A new report published by Oxfam last week calls on governments to reduce inequality by changing the rules and systems that have led to extreme inequality, and by prioritising policies that redistribute money and power. ‘Even It Up: Time to End Extreme Inequality’ firmly presents universal public services – including health and education – as part of the solution to out-of-control inequality.
Health is both a human right and a building block to tackling poverty and reducing inequality. The provision of good quality health care for all – free at the point of use – can mitigate the impact of skewed income and wealth distribution, by closing the gap in life chances between the rich and the rest. Moreover, universal free health care (UHC) with other public services, especially education, puts ‘virtual income’ into the hands of ordinary people, further helping to level the playing field. Between 2000 and 2007, the ‘virtual income’ provided by public services reduced income inequality by an average of 20 percent across OECD countries for example.
In addition, quality health care and education can transform societies, by giving people the tools and ability to challenge unfair rules that perpetuate economic inequality. For example, healthy and well-nourished children are more likely to spend more years at school and to have better cognitive skills that help learning.
But the extent to which public services are able to achieve their inequality-busting potential is heavily dependent on how these systems are designed, financed and delivered. Low levels of public spending and a continued reliance on out-of-pocket payments to fund health services are disproportionately harming poor and marginalised women and men. User fees and other forms of out of pocket payments can push struggling families further into poverty and prevent people from getting the treatment they need.
“I went for a cataract operation. They told me it costs 7,000 Egyptian pounds. All I had in my pocket was seven so I decided to go blind” – a 60-year old woman in a remote village in Egypt”
When health care is not free, poor people are excluded from service or are forced to sell assets and borrow money; leading to debt and thus further perpetuating existing economic hardships. This happens even in rich countries; in the USA, medical debt contributed to 62 percent of personal bankruptcies in 2007.
All too often the amount of money available for governments to spend on public services is limited. Taxation is critical to ensure sufficient public funds can be invested in delivering free healthcare for all. However, the exploitation of tax loopholes, unfair tax rules and tax dodging results in governments’ loss of millions of dollars each year. For example, in 2008/09 the Rwandan government authorized tax exemptions that could have been used to double the health and education spending.
Decent investments in public health services that are free at point of delivery will boost the rights and opportunities of poor people. The growing momentum for UHC – under which all people should get the healthcare they need without suffering financial hardship – has the potential to vastly improve access to healthcare, and drive down inequality.
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:
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
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:
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
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:
Sidua Hor is coordinator for the Ghana Universal Access to Healthcare Campaign Coalition
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