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.
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.
Yesterday, the UN General Assembly met in New York to adopt a resolution on universal health coverage (UHC).
This UN resolution draws attention to the 100 million people who are driven below the poverty line every year as a result of paying for healthcare, and shows the extent to which direct, out-of-pocket payments discourage people, particularly the poorest, from seeking or continuing care.
It calls on countries to adapt the way in which health systems are financed in order to increase coverage of health services and ensure that individuals are not impoverished as a result of accessing healthcare.
The resolution was drafted and championed by the Foreign Policy and Global Health Group (Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand) who have been highlighting the relevance and importance of health for foreign policy and development.
There were initial fears that it would be difficult for governments to negotiate a meaningful resolution on UHC, particularly when many countries are so far from achieving it themselves. The opposite turned out to be the case with many countries strongly supporting the issue and even co-sponsoring the resolution.
By adopting this resolution, governments have recognised their responsibility to urgently scale up efforts towards universal coverage of health care services, with a special emphasis on reaching those populations most in need.
Although the resolution falls short of calling for the total removal of direct, out-of-pocket payments it does demonstrate overwhelming global consensus that working towards UHC is not only possible, but necessary for realising the right to health and achieving the health-related MDGs.
A key question now is how the recommendations and principles of the resolution are going to be put into practice. Hopefully the Foreign Policy and Global Health Group, along with the other sponsors of the resolution, will not consider their job to be done with the adoption of the resolution and will take concrete steps to support those countries with the greatest health challenges to adapt their health systems to meet the needs of the whole population.
As discussions about a post-2015 development agenda gain pace, this timely resolution will help to ensure that UHC stays high on the agenda.
Louise Holly is the Senior Health Advocacy Advisor at Save the Children UK. To read Louise’s full blog please click here
As part of the growing global movement for universal health coverage (UHC), civil society groups met with World Bank president Jim Yong Kim at the World Bank annual meetings in Tokyo earlier this month asking that he support developing countries to achieve universal health coverage. Health was a theme of this year’s meetings.
They presented Dr. Kim with an open letter signed by 110 organizations from 40 countries, including the Ghana Universal Healthcare Campaign, World Vision, and Oxfam asking him to ensure the World Bank assists all people, especially the poorest and most vulnerable, to access quality health services.
The clear message of the letter – underlying all its demands – is that strong and equitable health systems are the key to achieving universal coverage. It emphasized that universal coverage should not just mean protection from catastrophic expenditure; it must mean that all people, especially the poorest and most vulnerable, are able to access quality essential health services when they are needed. To achieve this, the right kind of health systems must be built – systems that promote health services of good quality through investment in health workers, facilities, information systems and quality generic medicines. Health systems must also be structured and financed in a way that ensures all people, especially the poor, can access care that is free at the point-of-use.
That is why the letter’s first “ask” is for the Bank to help countries remove out-of-pocket fees, an essential component of any attempt to achieve UHC in developing countries, where evidence clearly shows that fees block access to healthcare for the poor, especially women. For too long, the Bank pushed user fees in developing countries as a way to recover costs and ration care. Next year marks the 20th anniversary of the Bank’s seminal 1993 World Development Report, “Investing in Health,” which – building on a previous publication (1) – made the case for cost recovery through user fees. The messages in this report, amplified by World Bank policy advice and technical assistance, influenced policies in scores of developing countries over the ensuing decades.
Encouragingly, President Kim has recently said that poor health and high out-of-pocket healthcare expenditures are leading causes of poverty. The tide at the World Bank on this issue is slowly turning, as evidenced by the recent example of Sierra Leone, where the Bank played a helpful role, alongside other donors, in providing financial support to the country’s successful free care policy for pregnant women and children. However, there is wider demand for this type of support: 12 countries (2) in sub-Saharan Africa have made healthcare free at the point-of-use specifically for maternal and/or child health services over the last decade. The Bank is still too slow to provide assistance to most of these countries and to others who are interested in pursuing broader fee removal policies.
In order to help countries achieve UHC, the letter also calls on the World Bank to take additional steps, such as providing support to expand public financing; offering balanced policy advice that does not privilege private sector solutions over publicly financed and delivered health systems; ensuring space for civil society involvement in national health policy development; and collaborating with the World Health Organization and other global health institutions.
With a health expert committed to evidence-based policy-making at the helm of the World Bank, and strong leadership from the Bank’s health sector team, there has never been a better time to make progress on this issue. And as this letter demonstrates, there is also overwhelming demand from civil society for action from the World Bank to make universal access to quality healthcare a reality for all.
References
(1) World Bank, (1987) “Financing Health Services in Developing Countries: An Agenda for Reform”1
(2) Benin, Burkina Faso, Burundi, Ghana, Kenya, Madagascar, Mali, Niger, North Sudan, Senegal, Sierra Leone, Zimbabwe. Source: Sophie Witter (2010) HLSP Institute, ‘Mapping user fees for health care in high-mortality countries: evidence from a recent survey.’
Katie Malouf Bous is a Policy Advisor for Education and Health at Oxfam International
Dans le cadre du mouvement mondial en faveur d’une couverture santé universelle (CSU), des groupes de la société civile ont rencontré le mois dernier le président de la Banque mondiale Jim Yong Kim lors des assemblées annuelles de la Banque mondiale à Tokyo, pour lui demander de soutenir la mise en place d’une couverture en santé universelle dans les pays en développement. La santé était en effet l’un des thèmes de l’assemblée cette année.
Une lettre ouverte signée par 110 organisations provenant de 40 pays, dont Ghana Universal Healthcare Campaign, World Vision et Oxfam, a été présentée au Dr Kim pour demander à la Banque mondiale d’aider les populations, notamment les plus pauvres et vulnérables, à accéder à des services de santé de qualité.
Cette lettre, ainsi que l’exprime clairement l’ensemble des demandes formulées, appelle la Banque à soutenir la mise en place de systèmes de santé solides et équitables seuls à même de permettre l’avènement d’une véritable couverture universelle. Celle-ci ne doit pas seulement prendre en charge les dépenses de santé dites « catastrophiques », mais également établir le principe selon lequel les populations, en particulier les plus pauvres et les plus vulnérables, doivent pouvoir accéder à des services de santé de base en cas de besoin. Pour y parvenir, il convient de mettre en place des systèmes de santé appropriés, capables de promouvoir un bon niveau de qualité à travers des investissements en personnels de santé, installations, systèmes d’information et médicaments génériques sûrs. Les systèmes de santé doivent également être structurés et financés de manière à offrir l’accès gratuit aux centres d’accueil et dispensaires, en particulier des populations les plus pauvres.
C’est pourquoi il est demandé en premier lieu à la Banque d’aider les pays à supprimer le paiement direct, une étape essentielle à toute politique de prise en charge universelle dans les pays en voie de développement. Ces frais constituent la première barrière financière à l’accès aux soins des plus pauvres, notamment des femmes. Depuis trop longtemps, la Banque a incité ces pays à s’appuyer sur le paiement direct des soins par les usagers pour compenser les coûts des soins de santé. L’année prochaine marquera le 20e anniversaire du Rapport mondial sur le développement de 1993, « Investing in Health », élaboré à partir d’une précédente publication (1), qui a établi le principe de la récupération des coûts sur les frais restant à la charge des patients. Les messages envoyés par ce rapport, amplifiés par les recommandations et l’assistance technique de la Banque mondiale, ont considérablement influencé les politiques des pays en voie de développement au cours des décennies qui ont suivi.
Fait encourageant, le président Kim a récemment déclaré que la mauvaise santé et le coût souvent élevé du paiement direct des soins sont les causes principales de la pauvreté. L’approche de la Banque mondiale est toutefois en train d’évoluer doucement, comme en témoigne l’exemple récent de la Sierra Leone où la Banque a apporté un soutien financier déterminant, aux côtés d’autres donateurs, au programme national de gratuité des soins pour les femmes enceintes et les enfants. Il existe cependant une demande bien plus large pour ce type d’initiatives : 12 pays (2) d’Afrique sub-saharienne ont en effet mis en place la gratuité des soins dans les dispensaires ces dix dernières années, en particulier pour les services de santé maternels et infantiles. La Banque répond encore trop lentement aux demandes d’aide de la plupart de ces pays comme des autres nations souhaitant aussi renforcer leurs politiques d’abolition du paiement direct.
Afin d’aider les pays à mettre en place une CSU, la lettre appelle également la Banque mondiale à prendre des mesures supplémentaires, comme soutenir le développement des financements publics, offrir des recommandations équilibrées qui ne privilégient pas les solutions du secteur privé au détriment des systèmes financés et organisés par les pouvoirs publics, veiller à ménager un espace pour l’engagement de la société civile en faveur des politiques de santé publique et collaborer avec l’Organisation mondiale de la Santé et d’autres institutions mondiales de la santé en faveur de la couverture universelle en santé.
Avec, à la tête de la Banque mondiale, un spécialiste de la santé engagé à élaborer des politiques fondées sur des données probantes et un leadership fort de la part de l’équipe en charge du secteur, le moment est plus que jamais propice aux avancées dans ce domaine. Et comme le démontre cette lettre ouverte, il existe une demande considérable de la société civile appelant à une action de la Banque mondiale pour que l’accès universel à des soins de qualité devienne une réalité pour toutes et tous.
Références
(1) Banque mondiale. « Financing Health Services in Developing Countries: An Agenda for Reform – 1 » (1987)
(2) Benin, Burkina Faso, Burundi, Ghana, Kenya, Madagascar, Mali, Niger, Nord Soudan, Sénégal, Sierra Leone, Zimbabwe. Source : Sophie Witter. HLSP Institute. « Mapping user fees for health care in high-mortality countries: evidence from a recent survey. » (2010)
Katie Malouf Bous est conseillère en politiques d’Éducation et de Santé chez Oxfam International
