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
In 2009 Oxfam published “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” to help redress what we saw as an international health discourse increasingly dominated by unchallenged private sector advocates. Some of those same advocates accused Oxfam of being purposefully selective with the evidence.
The health team at Oxfam were therefore very pleased to see the recent publication of a thorough and balanced independent appraisal of peer-reviewed evidence on this topic in PloS Medicine. The study supports many (not all) of our conclusions about both the public and private sector.
In their research Basu et al. assess the comparative performance of the private and public sectors in health across a range of health system performance areas. They are clear that comparative evidence is often lacking and that distinctions between what is public and private are often difficult (for example when public facilities act more like commercial operators by charging fees). With these limitations acknowledged, the authors’ own conclusion states:
‘Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients’.
Like Oxfam, the authors of this comparative study make special note of the World Bank as an influential advocate of public-private partnerships in health, but one whose claims are often unsubstantiated by their own data. The authors raise concerns about a conflict of interest for the World Bank that may undermine the validity of their research and analysis on this topic.
Some highlights from the paper are listed below (though I recommend reading this important article in full – especially for interesting country examples):
Access and responsiveness
Accountability, transparency and regulation
Fairness and equity
Other important findings
And on the World Bank….
The evidence from this study shows that while public health systems are often weak and under-resourced they still deliver better quality of care, more equitably and with greater efficiency than the private sector. The study highlights the tendencies of private providers to serve higher socio-economic groups, have higher risk of low-quality care, create perverse incentives for unnecessary testing and treatment, and suffer from weak regulation. It also suggests there are a number of ways public health systems can do better. They must be more responsive to patients and more accountable to citizens, improve systems for distributing essential inputs like medicines, and address financial barriers to accessing care (such as formal and informal fees).
These are legitimate challenges that deserve thoughtful attention and action, but they should not be used as evidence of the superiority of private sector approaches. Instead, the policy response to these findings should be very clear: far more effort and resources must be mobilized to maximize the clear advantages of public health systems, rather than further starving them of the resources and support they need to deliver equitable and quality health care for all.
On World Malaria Day there is much to celebrate. Today’s UK Guardian cites malaria control as ‘one of the most notable achievements of international aid’. Dramatic reductions in malaria deaths from Ethiopia to Zambia have been attributed to large scale free prevention, diagnosis and treatment via trained health workers. But the Global Fund for HIV, TB and Malaria, one of the major vehicles responsible for delivering these approaches and capable of further scale up, now faces a severe financial crisis. Meanwhile some donors are making the choice to invest more precious aid resources into a different unproven and risky scheme – the Affordable Medicine Facility for malaria (AMFm).
Recently the UK and Canadian governments as well as UNITAID decided to inject more funding into AMFm which actively promotes the sale of the only effective treatment left for malaria (Artemisinin Combination Therapy or ACT) via unqualified shopkeepers. Not only does this go against WHO guidelines that say malaria must be diagnosed, it also risks lives because:
Last year, uncontrolled ordering by AMFm buyers also threatened to destabilise the market for Artemisinin Combination Therapy (ACTs) and led to a funding gap in the AMFm of $120m. For example, buyers in Zanzibar, a country where malaria has almost been eliminated, have ordered over 240,000 treatments when the number of malaria cases is around 10,000 per year. These cases of unnecessary over-ordering constitute a massive waste of aid.
The AMFm experiment presents a great risk of repeating the sad story of chloroquine – an effective drug rendered useless in Africa because of resistance. Despite being cheap, poor people could not afford a full treatment course allowing resistance to develop. A few years ago the first cases of resistance to ACTs were identified along the Thai-Cambodia border – where resistance to chloroquine first emerged. Alarmingly, recent research has found more cases of ACT resistance on the Thai-Burmese border.
The threat of growing resistance to ACT cannot be taken lightly and containing it must be a global priority if the world is to avoid losing the battle against the malaria parasite. As well as specific measures in the regions affected, that means using aid to scale up proven approaches of diagnosing and treating patients free of charge via trained community health workers or primary health care units. Instead, with donor support, UNITAID (the international drug purchasing facility) has made the recent decision to invest $34 million over 3 years in the sale of RDTs by shopkeepers. The decision could result in RDTs flooding the private-sector market without prescribers being qualified to use the tests, without the drugs necessarily there to accompany them, and without addressing the treatment of those who test negative for malaria.
Supporting the AMFm is not only a risk to public health it is also a waste of precious resources. With donors including the UK government ever more focussed on ‘results’ it makes sense to rethink support for the AMFm and instead focus limited aid resources on scaling up evidence-based approaches that have already worked to save so many lives. That means fully financing the Global Fund to deliver free malaria prevention, diagnosis and treatment by trained health workers.
This blog was co-authored by Dr Mohga Kamal-Yanni, Senior Health and HIV Policy Advisor for Oxfam GB
At the current rate of progress there are legitimate fears that Millennium Development Goal 5 to reduce maternal deaths by 75% will be missed. Research has shown that financial barriers to obstetric care are one of the major causes of the high rate of maternal and child deaths in Sub Saharan Africa. In 2005 Mali introduced fee exemptions for caesarean sections and a recent USAID evaluation of the policy found that it increased access to caesarean section and reduced maternal and neonatal deaths. These findings support the growing body of evidence that removing user fees for health services is an effective way of saving millions of vulnerable lives.
In Mali, maternal mortality is as high as 464 deaths per 100,000 live births. In addition less than 50% of women give birth in a healthcare facility. These trends are driven primarily by socio-economic factors, with poorer women having disproportionately less access to health care due to financial barriers created by user fees. In response, in 2005 the government of Mali initiated a universal policy on user fees exemption for caesarean section. Under the policy, the government pays for the direct cost of caesarean services for all women regardless of their socio-economic status. However, indirect cost associated with receiving these services such as transport costs to hospital are borne by households and in some cases community based solidarity funds.
But six years since the implementation of Mali’s free caesarean policy, what has been the impact of the policy on maternal health and what lessons can be learnt? A recent evaluation of the policy by USAID has found that between 2005 and 2009 caesarean rates in Mali has doubled from 0.9% to 2.3%, while facility deliveries also increased from 53% to 64 %. The policy also resulted in a decline in post caesarean and neonatal deaths.
The free caesarean policy was initiated by the Government of Mali and fully funded from internally generated funds. This, contrary to the much held view that poor countries are not financially capable of providing free healthcare, is an indication that given the right political commitment poor countries can mobilise the needed funds to provide free healthcare for their population.
Mali’s free caesarean policy still faces many challenges that need to be addressed. Firstly, the evidence from the USAID report suggests that the policy was less pro-poor than intended, with only 23% of women delivering by caesarean section in public facilities belonging to the lowest socio-economic group. The report finds that there are still barriers to access among women from the lowest socio-economic groups including a high cost of prescription drugs and indirect costs such as transport. These barriers need to be addressed if the policy is to have greater positive impact on the poor women. Christine Sow, who leads UNICEF’s Child Survival Section and is the Chair of Mali’s Health Sector Technical and Financial Partners Working Group noted at national conference on free health policy, these initiatives [ the caesarean policy] should not only increase access, but should ensure that the most vulnerable can and do benefit.”
Secondly, the report also shows that Mali’s free caesarean policy was limited by poor referral and the lack of emergency transport system. In addition, the policy is challenged by poor road conditions; poor supply of drugs and caesarean medical supplies; lack of awareness about the specific components of the policy; and socio-cultural barriers to maternal healthcare utilisation.
Indeed, the above highlights several important lessons in trying to improve access through the elimination of user fees. First, policies that deal with access to healthcare need to recognise that barriers to access are multi-faceted which requires coordination of the activities of different sectors of government and the involvement of diverse players in order to deal with healthcare access effectively. Second, it is important for policy makers to recognise that user fees removal creates a welcome increase in demand for healthcare, and thus, there is a need to expand healthcare resources and supply to meet this demand.
The free caesarean policy in Mali has shown that the elimination of user fees for healthcare is an effective approach for enhancing maternal and child health. It also demonstrates that domestically funded free healthcare policy is feasible in poor countries (albeit that this is limited to C-sections in Mali), and that by paying attention to other aspects of healthcare cost and access, the removal of user fees can serve as an effective measure for enhancing access to healthcare and improving health outcomes.
Selon le niveau de progression actuel, il existe des raisons légitimes de penser que le 5ème objectif du millénaire pour le développement visant la réduction de la mortalité maternelle de 75 %, ne sera pas atteint. Des études ont démontré que les contraintes financières pour l’amélioration des soins obstétriques constituent les principales causes du taux élevé de la mortalité infantile et maternelle en Afrique sub-saharienne. En 2005, le Mali a mis en place un système d’exemption de paiement pour les césariennes, et une évaluation récente de cette mesure, conduite par l’USAID, a montré qu’entre 2005 et 2009 le taux de césariennes a doublé allant de 0,9% à 2,3%, tandis que le taux de fréquentation des services de maternité a augmenté de 53% à 64%. La politique a également eu pour conséquence une baisse de la mortalité post-césarienne et néonatale. Ces résultats viennent renforcer les preuves de plus en plus nombreuses indiquant que l’abolition du paiement direct au niveau des services de santé est un moyen efficace qui permet de sauver des millions de vie vulnérables.
Au Mali, la mortalité maternelle a atteint 464 décès pour 100000 naissances. En outre, moins de 50% des femmes accouchent dans un centre de maternité. Ces tendances résultent principalement de facteurs socio-économiques : de manière disproportionnée, les femmes les plus démunies ont un accès limité aux soins de santé à cause de la barrière financière que représente le paiement direct par l’usager. En guise de réponse, le gouvernement malien a initié en 2005 une politique universelle d’exemption de paiement pour les accouchements par césarienne. Afin de mener une telle politique, le gouvernement subventionne le coût de la césarienne pour chaque femme quel que soit son statut socio-économique. Cependant, les coûts indirects associés à un tel service, comme le transport vers l’hôpital restent à la charge des ménages et parfois ils sont supportés par un fonds de solidarité communautaire.
Six ans près la mise en place de la politique malienne de gratuité de la césarienne, quel en a été l’impact sur la santé maternelle et quelles sont les leçons à retenir ? Selon une évaluation récente de cette politique par l’USAID, entre 2005 et 2009 les taux de césarienne au Mali ont doublé de 0,9% à 2,3%, tandis que le taux de fréquentation des centres de santé a également progressé de 53% à 64%. Cette politique a donc eu pour conséquence la baisse de la mortalité post-césarienne et néonatale.
Cette politique de gratuité de la césarienne a été initiée par le gouvernement malien et entièrement financée par des ressources domestiques. Ce qui, contrairement à l’argument récurrent selon lequel les pays pauvres sont dans l’incapacité financière de fournir des soins de santé gratuits, démontre que lorsque l’engagement politique est réel les pays pauvres sont en en mesure de mobiliser les fonds nécessaires pour délivrer des soins de santé gratuits à leur population.
La politique malienne de gratuité de la césarienne est néanmoins toujours confrontée à des défis qui doivent être résolus. En premier lieu, la preuve émanant du rapport de l’USAID suggère que cette politique a moins bénéficié aux démunies que prévu. En effet, seuls 23% des femmes accouchant par césarienne dans des services de santé publics sont issues de la catégorie socio-économique la plus basse. Selon ce rapport, il existe toujours des barrières à l’accès pour les femmes appartenant aux groupes socio économiques les plus défavorisés : le coût élevé des ordonnances et des coûts indirects liés au transport. Ces barrières à l’accès doivent être prises en considération pour permettre à cette politique d’avoir un impact positif plus significatif sur les femmes démunies. Christine Sow, qui dirige la division de l’Unicef pour la survie de l’enfant et la Chaire malienne du groupe de travail des partenaires techniques et financiers en santé a indiqué lors d’une conférence sur les politiques de gratuite en santé que « ces initiatives [la gratuité de la césarienne] ne doivent pas seulement augmenter la capacité d’accès aux soins, mais aussi garantir que les couches les plus vulnérables peuvent concrètement en bénéficier ».
En second lieu, ce rapport montre également que la politique malienne de gratuité de la césarienne a été freinée par un système médical de référence ? Défaillant ainsi qu’un manque de système de transport d’urgence. En outre, cette politique est mise en difficulté par le caractère vétuste du réseau routier, une fourniture faible en médicaments et en matériel médical pour la césarienne ; le manque d’information sur les composantes spécifiques de cette politique ; les barrières socioculturelles liées à l’utilisation des soins de santé maternelle.
Aussi, ces éléments mettent en exergue plusieurs leçons importantes à retenir dans le processus d’amélioration de l’accès aux services de santé par l’élimination du paiement direct par les usagers. Tout d’abord, les politiques en faveur de l’accès aux soins de santé doivent prendre en compte la complexité des barrières à l’accès aux soins et la nécessité d’une coordination des activités des différents secteurs du gouvernement de même que l’implication de divers acteurs afin de pouvoir gérer efficacement l’accès aux soins. Ensuite, il est primordial que les décideurs acceptent que l’élimination du paiement direct génère une augmentation souhaitable de la demande en soins de santé, ce faisant, il est nécessaire d’accroître les ressources en soins et fournitures de santé afin de répondre à une telle demande.
La politique malienne de gratuité de la césarienne a démontré que la suppression du paiement direct par les usagers constitue une démarche efficace pour l’amélioration de la santé maternelle et infantile. Elle a également prouvé que le financement des politiques de gratuité des soins de santé par des ressources nationales est réalisable dans les pays pauvres (même si cela se limite à une politique de gratuité ciblée au Mali). Aussi, en considérant les autres aspects liés à l’accès et au coût des soins de santé, la suppression du paiement direct est une mesure efficace pour renforcer l’accès aux soins de santé et améliorer le niveau de santé.