaven industry. It lead for instance to Portuguese and Spanish multinationals to avoid paying tax in their respective countries. Both Spain and Portugal have to severely cut their public spending on health expenditures and privatize part of their health services, as required by austerity measures set by the European Union. Even the G20 starts to recognize that the tax avoidance by big business is a big problem for the social development of societies.
These examples merely indicate that the issue of fiscal space and progress on UHC are closely interlinked. The Lancet Article ‘Political and economic aspects of the transition to universal health coverage’ explains it as follows: “UHC will only be achieved if public policies ensure that a large share of this increased spending is pooled through a mechanism that promotes equitable and efficient utilization of care. The exact mechanisms for pooling will depend on social processes and political action that establish the parameters for an acceptable public role in health care. In some cases, the result will be a government that primarily regulates the health-care sector, in other cases a government that finances or directly provides care.” In many emerging economies, such as South-Africa, Indonesia; but also in European countries with traditional generous social security systems, there is strong political pressure to remain attractive for international (financial) investors. In parallel there is similar pressure to reduce public spending on health care and create space for health insurance companies in the market of (mandatory) social insurance packages. Authors have coined this process of tax competition “a race to the bottom in slow motion”, with specific policies becoming less generous without disappearing, or creating a public debt that will eventually force their termination.
The authors also suggest a mechanism to mitigate this race to the bottom, the so called social protection floor. The idea underpinning this initiative is that all states would commit to agreed minimum levels of social protection tailored for their respective country. The UN General Assembly resolution concerning universal health coverage acknowledges the link between universal health coverage and social protection mechanism, and urges member states to give priority to these links within their national social programs and policies.
The contradiction is obvious: There is a strong drive to have Universal Health Coverage included in the post 2015 development agenda and for countries to advance UHC at national level. At the same time these countries are dealing with (global) tax competition, tax evasion and a deregulated financial sector that is playing with casino capital at a global level. It is a good first step that WHO and World Bank work with member states to increase capacity and undertake steps towards universal health coverage. Actors working on advancing UHC inevitably will come to the issue of claiming national policy and fiscal space as a basic macro-economic condition for a country to advance its coverage of social protection and health services. Good examples in these include Brazil and Thailand.
The question is whether all the countries that are now supporting the cause of UHC are willing to make progress on further regulation of the financial sector and reform of their fiscal policies. Are these countries able to agree on global redistribution mechanisms and regulatory mechanism to curb the massive amount of untaxed wealth and casino capital, and hence free considerable resources to fund the national social protection floors? Will countries be able to develop true “progressive” taxation schemes, not merely income or VAT based, but rather on wealth and CO2 emission? Or do we want rather global philanthropy to provide the complimentary funds for advances in UHC and social security?
Bottom line: Universal Health coverage is in essence linked to political demands, choices and inherent power relations, both at the national and global level. If we all agree to have UHC included in the post 2015 agenda, then we should be willing to be truly involved in the political and ideological battle that will enfold over the coming period.
Remco van de Pas is a Senior Health Policy Advocate at Wemos
This post was first published as an editorial in MMI Network news, 26 February 2013. Reposted here with permission.
In a country like Mozambique people face numerous barriers when accessing the health services that they need. I recently visited Mozambique with colleagues from the Action for Global Health network. This was one of a series of ‘fact-finding missions’ to explore issues of health service provision, access and financing faced by low-income countries, and the role of European development assistance.
Mozambique is a country that – even if all of its international and national commitments to health spending are met – still needs an extra $35.2 USD per person per year to ensure that all of the population has access to basic healthcare. The burden of making up for this financing gap inevitably falls on the population through direct and indirect out-of-pocket payments for health services. This is an impossible situation for a country that is still ranked at 184 out of 187 nations on the UN’s Human Development Index, and that has millions of people living in poverty.
While in Mozambique, we made a film that looks at all of the barriers that people face in accessing healthcare. Urban and rural settings present different challenges, but for this film we looked at the rural setting of Tsangano in the province of Tete, a huge region in the centre of the country.
The examples of Tsangano and Tete clearly show that all parts of a health system need to come together in order for the system as a whole to function. Tete has two million inhabitants and just 63 doctors. That means that there is just one doctor for 30,000 people, and one nurse for 8,000 people. When we advocate for an end to out-of-pocket payments we must ensure that the ‘key ingredients’ which make user fee removal a success are also addressed – the financing for the system as a whole and ensuring increased investment in transport and infrastructure, particularly in rural areas, the health workforce, access to medicines and better information for the population to demand their right to health.
You can watch the film we made here to find out more about access to healthcare in Mozambique.
Julia Ravenscroft is a Project and Communications Officer at Action for Global Health
Action for Global Health is a network of 15 NGOs working in six European countries and at the EU level in Brussels.
In August, I went to El Salvador with a group of fellow healthcare professionals from the US to learn firsthand about the health reforms initiated by the current Farabundo Martí National Liberation Front (FMLN) government to provide free health care to all. We were told what a precious moment this is for the FMLN: the first time in El Salvador’s history that the left has led the country. As Dr. Peñate, one of the Regional Directors of the Ministry of Health told us, “Transformation is not easy but it is possible. We have the opportunity to re-write and construct a new history.”
Under the right-wing National Republican Alliance party (ARENA), which governed from 1989 to 2009 with continued US backing, neoliberalism flourished. Corruption was rampant; hundreds of millions of dollars of public funds would disappear with nothing to show for them. For example, past governments borrowed funds from the International Monetary Fund (IMF) – twice – to rebuild the Maternity Hospital that was damaged in the 2001 earthquake; not a brick was laid. (Former officials, including the ex-Minister of Health, were arrested on corruption charges under the new administration).
When the FMLN came to power, the country was an economic disaster. The previous administrations had deliberately restricted access to health care as part of the attempt to privatize; by 2006, 47% of Salvadorans were outside of any health care system. To go to a public hospital or clinic, a “voluntary” donation was demanded; that was abolished the day that President Funes was inaugurated in 2009.“
Now, medicines, clinic visits, specialty services, and hospitalization through the Ministry of Health, which serves between 80-85% of the population, are free. As the Ministry told us, guaranteeing health care for all depends not only on access, but also on political will, economic justice, and a more equal distribution of resources.
The two-year-old reform is based on primary care, prevention, and public health. Hundreds of new clinics, which are staffed by Community Health Teams (ECOS), have been established in the poorest, largely rural, areas of the country, which had the least-available health care services. Each team, composed of a nurse, doctor, nurse’s aide, and several health promoters, is charged with surveying the population in their area (6-9,000 people) through home visits to document health risks of individuals, families and the community. The health care workers we met are extremely committed, working long hours with a lot of love and care. We walked for hours – across rivers, over mountains – with promoters to visit patients who live at the end of muddy paths, in areas with no vehicle access.
The ECOS are the smallest units in local, regional and national networks of integrated health services.
Within a network of 4-6 ECOS, there is also a specialty clinic with a lab, paediatrician, internist, gynaecologist, dentist, health educator, nutritionist, and physical therapist as well as psychological and ER services. I was repeatedly told that people who needed emergency specialty evaluations could get seen in 24 hours and that routine consultations were available within 15 days. Compare that to the many months my patients in the US have to wait!
The FMLN’s healthcare reform raises the standards for other countries by providing world-class, universal healthcare. One of the things that most impressed our delegation was how much has been accomplished with so few resources; in just two years, they have made extraordinary progress. Maternal and infant mortality rates have decreased; in fact, El Salvador recently met the UN Millennium Development Goal for reduction of maternal mortality – four years ahead of schedule.
Despite the opposition of the right-wing, the FMLN managed to increase the budget for the Ministry of Health from 1.7% to 2.5% of Gross Domestic Product. However, nearly everyone we met with emphasized the need for more resources – from stethoscopes to medication to MRIs. The dearth of supplies was nowhere more evident than during our meeting with union workers at the Benjamin Bloom Children’s Hospital, who told us that even with “free” health care, parents may have to buy a syringe when the hospital runs out so that their child can receive an injection. For example, the union had to raise funds themselves for a refrigerator to store vaccines.
Though many of these workers and their union are very supportive of the FMLN, they expressed serious concerns about the conditions of their hospital under the new government. These militant workers made it clear that fiscal reform to make the wealthy pay taxes is the solution. We heard this message from workers and administrators alike: requiring corporations and the wealthy to pay their fair share is the only sustainable way to fund this system (Sound familiar?)
We also heard concerns about the fragility of programs like the ECOS, which are based on the political will of the FMLN and the Funes administration, not guaranteed by law; a change in government could end the reform. That’s why the Ministry has been helping to organize Community Health Committees, with a goal of helping the population to internalize and defend their right to health care and a better life. As the Vice-Minister of Health, Dr. Violeta Menjivar, told us, “The people should be the primary actors for their own health. We do good work but it’s the people who must defend the changes.”
The main message I was asked to covey to people in the US was that El Salvador is a small country struggling to make a better world. The FMLN government is young and still learning, making mistakes, and working to improve. I was asked to let people know about the health reform so that we in the US can help prevent the destruction of its gains. As William Hernández of the FMLN told us, “Our big fear is that the US will intervene in the internal affairs of El Salvador. We have the maturity to solve our own problems.”
I believe that health care is a basic human right. We must call upon our own government for universal healthcare with access to quality care for all instead of enriching the insurance companies. We must also oppose any attempt by the US government to intervene in El Salvador in order to privatize their health and other social services.
The pioneering reforms that I saw in action in El Salvador were inspiring. As this effective model continues to be developed, the Salvadoran people will achieve better health and the government will meet its goal of improving people’s quality of life, even with limited resources. I am grateful for the opportunity to have witnessed the gains being made by Salvadoran society and I will fight for their right to continue.
Amanda Bloom is a medical doctor from Oakland, California. This blog is posted with permission from CISPES.