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.
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.
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.
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”.
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:
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:
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.
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 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.
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:
 Country presentation at EMRO meeting in Cairo
Country presentation at the EMRO meeting in Cairo
India’s health care delivery system portrays many contradictions. Enthusiastic policy discourse on Universal Health Coverage (UHC) and user charges co-exist. Grand plans for international health tourism focusing on super-specialty hospitals in the cities are made, while health payments push 60 million Indians below the poverty line every year. The overall public expenditure on health is at just over 1% of GDP but more budget cuts and insurance-based financing are being proposed. Oxfam India’s new Working Paper, “Financing Healthcare for All in India: Towards a Common Goal” highlights some of these contradictions and explores the challenges facing India’s health sector.
Sengupta (2013) observes that one reason for the unified support of UHC among international agencies was the global rise in catastrophic Out Of Pocket Spending (OOPS) on healthcare. This is in the backdrop of crumbling public health systems, which in turn was a consequence of a prolonged period of neglect of public healthcare and privatisation of health systems, as prescribed by the World Bank reports in 1987 and 1993.
Because of the devastating effects of payments during health shocks, OOPS became politically untenable and UHC was seen as a solution. Evidence of adverse effects of user charges was mounting too. In a way, for many international institutions, promotion of UHC meant a reversal of some of their previously held policy positions.
In 2014, the World Bank president Jim Yong Kim admitted : “There’s now just overwhelming evidence that those user fees actually worsened health outcomes. There’s no question about it. So did the bank get it wrong before? Yeah. I think the bank was ideological”.
Unfortunately, this new consensus has not yet shown much policy impact in India. The Indian public healthcare delivery system still has user charges, and exemptions for low-income groups are known to be extremely ineffective. The system is also being pushed towards an insurance-based model, which promotes private sector providers. Reportedly, India’s efforts towards UHC is to be based on the experience of Rashtriya Swasthya Bima Yojana (RSBY)– an insurance-based scheme targeting households below the poverty line.
This centrally sponsored scheme – which has been in operation for seven years – gives selected poor families (up to five members) an annual coverage of up to $470 worth of secondary level care for an annual fee of less than half a US dollar. RSBY, and several similar regional schemes operating in the last ten years have failed to significantly expand coverage – official data just released indicate that as much as 86% of the rural population and 82% of the urban population are still not covered under any government sponsored insurance scheme.
Despite the inconclusive and generally negative evidence on its impact, the high praise given to RSBY and other health insurance schemes by influential agencies including the World Bank and the International Labour Organisation (ILO) has contributed significantly to its policy popularity. An Oxfam paper described such praise as “both premature and dangerously misleading”.
Despite the popularity of government- funded insurance schemes at the highest levels of policymaking, there is resistance within the government structures to objectively evaluate the performance and impact of the schemes. Fan and Mahal (2011) observed that politicians and administrators often presume that independent evaluations cause more damage than benefit, and governments in India are known to be hesitant towards conducting independent evaluations of health insurance schemes such as RSBY. It is often claimed that some “rigorous assessment” of its impact is done, but RSBY shares the scheme data “only with a carefully selected group of researchers” – this lack of transparency prevents public scrutiny.
Until now there is no disaggregated data available on government’s reimbursement to the health providers through RSBY. Simply put, we do not know how much money is going to the private sector, or how much is flowing back to the public sector. After it was quoted as a successful international UHC case study, and a potential model to expedite India’s UHC, the RSBY data portal stopped uploading even the basic state level data, which was being infrequently updated earlier.
The latest data available on the portal is from the first quarter of 2014. The latest evaluation published is from the first quarter of 2013. For many states like Bihar, latest data from many districts are from 2012. The allegation that RSBY is a private sector subsidy scheme still stands, particularly in the light of high prevalence of corruption and the limited or even negative impact that the scheme seems to have on OOP spending.
In the light of latest government’ evidence showing that a decade of promoting health insurance schemes across the country has resulted in only about 12% urban and 13% rural population getting covered, there is dire need of a rethink about how India can really achieve UHC. It needs to start with strengthening the public system that India already has rather than reinventing the wheel.
On 2nd July 2015 at the International Conference on Public Policy (ICPP), Oxfam, together with Dr. Anuj Kapilashrami of the Global Public Health Unit, University of Edinburgh, convened a session entitled ‘Private sector and Universal Health Coverage: Examining evidence and deconstructing rhetoric’.
As an earlier blog explained, the session aimed to look at new and existing evidence on the role of the private for-profit sector in health, and to critically evaluate this in the context of achieving UHC in low- and middle-income countries. The five papers presented at the session looked at a wide range of private sector actors in health care delivery but raised a number of common themes and challenges.
High costs, and continued challenges around out-of-pocket spending (OOPS), was a common theme across the papers. One paper presented by Asha Kilaru, examined state insurance schemes in Karnataka, India, and found that OOPS were prevalent across the schemes, even where all costs should be covered. The study found 93% of those insured by at least one government scheme sought care from a private hospital, but only 8% reported receiving completely free care. Where healthcare was provided for free, additional costs (such as multiple hospital referrals for different tests and treatment) meant OOPS still occurred. It seems that this was a problem particularly associated with private provision of healthcare, as evidenced by one respondents’ interview:
‘Only the operation [C-section] was free. At the government hospital, a C-section would be only Rs3-4000, but we went to a private hospital since we had insurance and wound up spending so much. It seems like government are agents that send us to a private hospital. In this yojana [Yeshasvini insurance scheme] the government spends and we also spend’.[i]
Difficulties faced in controlling the level of fees charged by private providers were also highlighted. In a paper by Jane Doherty examining the for-profit private healthcare sector in East and Southern Africa, it was noted that out of sixteen countries, ‘no country places a ceiling on the prices that its private hospitals may charge’ (although there may be some limitations to reimbursement payments made by insurers in two of the countries). The paper also explained that ‘there is little control of the fees charged by health professionals or limits placed on their total incomes, except in Kenya’.
Equity and access for the poorest
Challenges in controlling OOPS and the overall costs of private healthcare present significant obstacles to achieving UHC, and especially to ensuring access to healthcare for the poorest. Another recurring barrier to equitable access highlighted is the location of private services. A paper mapping India’s private healthcare provision by Mukhopadhyay et al highlighted that urban, metropolitan areas benefit from the majority of private hospitals, while in rural areas, disproportionately populated by poorer people, the private sector is largely comprised of individual practitioners. Moreover, almost half of India’s private hospitals were located in cities with a population of more than 5 million. Mumbai alone has 16% of all India’s private hospitals.
Poor quality and regulatory challenges
Usar’s paper investigating perceptions of shops selling medicines in Nigeria highlighted major concerns around their ‘pervasive regulatory infringements’ – and especially the selling of drugs beyond the scope of their licenses – as well as the lack of training of staff. The same paper pointed to the challenges of regulating medicine vendors in Nigeria in order to improve their quality, highlighting that regulation has been constrained by inadequate funding, weak institutional capacity, the often-remote location of the shops, and inter-regulatory agency conflicts.
Doherty’s research examining East and Southern Africa’s for-profit private providers pointed out that both an absence of regulation, and poor enforcement of regulation where it exists, contribute to problematic dynamics around private sector healthcare actors there. We have already heard how little legislation exists to control costs within the sector, but the study also found that that there is almost no regulation that guards against anti-competitive behaviour. Furthermore, ‘there is little monitoring by governments of quality and health outcomes, or attention to how the private health sector supports national health objectives’.
The same paper flags additional challenges to regulation, including patchy regulatory frameworks, the high cost of introducing new regulation, limited available information on the private sector, and the resistance of key stakeholders to regulation, or their “capture” of regulation to safeguard their own interests. In South Africa, for example, attempts to regulate dispensing fees for pharmacists have been resisted heavily.
Impact on the public system
Doherty concludes that ‘legislative gaps and enforcement problems, together with the fact that prices are not contained in any meaningful way, either through price controls or active reimbursement mechanisms, mean that for-profit private care in the region is likely to become increasingly unaffordable for any but the wealthiest’. Yet, if the for-profit private sector is poorly regulated and potentially growing, what impact could this have on the public health system left for the majority of the population?
Doherty points to South Africa as an example, where one impact of a strong private sector has been the ‘brain drain’ of human resources away from the public sector to much more lucrative private providers. The final paper by Jisha C. J., examining a state health insurance scheme in India (Kerala), highlights an additional worrying trend, where some private hospitals register in the state insurance scheme, only to de-register themselves once they have attracted some new patients to their facility. It can be assumed this trend will waste public resources spent on administration, as well as raising serious concerns about both equitable access and the behaviour of private providers.
The evidence presented at the Oxfam-University of Edinburgh session makes a further contribution to the debates over the role of the private sector in achieving UHC. While the papers can only shed light on the specific areas they analyse, it is clear that the wider themes they highlight chime with the findings of broader studies on the comparative roles of the public and private sectors.
Oxfam hopes to continue these discussions further, and will be hosting additional blogs on Global Health Check from the contributing authors and discussants exploring the details of the evidence presented in the coming months.
[i] The paper notes that ‘while it is claimed that [the] Yeshasvini [scheme] is self-funded, it received Rs. 40 crore as a government grant in 2012-13 and Rs. 45 crore in the 2013-14 budget’. Rs 40 crore is equivalent to more than USD 6 million while Rs 45 crore is equivalent to almost USD 7 million.