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Let’s be clear: Universal Health Coverage must mean health coverage for all

A growing consensus for Universal Health Coverage (UHC)

The patchy progress towards meeting the health-related MDGs underlines the urgent need for countries to build free, universal health care systems. Cost is a major barrier for people to access healthcare. 150 million people facing catastrophic healthcare costs every year, while 100 million are pushed into poverty because of direct payments.

There is a growing consensus that UHC should be included in the post 2015 framework. During the 67th World Health Assembly in May 2014, UHC was one of the most discussed topics, from side events to technical briefings, including in the official meeting agenda.  UN member States adopted a resolution on Health in the post 2015 agenda that states clearly that UHC is one of the core components of the post-MDGs.

But do we agree on the definition of Universal Health Coverage?

During the World Health Assembly, another important thing happened: the World Bank and WHO launched the final version of a monitoring framework for measuring progress towards UHC at country and global levels. The monitoring framework is a technical instrument, aimed at providing tools for countries to monitor their own progress towards UHC. But in the context of the intense initial negotiations on defining the health goal in the post 2015, it gives a clear political indication on what is understood by UHC and how we can measure it. The monitoring framework sets out clear commitments to reduce out-of-pocket payments and improve access to health care for the poor with two new targets:

  • By 2030, everyone has 100% financial protection from out-of-pocket payments for health services.
  • By 2030, all populations, independent of household income, expenditure or wealth, place of residence or gender, have at least 80% essential health services coverage.

Having clear targets and deadlines is welcome, so is the fact that the framework recognises the need to disaggregate data by gender, wealth and place of residence. This will make it possible to measure equity although a more comprehensive disaggregated data should also include age.

    Abolition of user fees

    We welcome that the financial protection indicator is no longer just focusing on preventing people being pushed into poverty, but on protection from out of pocket payments. Indeed, out of pocket payments are not just a problem because they push people into poverty but because they prevent people from accessing services altogether. But reducing direct payments does not automatically make health care affordable – especially if these are replaced with prohibitive health insurance premiums where membership is linked to contributions or if medicine prices remain high.

    UHC should be based on the principle of social solidarity in the form of income cross-subsidies – from rich to poor – and risk cross-subsidies – from the healthy to the ill – so that access to services is based on need and not ability to pay. This means that health services must be provided free at the point-of-use. Health user fees are the most inequitable way of paying for health care – they prevent poor people from accessing lifesaving treatment and push millions of them into poverty each year. In the words of Jim Yong Kim, President of the World Bank Group “Even tiny out-of-pocket charges can drastically reduce [poor people’s] use of needed services. This is both unjust and unnecessary”

    Universal health coverage must mean health coverage for all

    Oxfam cannot possibly support the coverage target proposed by the World Bank and WHO. Let’s take a step back. For Oxfam, UHC is anchored in the right to health and an answer to people’s asks for Health For All. For Oxfam, UHC means Health Coverage For All.  Therefore, we need a strong commitment of the international community in the post 2015 agenda on this goal.

    By stating the coverage target at 80%, the monitoring framework gives to the international community the signal that UHC cannot, in fact, be universal, because it is unrealistic. We disagree.
    UHC means that ALL people are able to access ALL the health services they need, without fear of falling into poverty. It doesn’t mean that all people will use the services, but that people are able to access good quality services when they need them.

    Strong public services and public financing

    Scaling up health care services to achieve UHC requires a strong public health sector providing the majority of services. Governments should therefore ensure that adequate proportions of national budgets are allocated to health, in line with the 15 per cent target agreed in the Abuja Declaration. It is essential that steps are taken to ensure that domestic tax collection becomes progressive, and robust, and that both individuals and companies pay according to their means. Tackling tax evasion and tax avoidance must also be a crucial priority within the new framework.

    A focus on UHC in the framework provides an opportunity to accelerate progress on the health related MDGs, and address the burden of non-communicable diseases. Most critically, it is an opportunity to move towards a more comprehensive approach to deliver on the right to quality, affordable, and equitable health care coverage for all. The new framework must include a standalone goal on achieving Universal Health Coverage for all by 2030.

    Charlotte Soulary works for Oxfam International as a Health and Education Policy Adviser


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    New World Bank and WHO targets announced on health coverage for the poorest 40%

    At a high-level meeting in Tokyo a couple of weeks ago World Bank Group President Jim Yong Kim was unequivocal – “achieving universal health coverage and equity in health are central to reaching the [World Bank] global goals to end extreme poverty by 2030 and boost shared prosperity.”

    Kim’s emphasis on equity and the need to prioritize policies that actively redistribute resources and reduce disparities in health coverage marks a crucial and welcome turning point for the World Bank. As Oxfam argued in a recent paper, UHC reforms must be explicit about reducing inequality in access to health services, so that everyone has the same financial protection and access to the same range of high quality health services – according to need and not their ability to pay. Equity must be designed into the system from the beginning with governments and donors ensuring that the poor benefit at least as much as the better off at every step of the way towards universal coverage.

    But by far the most significant outcome of the conference was the release of a joint World Bank and World Health Organization proposed framework for monitoring progress towards UHC. The framework sets out clear commitments to reduce out-of-pocket payments and improve access to health care for the poor with two new targets:

    •  halve the number of people impoverished by health care payments from 100 million to 50 million by 2020, and eliminate the problem altogether by 2030;
    • double the number of poor people (the poorest 40%) with access to health care services by 2020 – from 40% to 80%.

    These clear targets and deadlines give something progressive to hold the World Bank Group accountable to but why set an 80% rather than 100% target? And if the Bank is serious about them the targets they should be monitored annually and included in the Bank’s new corporate scorecard currently under negotiation.  And most importantly, what action will the Bank take to deliver against them?

    User fees are the most inequitable method of financing health care services, yet they continue to exist in most poor countries. Three people every second are pushed into poverty because of them but donor support for fee removal has remained unacceptably low. The World Bank should break from history and play a clear pro-active role in helping governments to remove fees and to raise and distribute revenue for health equitably across populations.

    At the same time the Bank needs to be much clearer that user fees should not be replaced by health insurance schemes that have been proven to  prioritize already advantaged ‘easy to reach’ groups in the formal sector or rely on collecting premiums from people who are too poor to pay. As Oxfam’s recent paper showed, the countries making most progress towards UHC have prioritized spending on health from general taxation – either on its own or pooled with formal sector payroll taxes and international aid. Governments and donors, including the World Bank, should use the recent lessons from these countries and build on them.

    At the Tokyo event we once again heard calls from Jim Kim for investment in ‘affordable’ ‘quality’ ‘health coverage’ for all, with an emphasis on ‘primary health care’. This is positive but we need greater reassurance that the Bank has shifted to a genuine focus on comprehensive primary health care for all as part of its UHC agenda. This would stand in stark contrast to its historic emphasis on ‘basic’, ‘selective’ or ‘minimum’ interventions or packages of care.

    We hope world leaders listen to the clear call from the World Bank and WHO for UHC to be included in the post-2015 development framework. Universal health coverage provides the opportunity to accelerate progress on the health-related Millennium Development Goals, address the growing burden of non-communicable diseases, and most critically to move towards a more comprehensive approach to deliver on the right to equitable and affordable health care for all. This is something all world leaders should embrace as negotiations on the post-2015 development framework commence.

    Ceri Averill is a Health Policy Advisor for Oxfam GB and author of Universal Health Coverage: Why Health Insurance Schemes are Leaving the Poor Behind

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    Ten years on and major pitfalls still hindering Ghana’s National Health Insurance Scheme

    As the Government of Ghana gears up its plans to celebrate the 10th anniversary of its now internationally famed National Health Insurance Scheme, Ghana’s Universal Access to Healthcare Campaign today launch our own assessment of progress to date. Our new paper explains how 65% of the population is still paying out-of-pocket in the old ‘cash and carry’ system and that at the current rate of progress UHC will not be achieved until at least the year 2076. Our campaign argues that progress will continue to stall as long as the NHIS structure excludes the very people it seeks to protect through overly-burdensome and unworkable insurance premiums.

    Next week Ghana’s National Health Insurance Authority (NHIA) will host a three day International conference in Accra with the theme: “Towards Universal Health Coverage: Increasing Enrolment whilst Ensuring Sustainability”.  The conference will attract Universal Health Coverage (UHC) practitioners, academia, policy makers, NGOs and CSOs in their numbers, and seeks to examine the successes and challenges of the NHIS, and elicit feedback and proposals for reform.

    While the Universal Access to Healthcare Campaign (UAHCC ) welcomes the anniversary event, we are concerned that inherent pitfalls of the NHIS have been consistently left on the sideline over the past decade and if unadressed will stifle any prospect the NHIS has of achieving UHC in the near future. The UAHCC will convey this position at the anniversary conference, where we have been invited to participate in a panel discussion, but also in our own civil society forum today to which government officials and donor agency staff have been invited.

    The paper launched today acknowledges some strengths of the scheme including its generous benefits package, comprehensive level of care and treatment coverage and relatively broad range of exemption categories. However, these strengths are only relevant to NHIS active members. The UAHCC calls on the Government of Ghana to act on the glaring short falls of the scheme including:

    • Lack of coverage and access to service: in 2012, only 35% of the population was recorded as being active NHIS subscribers – a less than 2% increase from 2010.  The NHIS is therefore irrelevant to the 65% of the population who still pay out-of-pocket in the burdensome and inequitable “cash and carry” system.  At the current rate of progress Ghana will not achieve UHC until 2076!
    • Exclusion of poor and low-income earners: a growing body of evidence shows that premium payments are beyond the means of a large portion of informal sector workers and constitute a significant barrier to joining the NHIS.  The rich are twice as likely to join and benefit from the scheme as the poor. The value of the premiums is in serious question – while constituting a massive obstacle to progress on UHC they constitute less than 5% of the total annual inflow to the NHIA.  There must be a shift in focus from extracting premium contributions from people who are evidently too poor to pay, to prioritising spending on health, for example through a reduction of inefficiencies and improvements to general progressive taxation.
    • Unsustainable and inequitable financial model: the NHIS was created with a solid financial base, however by 2011 it was facing a deficit of more than GHC 47.3 million.  This is due in part to large scale inefficiencies and cost escalation in the system and the continued belief that financial sustainability will be solved by increased enrollment of members from the informal sector.  More effort must be focused on identifying alternative sources of financing by tackling service provider fraud and corruption, reducing funding leakages and waste across the health system and by instituting progressive reforms to taxation.

     

     

    Sidua Hor is coordinator for the Ghana Universal Access to Healthcare Campaign Coalition

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    Waiting for a second chance in Georgia

    Maya says: "I don’t want to die and leave my daughter alone. That’s my biggest fear. She’s been through so much she deserves to have a better life." Maya Giorgadze, 47, is a single mother, from Gori, Georgia. She has a 15-year-old daughter, Dea. Maya was diagnosed with breast cancer and had a lumpectomy but cannot afford follow up treatment. Photo: Justyna Mielnikiewicz. Oxfam

    Giorgi’s shy innocent face stares out of a billboard in Tbilisi. The words ‘I have a right to live’ are printed across the frame. A famous Georgian journalist tenderly holds Giorgi’s hand, urging the country to hear their urgent call to action. 13-year-old Giorgi has just a few critical months to find a bone marrow donor to save his life.

    Giorgi is part of a campaign run by leading Georgian journalists, and supported by Oxfam, to ask the Government to urgently invest in the healthcare sector, and save the lives of children affected by leukaemia. For Giorgi, the journalists’ crusade is his last hope. Giorgi’s mother, Jakhia, explains,

    “We have no money. We only receive 125 lari (£48) per month from the state, which is barely enough to feed my family. We have nothing to sell, and I don’t know how we’ll cope,” she says wiping away tears.

    Although the Georgian government provides chemotherapy and medicines to children affected by leukaemia, there are currently no facilities in the country to facilitate bone marrow transplants and no database to find donor matches. Giorgi’s mother may be forced to seek refugee status abroad to pay for her son’s transplant which costs around 100, 000 euros (£85, 000)– an insurmountable amount for the majority of Georgia’s population.

    Giorgi’s story is representative of hundreds of people across Georgia who are struggling to access affordable health care. The health system in Georgia requires families to take drastic measures to save their children’s lives.

    In Gori, the former home of Stalin, Maya, a young single working mother largely dependent on social benefits, is unable to afford the cost of her post cancer treatment. Rising food prices are also having an impact on her family and pushing health care even further out of reach. Maya looks sadly out of the window of her small dilapidated ex Soviet apartment, which she shares with fourteen other families “Sometimes I go to bed hungry at night so I can pay for medicine for my daughter.”

    Elsewhere, people like Elguja, who used to be an actor, have no choice but to buy low quality cheap medicines. Elguja who turned blind at 22, says, “My pension is 125 lari (£48) each month but medicine costs 100 lari (£38). I have to buy cheap medicines but it makes my asthma worse. You can’t imagine what it’s like when you can’t breathe, especially at night.” Elguja often has pain in his eyes but cannot afford the high costs of eye medication. “I miss being able to see people’s eyes on stage,” Elguja wistfully remembers, “The eyes are the window to the soul,” he waves his walking stick like a wand as if he is playing the part of a blind man in a play.

    For Giorgi, Maya, and Elguja, the new Government’s pledge for universal free healthcare for Georgia’s population, and the promise to establish a transplant centre for children affected with leukaemia offers hope. Oxfam is working to raise awareness amongst young people about their health rights and have a say in the future health care system. For young Madea, who is taking part in the project, it gives her a chance to have a voice, “Healthcare is the most important thing, especially for children as they are the future of the country. We often have meetings with municipality representatives to have a say in the healthcare system and lobby for changes.”

    Meanwhile, Giorgi’s message ‘I have a right to live’ remains on billboards across the capital, a stark reminder of the urgent need for healthcare reform in Georgia. I hope that Oxfam’s campaign gives Giorgi, Maya and Elguja a second chance.

    Caroline Berger is the Oxfam Regional Digital Media Coordinator for the CIS

     

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    Universal Health Coverage: key to the success of the World Bank’s new vision

    “We must be the generation that delivers universal health coverage.” – WBG President Jim Yong Kim in a speech to the World Health Assembly, May 2013

    As the World Bank Group’s Annual Meetings come to Washington this weekend, there is much talk of President Jim Yong Kim’s new strategy to achieve the institution’s updated vision: to end extreme poverty by 2030 and promote “shared prosperity,” Bank-speak for reducing inequality.

    We would argue that pursuing Universal Health Coverage (UHC) – alongside robust investments in other aspects of human development – must be utterly central to the Bank’s strategy to achieve its two goals.  While Dr. Kim’s Annual Meetings opener speech last week touched on the importance of health (and education) in achieving its goals, human development is not articulated as a central component of the Bank’s new strategy to achieve the goals, which its Board will be approving on Saturday.

    The Bank says this is because the strategy is meant to describe an overall approach rather than privileging any particular sector.  That may be, but it is hard to see how the Bank’s two goals can be met without a clear vision for how the fruits of economic growth can be equitably shared through transformative essential public services. We hope to see this change as the implementation details of the strategy become clearer.

    Nevertheless, President Kim’s recent speeches and writing provide clues to his vision of the importance of health in reducing poverty and inequality. In a recent article he wrote that “to free the world from extreme poverty by 2030, countries must ensure that all their citizens have access to quality, affordable health services.” At the World Health Assembly in May, he pointed to a hopeful new direction for the Bank by committing to help countries work towards UHC and stating that point-of-service fees are “both unjust and unnecessary.” But will these high level statements really translate to a change in the way the Bank works in countries?

    We hope so.  The Bank’s expertise in building health systems can be powerfully harnessed for the cause of UHC, but this means a break from business as usual.  Building health systems isn’t enough; they must be the right kinds of systems — systems that are equitable and truly universal.

    Oxfam’s new paper, “Universal Health Coverage: Why health insurance schemes are leaving the poor behind,” examines the conditions necessary for health systems to be equitable and universal.  The paper looks at four key ingredients to successful financing for UHC: removal of direct payments and other financial barriers, compulsory pre-payment, large risk pools, and financing from general revenues to cover the uncovered.  In our analysis, conventional insurance schemes – whether private, community-based or European-style social health insurance – come up short when measured against these criteria.

    Since UHC is about access to quality care for everyone regardless of ability to pay, governments must move away from relying on employment-based and contributory insurance models.  Instead, health care must become a right of citizenship (or residency), financed in large part through general government revenues.  As the diverse but successful UHC experiences of Mexico, Thailand, Sri Lanka, Brazil and Kyrgyzstan show, equity must be designed into the system from the beginning, rather than starting with the easiest to reach in the formal sector.

    The World Bank Group has a history of promoting health insurance as a financing mechanism to generate revenues in the health sector in environments of fiscal constraints.  Some examples include a recent policy series on private health insurance, previous work in countries such as Ghana, and IFC investments to support insurance schemes in Africa.

    But things may be changing at the Bank.  In a series of 22 recently released case studies on UHC, the Bank finds that, across countries, the use of financing from general taxation to expand coverage is an important commonality, and that prioritizing equity is a key lesson.  We also hear the Bank is playing a more constructive role in certain countries to encourage universal system design. And new leadership in the health sector and from the President should be cause for optimism.

    A real test of the potency of the new World Bank strategy will be whether the World Bank Group throws its full weight behind equitable, universal health systems – systems that are financed largely through tax-based general revenues and which include all members of society – through its global knowledge products, its policy advice and technical assistance, and through its lending choices.

     

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    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.