Question: What do the following have in common?
One answer might be that these projects are not designed to deliver health services for the poorest sections of the population. The Lagos insurance scheme excludes all informal sector workers, while one IVF cycle at The Bridge Clinic costs $4,600.
A second might be that both projects make a deeply questionable contribution towards a country’s attainment of Universal Health Coverage (UHC), given their provision of services to small, predominantly urban, and comparatively wealthy elite.
A third is that they have both benefited from investments made as part of the International Finance Corporation’s (IFC) Health In Africa Initiative.
Health In Africa is a $1 billion investment project launched by the IFC in 2008, which aimed to ‘catalyze sustained improvements in access to quality health-related goods and services in Africa [and] financial protection against the impoverishing effects of illness’, through harnessing the potential of the private health sector. Specifically, it sought to improve access to capital for private health companies, and to help governments incorporate the private sector into their overall health care system. Health In Africa would do this through three mechanisms: an equity vehicle, a debt facility, and technical assistance. Perhaps of most importance, the initiative would make extra efforts to ‘improve the availability of health care to Africa’s poor and rural population’.
Emanating from the World Bank Group, Health In Africa’s focus on delivering health care for people living in poverty makes sense. Anything contrary would be at odds with the Bank’s mandate and overarching goal to end extreme poverty by 2030. Oxfam welcomes World Bank President Jim Kim’s emphasis on the centrality of achieving Universal Health Coverage (UHC) to see this goal attained, and the Bank’s target to deliver health care for the poorest 40% by 2020.
However, it seems that with the Health In Africa initiative, the IFC may be working deeply at odds to these stated World Bank aims. Today, Oxfam launched Investing for the Few, analysing the investments made as part of Health In Africa to date. Oxfam’s assessment of the sporadic investment information available finds that far from delivering health care for the poorest, Health In Africa has favoured high-end urban hospitals, many of which explicitly target a country’s wealthy and expatriate populations. The initiative’s biggest investment to date has been in South Africa’s second largest private hospital group Life Healthcare. This $93 million endowment no doubt supported the company in its subsequent expansion (Life Healthcare acquired a 26% stake in one of India’s largest hospital groups in 2011), but there is no evidence it has used this investment to expand access to health care for the 85% of South Africans without health insurance.
Oxfam’s findings show that Health In Africa has also failed to deliver expansion of health care at any sufficient scale or pace to meaningfully contribute towards UHC. Instead the initiative has supported high-cost, low-impact investments. The Lagos health insurance scheme mentioned above cost triple the annual Nigerian government per capita health expenditure for example, and took over five years to secure fewer than 9,000 enrolees. In Nigeria, scaling up to reach UHC at this rate would take over 100,000 years.
Another major concern is the absence of sufficient attempts by Health In Africa to measure its performance. The initiative’s own mid-term evaluation found Health In Africa had failed to define and assess its anticipated results, and that the performance indicators it has used are inadequate to measure any development impact. Whilst an equity fund employed by Health In Africa boasts of its success at reaching patients at the so-called ‘base of the pyramid’, one of the annual income targets used to define this group include all but the top five per cent of earners in sub-Saharan Africa. It is likely Health in Africa’s use of financial intermediaries contributes to this failure to effectively measure impact on poor women and men. Such an arms-length approach to investment brings inherent problems around oversight and transparency.
Oxfam is clear that the IFC must improve the transparency and accountability of the Health In Africa initiative. Our report calls on the IFC to cease all Health In Africa investments until a robust, transparent and accountable framework is put in place to ensure that the initiative is pro-poor, and geared towards meeting unmet need. In addition, it calls on the World Bank Group to conduct a full review of the IFC’s operations and impact to date in the health sector in low- and middle-income countries, to investigate how they are aligned with, and are accountable to, the overarching goals of the World Bank Group: to end extreme poverty and promote shared prosperity.
The IFC needs to fundamentally rethink its activities in health, and ensure any potential projects are aligned with the Bank’s goals. The World Bank Group should focus on supporting African governments to expand publicly provided health care – a proven way to save millions of lives worldwide.
Civil society groups at the recent World Health Assembly criticized the continued focus on insurance schemes in the push for Universal Health Coverage (UHC), which all too often includes significant private sector participation. Evidence to support the claim for private sector involvement of this kind remains extremely thin and a new study by the Municipal Services Project shows it could jeopardize public health in the South.
The study compares health outcomes in Chile and Costa Rica, two countries that have come to epitomize contrasting approaches to ‘Universal Health Coverage’ in Latin America. Chile’s focus has been on insurance-based UHC while Costa Rica has built a single public health system. The research provides strong evidence to show that there are widespread and consistent advantages to promoting UHC through a strong public system that funds and provides all medical and preventive services to citizens rather than through a fragmented public-private mix.
It is important to note that both countries have achieved the lowest infant mortality rates and the highest life expectancies in the region thanks to major advances in primary care. But Chile’s health ‘market’ has led to inefficient use of resources, with higher administrative costs and more irrational medical procedures (e.g. caesareans) resulting from oligopolies and collusion among private providers.
One of the major goals of UHC is financial protection for poor households when they face illness. Yet Chileans systematically need to make higher out-of-pocket payments to get medical care in comparison with Costa Ricans. This situation is produced in part by the fact that Chileans pay for health conditions, services or products that are not covered by their insurance (e.g. prescription drugs).
In contrast, Costa Rica’s public health care system remains relatively affordable and more efficient, with total per capita health expenditure standing at US$811 compared to US$947 in Chile. Importantly, Costa Rica has also consistently prioritized preventive health care. Expenditure on prevention and public health services from 2002-2006 in Costa Rica is more than double that of Chile (6-7% vs 2-3%). This focus on prevention is more cost-effective and can yield greater public health impacts in the long term.
Using comparable data (Latinobarómetro), the Municipal Services Project study shows that twice as many people reported facing access barriers to health care in Chile compared to Costa Rica, citing distance to hospital, time to obtain an appointment, and cost of seeing a doctor as the major reasons. In addition, lack of access to health services as a result of financial barriers in Chile still stands at 4.2% compared to 0.8% in Costa Rica.
Costa Ricans continue to be largely satisfied with the quality of their healthcare services, more so than Chileans. Interestingly, LAPOP 2012 results show that most people in both countries think that government, rather than the private sector, should be responsible for health care (71.1% in Chile and 67.5% in Costa Rica).
According to the notions of “active purchasing” and “managed competition” – frequently used to promote insurance schemes – the existence of different providers competing for resources should have produced higher levels of quality at lower costs in Chile. The evidence presented in this report shows that such assumptions are not always true.
The Chilean health system is an example of how segmentation produced by the coexistence of private and public insurances is detrimental to efficiency and equity. Collusion among private providers and oligopolies are realities that are ignored in the competition argument.
Debates over the best institutional arrangements to organize universal health care are far from over, but this case study demonstrates that insurance schemes as promoted by some proponents of the UHC agenda are neither the only nor the best option.
Luis Ortiz Hernández is Professor in the Health Care Department, Universidad Autónoma Metropolitana Xochimilco, Mexico and visiting professor at Queen’s University, Canada. His most recent publication, “Chile and Costa Rica: Different roads to universal health in Latin America,” is available here.
This great new two minute video captures the motivation and the rationale for the movement against a greater role for the private sector in the health care systems of low- and middle-income countries.
The video highlights the manipulation of the Universal Health Coverage agenda to serve the interests of profit making companies while simultaneously starving already crumbling public health services from badly needed investment.
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
John Lister is well-known as a researcher, writer and campaigner against cutbacks and privatisation in the NHS. But his new book Global Health Versus Private Profit focuses on the changes taking place in global health care systems. It has received glowing endorsements from a number of specialists in the field, and described as “penetrating, highly readable, and extremely well researched”. We caught up with John and asked him to talk about the book.
Can you sum up the book’s main point in two sentences?
Who will be interested in reading the book?
This book is for all those working to achieve universal access to health care, and anyone interested in the evolution of international health and the different ways in which the
I also hope it might be read by some of the people working for the institutions assessed in the book including the WHO, World Bank (and especially IFC), for national health care systems and for NGOs and donor agencies. My analysis is based on research, analysis, literature and evidence, and I would be delighted to see a debate on issues which people find contentious. neoliberal agenda has brought its influence to bear on international health over time.
Global Health versus Private Profit offers a detailed analysis of the main “menu” of market-style reforms to health care systems that have been rolled out in country after country, despite the absence of evidence for their effectiveness, and ignoring the evidence of harm that is being done.
These include the emphasis on competition rather than planning and cooperation, the splitting of health care systems into purchasers and providers, privatisation in various guises – including buying in services from the private sector that were previously delivered by public sector providers – the imposition of user fees, and the focus on health insurance and managed care in place of social provision and universal coverage.
Many of these policies are being implemented in rich countries and poor alike, but they are having the most devastating impact on the poorest. They sap vital resources, dislocate and fragment systems, prevent them from responding to health needs, and obstruct the development of planning.
What evidence does the book bring to light of this conflict between global health and private profit?
Perhaps the most important examples come in the chapter entitled “The Missing Millennium Development Goals” which underlines the massive global gaps in provision of care for the growing elderly population, in mental health care and services for people with physical disabilities.
All of this is health need, but countless millions of people can’t pay a market price for care, and so they are the “customers the private sector doesn’t want”. The longer health care is shaped by the quest for private profit the larger these gaps will become.
So are we just looking at wrong-headed ideas, or is there more to it than that?
My book argues that these so called “reforms” are driven not by evidence, but by ideology – but that behind the ideology is a massive material factor: the insatiable pressure from the private sector which is desperate to recapture a much larger share of the massive $5 trillion-plus global health care industry, much of which only exists because of public funding.
That’s why rather than relying on hopes of expanding on the basis of private insurance, the private sector has been eager to get a larger slice from public sector budgets.
Why do you draw specific attention to the UK’s NHS in your book?
The costly experiments with competition, and slicing up publicly provided services to encourage private providers, have gone furthest in England, but that’s partly because compared with other countries there was a more integrated and publicly-provided service to dismantle.
But sadly England is not unique. Similar “reforms” from the same discredited menu are being adapted in different ways to different systems across much of Europe, and are even being driven in to the poorest developing countries where they are even less appropriate and more disastrous in their consequences.
For example, one growing problem is the international spread of “Public Private Partnerships,” to finance new hospitals, many of them drawing on the trail-blazing Private Finance Initiative (PFI) in the UK, which is proving itself to be a major liability, bankrupting hospitals in a cash-strapped NHS.
Despite many costly flaws, failures, and false starts, more PPPs (P3s in Canada) are now under way in OECD countries, but also in Latin America, Asia, South Africa and even Lesotho – in a costly $120m scheme I have written about for Global Health Check.
Where do you get the information for your critique?
I have made a point of using the most up to date material available from the World Bank (and its privatisation wing, the International Finance Corporation) and the IMF, as well as official figures from governments and the rich countries’ club, the OECD. It’s important to use data that cannot be refuted – and in many case, let’s be honest, these are the only figures available.
Does the book raise any new issues?
I am not claiming to have invented many of the ideas in the book, but I hope I have helped to update, popularise and develop the argument for them.
And my concluding chapter “It doesn’t have to be this way” brings together a lot of different ideas, emphasising that the policies we are opposing are not inevitable products or even a rational response to the current situation, but choices that have been deliberately made by politicians working to a neoliberal agenda. They can be rejected and defeated by mass political action.
How do you hope the book will be used?
As I say in the preface, good ideas must be turned into political action to change the world. Bad ideas must be fought through political action too.
Sometimes good arguments can begin to prevail, such as the success that has been achieved by Oxfam and other campaigners challenging the logic of imposing user fees on health care.
So I hope my book will not sit gathering dust on library shelves, but be brandished — even used as a weapon — by those fighting for change.
A reinforced hardback edition may yet be needed to ensure we win!
Health Policy Reform: Global Health versus Private Profit, by John Lister is available from www.libripublishing.co.uk
(use voucher code HPR13 when purchasing to get discounted price of £20).