One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12^th 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.

Bad medicine

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:

• Earmark adequate financing for the public system that should aim to reach 5% of GDP in the medium term
• Streamline structures and human resources in facilities to improve efficiency, as well as rationalize costs of care in public facilities
• Provide more equitable access across rural and urban areas
• Set standard treatment protocols to ensure quality of care
• Establish mechanisms to empower communities to hold health authorities accountable

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

Novartis has been trying to challenge the Indian Intellectual Property law since 2006 when its patent application for Glivec was first rejected. Novartis claimed that Indian Patent Law did not conform to the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). It is worth noting that no other company or country has ever sought to make this claim against India to the World Trade Organisation – the body responsible for settling such disputes. After much debate, the court turned down the Novartis case.

The case rests on the way the India intellectual property law makes use of many of the flexibilities of the TRIPS agreement, including how the patentability criterion defines innovation.  Section 3D of the Indian law, which is condemned by Novartis and other pharmaceutical companies, prevents patents on new forms, uses, doses, formulations and combinations of known medicines or substances. Instead, to be granted a patent, the revised medicine must show significantly enhanced therapeutic efficacy.

In the Novartis case, although the company provided evidence of improved physical features of the medicine, it did not demonstrate improved therapeutic efficacy. Novartis presented some late evidence of increased bio-availability of the revised medicine but even that was based on comparison with the original molecule of imatinib which is actually no longer marketed as treatment. Moreover, increased bio-availability does not automatically mean enhanced therapeutic efficacy.

The claim by pharmaceutical companies that Indian patent law will stop innovation is without foundation. On the contrary, Section 3D encourages innovation (incremental or otherwise) by preventing companies like Novartis securing patent extensions for making trivial changes to their products – a practice known as ‘Evergreening’. Allowing companies to secure patents, and therefore profits, by making trivial changes to existing products acts as a disincentive for much needed R&D investment in new products to treat and prevent diseases.

Novartis, along with other companies are also claiming the court ruling will put an end to R&D investment by companies in India. They argue that the unlikelihood of securing patents removes any incentive for R&D investment. The reality is that other scientific and economic factors have proven much more important for R&D investment including the availability of a strong science base in a country, appropriate infrastructure and an industry-friendly tax system.

In short the court resolution means that more people suffering chronic myeloid leukaemia can be treated now. Novartis says that its patent on Glivec is protected in 40 countries. That means the rest of the world can now use generic versions of Glivec without worrying about patent issues. Developing countries need to learn from India in promoting the use of high-quality generic medicines so that patients can access treatment at affordable prices.

The story highlights the urgent need to review the dysfunctional intellectual property system and find new ways of stimulating R&D to produce new medicines that have real therapeutic value.  In the interim, pharmaceutical companies should stop spending millions of dollars on litigation in their effort to secure patents for evergreening their products. Instead they should invest in R&D for new products that could make a real difference to people’s lives.

Mohga Kamal-Yanni is a Senior Health and HIV Policy Adviser at Oxfam GB

Photo credit: Novartis AG / Foter.com / CC BY-NC-ND

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

• A significant proportion of services in some developing countries are provided by the private sector but figures vary enormously by country and by income level. When informal or unlicensed providers are excluded, the public sector provided the majority of care in 19 out of 22 low- and middle-income countries for which World Bank data is available.  
• Studies that measured utilization by income levels tended to find the private sector predominately serves the more affluent. In Colombo, Sri Lanka, where a universal public health service exists, the private sector provided 72% of childhood immunisations for the wealthiest, but only 3% for the poorest.
• Waiting times are consistently reported to be shorter in private facilities and a number of studies found better hospitality, cleanliness and courtesy and availability of staff in the private sector.

Quality

• Available studies find diagnostic accuracy, adherence to medical management standards and prescription practices are worse in the private sector.
• Prescribing subtherapeutic doses, failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely in the private sector, although there were exceptions.
• Higher rates of potentially unnecessary procedures, particularly C-sections, were reported at private facilities. In South Africa for example, 62% of women delivering in the private sector had C-sections, compared with 18% in the public sector.
• Two country studies found a lack of drug availability and service provision at public facilities, while surveys of patients’ perceptions on care quality in the public and private sector provided mixed results.

Patient outcomes

• Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV as well as vaccination. In South Korea for example, TB treatment success rates were 52% in private and 80% in public clinics. Similar figures were found for HIV treatment in Botswana.

Accountability, transparency and regulation

• While national statistics collected from public sector clinics vary considerably in quality, private healthcare systems tended to lack published data on outcomes altogether. Public-private partnerships also lacked data.
• Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, and with limited effectiveness.

Fairness and equity

• Financial barriers to care exist in the public and private sector.
• Private sector services tend to cater for higher income groups with studies showing exclusion and discrimination against poorer patients and women.
• Several studies suggested the process of privatizing existing public services increased inequalities in the distribution of services.
• Private contracting and social franchises showed potential for reaching impoverished groups, though findings are tentative because comparisons to the public sector are unavailable.

Efficiency

• Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation.
• The evidence is mixed (and often weak) on the cost of contracting to private providers – increasing expenditure in some countries whilst reducing it in others.

Other important findings

• Rather than adding resources, several studies reported that growth of the private healthcare sector, whether independently or via public-private partnerships, directly reduced public funds and staff available for public provision.

And on the World Bank….

• ‘The World Bank has made strong claims that investing in public-private partnerships will improve efficiency and effectiveness in the health sector, yet several of its publications revealed that these assertions were either unsupported by data or the data was not provided in sufficient detail to pass minimal inclusion criteria for this review’.
• Despite the lack of data about private sector performance, recent initiatives by the World Bank’s International Finance Committee (IFC) are underwriting the expansion of private sector services among low- and middle-income countries. For example in sub-Saharan Africa, the IFC has created a private equity fund to make 30 long-term investments in private health companies. These conflicts of interest pose a potential threat to the validity of World Bank-sponsored studies and raise the need for independent scrutiny.

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.

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.

The papers seem to suggest that fiscal reality is cast in stone and that within this fiscal reality countries have the political space to move forward to UHC. This approach, in essence, tells us something about the sad situation we have come to live in. A reality in which the financial oligarchy have taken over country democracies, according to Simon Johnson’s The Quiet Coup. A reality in which economic inequalities have an enormous negative impact on health equity and social wellbeing. Untaxed private wealth hinders many countries to finance strong public systems to reach or maintain Universal Health Coverage.

It is not only a problem of poorer countries. We have the same within the European Union. For instance 23.400 “mailbox” companies are registered in the Netherlands, with its infamous tax heaven industry. It lead for instance to Portuguese and Spanish multinationals to avoid paying tax in their respective countries. Both Spain and Portugal have to severely cut their public spending on health expenditures and privatize part of their health services, as required by austerity measures set by the European Union. Even the G20 starts to recognize that the tax avoidance by big business is a big problem for the social development of societies.

These examples merely indicate that the issue of fiscal space and progress on UHC are closely interlinked. The Lancet Article ‘Political and economic aspects of the transition to universal health coverage’ explains it as follows: “UHC will only be achieved if public policies ensure that a large share of this increased spending is pooled through a mechanism that promotes equitable and efficient utilization of care. The exact mechanisms for pooling will depend on social processes and political action that establish the parameters for an acceptable public role in health care. In some cases, the result will be a government that primarily regulates the health-care sector, in other cases a government that finances or directly provides care.” In many emerging economies, such as South-Africa, Indonesia; but also in European countries with traditional generous social security systems, there is strong political pressure to remain attractive for international (financial) investors. In parallel there is similar pressure to reduce public spending on health care and create space for health insurance companies in the market of (mandatory) social insurance packages. Authors have coined this process of tax competition “a race to the bottom in slow motion”, with specific policies becoming less generous without disappearing, or creating a public debt that will eventually force their termination.

The authors also suggest a mechanism to mitigate this race to the bottom, the so called social protection floor. The idea underpinning this initiative is that all states would commit to agreed minimum levels of social protection tailored for their respective country. The UN General Assembly resolution concerning universal health coverage acknowledges the link between universal health coverage and social protection mechanism, and urges member states to give priority to these links within their national social programs and policies.

The contradiction is obvious: There is a strong drive to have Universal Health Coverage included in the post 2015 development agenda and for countries to advance UHC at national level. At the same time these countries are dealing with (global) tax competition, tax evasion and a deregulated financial sector that is playing with casino capital at a global level. It is a good first step that WHO and World Bank work with member states to increase capacity and undertake steps towards universal health coverage. Actors working on advancing UHC inevitably will come to the issue of claiming national policy and fiscal space as a basic macro-economic condition for a country to advance its coverage of social protection and health services. Good examples in these include Brazil and Thailand.

The question is whether all the countries that are now supporting the cause of UHC are willing to make progress on further regulation of the financial sector and reform of their fiscal policies. Are these countries able to agree on global redistribution mechanisms and regulatory mechanism to curb the massive amount of untaxed wealth and casino capital, and hence free considerable resources to fund the national social protection floors? Will countries be able to develop true “progressive” taxation schemes, not merely income or VAT based, but rather on wealth and CO2 emission? Or do we want rather global philanthropy to provide the complimentary funds for advances in UHC and social security?

Bottom line: Universal Health coverage is in essence linked to political demands, choices and inherent power relations, both at the national and global level. If we all agree to have UHC included in the post 2015 agenda, then we should be willing to be truly involved in the political and ideological battle that will enfold over the coming period.

Remco van de Pas is a Senior Health Policy Advocate at Wemos

This post was first published as an editorial in MMI Network news, 26 February 2013. Reposted here with permission.

Fresh from its much-talked-about premiere at the Sundance Film Festival in Park City, Utah, last month, Fire in the Blood opens at the Irish Film Institute (IFI) in Dublin and the Prince Charles Cinema in London later this week. The film will be released in cinemas  across the UK on Monday 25th February.  The film tells a harrowing story of inhumanity and heroism, with a highly compelling cast of characters.  It details how it could come to pass that millions upon millions of people, primarily in Africa, were left to die horrible, painful deaths, while the drugs which could have saved them were being safely and cheaply produced and distributed just a short airplane ride away.

“I was curious to see what the reaction in the US would be”, says writer-director Dylan Mohan Gray.  “So much indoctrination about the necessity of high drug prices has gone on there that the Big Pharma Research & Development (R&D) defence is very much a sacred cow… even those with profound reservations about how the industry behaves tend to grudgingly accept its validity.  This is very easy for me to understand, since I was more or less that way myself when I began digging into all this.”  Gray was, however, gratified to discover that the American audiences who waited in line to attend six sold-out screenings at Sundance had much the same reaction after seeing the film that he had had when he began to work on the story.  “There is a very strong sense of betrayal when people find out what their governments have done in their name… and a very powerful conviction that the prevailing system of developing and commercialising medicine has to change”.

As the film points out, drug companies actually do very little basic research for drug discovery.  “84% of drug discovery research is funded by government and public sources”, says Gray, citing the landmark work of Professor Donald Light, “Pharmaceutical companies fund just 12% of such research, while the lion’s share of their spending goes into marketing and administration.”  These facts will come as little surprise to those familiar with the industry, but many have never really contemplated the repercussions of pricing essential medicines at levels only a tiny sliver of the world’s population can afford. 

While the film tells the story of how multinational drug companies and the Western governments collaborated to keep low-cost generic AIDS drugs out of the hardest-hit countries at the height of the HIV/AIDS pandemic – at a cost of ten million or more lives – it also tells the fascinating story of the unlikely group of people which came together in order to try and break this blockade.  Among this number were front-line doctors, HIV-positive activists, generic drugmakers, intellectual property specialists and individuals of global stature such as Desmond Tutu and Bill Clinton (both interviewed in the film).  “That’s what really set this story apart for me”, says Gray.  “It was a real-life David versus Goliath tale, full of incredibly interesting, daring, courageous mavericks who took on the world’s most powerful companies and governments to do what virtually everyone else at the time said was impossible (i.e. mass treatment of HIV/AIDS in Africa), and against all odds they won…” 

While the inspirational story of how low-cost generic AIDS drugs, first and foremost from India, came to save millions upon millions of lives in Africa (and beyond) is at the heart of FIRE IN THE BLOOD, the film concludes on a distinctly alarming note.  “The story this film tells was on the verge of being forgotten, something we can’t afford to let happen”, says Gray. The film details the tireless efforts of Western governments, working on behalf of industry, to impede and cut off supplies of affordable generic medicine from countries like India and Thailand to other parts of the global south, primarily by means of bi- and multilateral trade agreements which low- and middle-income countries are placed under enormous pressure to sign.

“The drug industry is stagnant, its pipeline is anemic and it has pinned all its future hopes on China and India”, notes Gray.  “Almost all these companies are publicly-traded, which means their bosses have to keep turning profits quarter-by-quarter if they want to try and keep their jobs… as they see it, they simply can’t afford to take a humanitarian view on issues of access.”  With the World Health Organisation having estimated that one-third of all deaths worldwide are attributable to treatable and preventable diseases, largely due to lack of access to medicine, the stakes could not be higher. 

Meanwhile, for all its insistence that high prices are the only practical trade-off for an industry that spends so much money on R&D to find new and innovative medicines, Gray noted with a wry smile that the who’s who of senior pharma executives will be gathering in London for the industry’s can’t-miss event, the Pharma Summit, just a few days after FIRE IN THE BLOOD opens theatrically in the UK.  “I was amused, but not surprised, to read that the theme of this year’s summit is Should pharma cut its losses and get out of R&D?”.

Araddhya Mehtta is a global heath campaigner for Oxfam GB.

Unregulated and unaccountable: how the private health care sector in India is putting women’s lives at risk from Oxfam Stories on Vimeo.

Low investment in the public health sector over the years has left India with a fractured and weak health system, unable to meet the needs of the majority of its citizens. Despite efforts in recent years to strengthen public health system – most notably through the National Rural Health Mission – India has one of the lowest levels of government investment in health in the world, with just four countries (Afghanistan, Chad, Guinea, and Myanmar) allocating a smaller share of their overall budget to health. In 2010 government expenditure on health was just 1% of GDP.

The gap left by the public health system combined with a government policy of proactively promoting the private sector has led to the proliferation of private health providers which are unregulated, unaccountable, and out of control. From initially providing 8% of healthcare facilities in 1949, the private sector now accounts for 93% of the hospitals and 85% of doctors. The number of first class private hospitals in India has ballooned in recent years and health tourism has become big business. But such first class service comes with a high price tag and is out of reach for the vast majority of Indians. Instead, poor people become dependent on unqualified drug peddlers, fake doctors (quacks), and unlicensed shops that are largely unregulated. Up to a million unregistered providers are practicing in India today. When the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their governments to account and to seek justice.Scandals of corruption, unethical practice and human rights violations frequently break out in national newspapers.

War on women: private clinics exploiting poor women for a profit in Rajasthan, Bihar and Chhattisgarh

Under-privileged women from poor communities in India are being left with crippling debts and poor health after being incorrectly advised by private clinics to have unnecessary hysterectomies. These procedures come with huge price tags and high medical risks. In the case of Bihar, Chhattisgarh, and Rajasthan, the government and the private hospitals in some districts have violated the fundamental rights of women and girls in their failures to provide adequate healthcare.
 
In the last few years NGOs and citizens legal networks have attempted to investigate the practices carried out by private clinics. Local NGOs, have filed a series of Right to Information (RTI) petitions which shed light on the high number of hysterectomies being conducted.

In Dausa, a district in the rural interior of Rajasthan, thousands of women have been subjected to hysterectomies by doctors looking to make a profit at their expense. Women from the most discriminated low castes and poor economic backgrounds are being targeted because access to free government healthcare is very limited and illiteracy rates are high. In April 2012, it came to light that four private hospitals in the state’s Dausa district removed the uterus of 226 women last year and earned about Rs 14,000 (around $220) from each patient. One of the women who underwent the surgery explained, “I had a constant stomach ache and they removed by uterus, but the pain did not go. Then I went to Jaipur for treatment and it was found that I was wrongly operated upon.”

Kaushalya, a farm labourer was told she must have a hysterectomy when she visited the clinic with stomach pains. She was charged 30,000 rupees for the operation (around $540). “I went to get medication and have a check up. Because the government hospitals are far away I went to a private clinic. They didn’t check me, they didn’t give me any medication. But they gave me an injection and performed an operation. Even though I only had a tummy ache, they took my uterus out. I still have the same stomach pain I had before. I can’t work, I can’t lift heavy things. Being a poor farmer I don’t have any money, so I had to borrow money. So far I have not even been able to pay just the interest.”

Durga Prasad Saini, an advocate for a local NGO, Akhil Bhartiya Grahak Panchayat, said: “women go to doctors with some sort of abdominal pains and are then advised to undergo a hysterectomy with little diagnosis of the problem. The doctors force them to undergo surgery even though it is not necessary and scare the women in their greed for money.” The NGO filed an RTI (right to information) case to try to get to the bottom of the problem. Only 3 of the 5 clinics provided the information but the results were shocking. Nearly 70 per cent of the women investigated had had their uterus taken out – a large number of the women were under the age of 29, with the youngest being just 18 years old. Despite the fact that complaints have been made to the police and local government, no action has been taken. A special committee, which included leading gynaecologists, public health experts and government officials from Jaipur, was set up over a year ago but to date none of the affected women have been visited by committee members or had their testimonies heard.

Dr Gupta, a medical expert and head of NGO Prayas –who work with Oxfam in India, states in his report that most of the women he interviewed in Rajasthan should not have undergone a hysterectomy, and could have been cured with other treatments. Moreover, he explains that a sonography alone is insufficient to determine a need for hysterectomy, and alternative treatments should always be attempted before this invasive surgery is performed.  Dr Gupta adds “Subjecting women to unethical, unreasonable and unnecessary hysterectomies or caesarean sections for financial gain is a violation of human rights and most awful form of gender based violence. The mass hysterectomies by private hospitals in Dausa are a wicked act, but such malpractices are happening in other areas as well. Prayas is initiating an intensive investigation against such unethical practices.”   Similarly news stories and investigation reports in Chattisgargh and Bihar indicate that unnecessary hysterectomies are common phenomena in rural areas.  Recent reports in the Indian Express exposed that many of the women who seek hysterectomies are not informed about the possible side effects, and think of a hysterectomy as an easy cure to stop menstrual problems. Prayas also found that the doctors are not obtaining informed consent for the hysterectomies.

In Bihar, Prayas found that several women had undergone hysterectomies at private hospitals on the same day as their initial hospital consultations. The women had only had sonographies – no additional tests were performed. As Dr. Gupta makes clear in his report, women should undergo several tests and be offered alternative treatments before a hysterectomy is performed. Many of the women interviewed in Bihar, Chhattisgarh, and Rajasthan were misled into believing that there was an emergency and that the surgery was urgent or made to believe they might get cancer if they did not comply with the doctors’ advice. In most cases the women received no paperwork regarding the surgeries, and many of the BPL (Below Poverty Line) women paid out-of-pocket for the operation. The fact-finding team also found that there is illicit recruiting in the villages, involving “middlemen” who convince women to go to private hospitals. Fraud committed by the private hospitals has also come to light, with physical examinations of former patients revealing that some of the surgeries never took place.

NGOs investigating this case have decided to go the Supreme Court to seek justice for these women and bring the unregulated and unaccountable private providers of healthcare to account.

Action for change: Implementing Universal health coverage

These cases are not ‘stand-alone’ cases of poor health care provision they are in fact symptoms of a failing and weak health care system that needs urgent rectification. Private health care providers need to be regulated and controlled and public health care provision needs to be scaled up and improved. 

In line with the recommendations of a recent High Level Expert Group report, Oxfam along with its partners is calling for the government to prioritise strengthening and scaling up of government health care which is available to all citizens.

Oxfam wants immediate action to regulate private providers and cease further promotion and funding of PPPs until regulation is enforced and quality and equity performance standards are shown to have improved. Private hospitals, nursing homes and other clinical establishments must be properly standardised to improve rationality of care, regulation of fees, and to uphold patient’s rights.

Oxfam calls on international donors to support evidence-based strategies to expand government provision of health care and not promote scaling-up of private-sector health service delivery in low- and middle-income countries. The private sector’s role needs to be clearly defined and regulated and donors should work with governments to strengthen their capacity to regulate existing private health-care providers.

This story has recently featured on BBC News Online - click here for more information

Araddhya Mehtta is an Essential Services Global Campaigner for Oxfam GB

Mozambique is a country that – even if all of its international and national commitments to health spending are met – still needs an extra $35.2 USD per person per year to ensure that all of the population has access to basic healthcare. The burden of making up for this financing gap inevitably falls on the population through direct and indirect out-of-pocket payments for health services. This is an impossible situation for a country that is still ranked at 184 out of 187 nations on the UN’s Human Development Index, and that has millions of people living in poverty.

While in Mozambique, we made a film that looks at all of the barriers that people face in accessing healthcare. Urban and rural settings present different challenges, but for this film we looked at the rural setting of Tsangano in the province of Tete, a huge region in the centre of the country.

The examples of Tsangano and Tete clearly show that all parts of a health system need to come together in order for the system as a whole to function. Tete has two million inhabitants and just 63 doctors. That means that there is just one doctor for 30,000 people, and one nurse for 8,000 people. When we advocate for an end to out-of-pocket payments we must ensure that the ‘key ingredients’ which make user fee removal a success are also addressed – the financing for the system as a whole and ensuring increased investment in transport and infrastructure, particularly in rural areas, the health workforce, access to medicines and better information for the population to demand their right to health.

You can watch the film we made here to find out more about access to healthcare in Mozambique.

Julia Ravenscroft is a Project and Communications Officer at Action for Global Health

Action for Global Health is a network of 15 NGOs working in six European countries and at the EU level in Brussels.

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.

Oxfam spoke to people in Ghana, to see what their experiences were. Christiana’s story highlights how harmful selling someone the wrong medicines can be. 

Christiana Donyinaa is 43 and makes a living selling cosmetics. A few months ago her youngest daughter, Gloria (age 12), became ill with a fever. Christiana went to a shopkeeper and described Gloria’s symptoms and was told her daughter had malaria. The shopkeeper sold her malaria drugs.  

“I gave Gloria the medicine and she felt better after a few days. The following week, schools were on vacation so she decided to visit her older sister, who lives in Accra. As soon as she got to Accra she felt sick again. Her sister took her to the hospital and she was diagnosed with typhoid fever.  She was admitted to hospital for several weeks.   

I got very worried because school had resumed and she was still in the hospital.  The doctor said Gloria had been suffering from typhoid for a very long time, but because we didn’t take her to the hospital, we didn’t realise it early enough.   
 
When I was told that she was sick, I was very concerned and quickly jumped on a bus to Accra.  When I got there her condition was serious and I stayed with her in the hospital for more than two weeks.”   

Gloria’s condition became quite serious, she found it difficult to breathe and couldn’t eat anything without being sick. Because Christiana was at her daughter’s bedside, she was unable to earn any money over those few weeks. She also spent all the money she needed to run her business on medical expenses. In the end Gloria spent several months off school recovering and has now fallen behind with her studies.

“Gloria’s sickness has affected her a lot. She wants to be a Nurse in future but her illness has set her back a bit.”
  
Christiana believes that malaria medication should only be prescribed and distributed by trained health workers and not through shopkeepers.

“The advice I have for the government and NGOs is that the malaria drug is very good, if you have malaria.  But they should not give it to the drug peddlers; they should give it only to clinics. Some of the drug peddlers have these medicines in their pockets. They sell it to you when you tell them you have a headache, they will just give you the medicines without any diagnosis.  This is very dangerous the drug peddlers don’t know what illness people have.

I will advise every parent that when their child is sick they should take them to a doctor. Because if I had taken Gloria to the hospital from the onset when she was sick I don’t think both of us would have suffered as we have done.”

Oxfam is warning against any further funding for the AMFm scheme and for money to be used to invest in the training and salaries of community health workers instead, who are proven to save lives.

Sarah Dransfield is the Essential Services Press Officer at Oxfam GB