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Debating the World Bank Report on Fiscal Constraints – A return of the 90′s?

A recent World Bank report on the fiscal dimensions of HIV and AIDS in a selection of sub-Saharan African countries has stirred significant debate. Here, Professor Brook Baker argues the report is ‘seriously out-of-date’ and ignores important new evidence on treatment-as-prevention.  Dr Markus Haacker, co-author of the report, responds…

Professor Brook K. Baker (professor of Law at Northeastern University School of Law and Policy Analyst for Health GAP (Global Access Project).

The World Bank has just recently issued a “new” report: “The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda.”  The Report doesn’t really feel “new” because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high impact, low-resource countries – instead the world must focus on “prevention.”  The World Bank is seriously out-of-date, or conversely, perversely pig-headed, for four main reasons:

First, it’s report now issued in March of 2012 is already seriously out of date since it relies almost exclusively on pre-2009 data.  Despite opportunities to do so in the editing process and in its media work, the World Bank has chosen to totally ignore the exciting new science concerning treatment-as-prevention – research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%!  This gold-standard research is now being confirmed by ecological data showing actual declines of new infections in places where anti-retroviral scale-up has reached a “tipping point.”  Some of the most exciting findings come from KwaZulu Natal province in South Africa, the epicentre of the pandemic, where community infections are dropping precipitously now that a deadly delay in treatment rollout has been reversed.

The Report is also seriously out of date because it fails to take into account recent evidence of greatly enhanced efficiencies in AIDS programming.  The US PEPFAR program has evidence that its treatment costs have decreased by over 2/3 in just the past few years.  Doctors without Borders is achieving stunning efficiencies by task-shifting treatment initiation and monitoring to nurses and community health workers respectively, by moving services to the community level, and by involving patients in groups support and adherence activities.  Both of these dramatic developments call most of the World Bank’s calculations into question.

Second, there is growing evidence, again ignored by the World Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like male circumcision, condoms, and needle-exchange can have significant impacts on new infections and thus future treatment costs.  One would think that a premiere economic think-tank like the World Bank could more strongly champion the idea that spend-a-dime-today instead of a dollar-tomorrow makes good economic sense.  The Bank has certainly strengthened its understanding of the fiscal impacts of HIV/AIDS by taking into account the predictable future costs of continuing and new infections, but it has failed to appreciate the Big Bang benefits of early investments.

Third, the World Bank uses magical thinking rather than evidence to rally support for unspecified “prevention” activities.  The Bank was one of the main proponents of prevention-only throughout the 1990s.  Treatment was too expensive, it wasn’t cost effective to treat poor people living with HIV, expenditures couldn’t exceed revenues, donors are fickle so don’t count on them, etc. Although the Bank’s language has become less coarse and callous, many of the same “truisms” are repeated in the current report.  Using the neutral language of quasi-liability (instead of what other pundits call a treatment mortgage), the Bank argues that the costs of treating people infected now and of those newly infected (discounted to present value) show that treatment expansion is “unsustainable.”  The Bank treats each and every country in its study solely within the context of its own economic resources showing severe domestic fiscal constraints, when it could in fact call for innovative global financing – like a financial transaction tax – and more predictable and long-lasting pooled global resources – like at the Global Fund.  It emphasizes – indeed almost excuses – donor defunding because of a global financial crisis that is too precipitous to permit a ramp-up in global health spending, but apparently a crisis that is not so serious so as to preclude a multi-trillion dollar bailout for banks and to continue numerous military follies.  The truth of the matter is that principles of global solidarity for global health should be promoted by the Bank as the real solution to short– and mid–term fiscal pessimism.

Fourth, the World Bank appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths.  Focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort is just plain strange.  Young and middle age adults are economically productive, they raise and help education children, and they care for elders.  In a pure economic sense, they build economies, promote economic development, pay taxes, provide care labour, and innovate.  Earlier deaths decrease the value of investments in education and impede social reproduction.   Likewise, the Report makes some reference to macroeconomic impacts of HIV on macroeconomic growth, but it seems to discount the long-wave impacts of successive losses of the middle-generation.  Focusing primarily on fiscal costs while forgetting economic benefits is an unbalanced way to inform policy choices.

Countries need advice on future costs, but they need it based on current facts.  They need advice not just about how selfishly the world economy and governance is currently constructed, but how they might be revised to make the right to health and Universal Access real.  The failure of the Report is not a failure of the collective researchers or the individual authors, but rather of the rigid and dogmatic ideology of the World Bank that consider “fiscal space” a law of nature, while ignoring newly discovered evidence that treatment is now one of the most promising tools for prevention.  Let’s hope the Bank issues a new, more hopeful report, responsive to recent development and cognizant of the power of new investments to end AIDS.


Response from Dr.  Markus Haacker (co-author “The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda”)

Dear Prof. Baker,

I have read your comments on the recent book on the “The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda.” As one of the authors, let me offer you a few notes on your comments.

The sustainability of HIV/AIDS programs is a matter of serious concern to governments and the leadership of national HIV/AIDS programs across sub-Saharan Africa and beyond. The book is a contribution to address these concerns, by providing an analysis of HIV programs from a fiscal perspective, to inform policymakers and donors on the extent of the challenge of financing the current HIV/AIDS program, and a springboard for addressing the dialogue about the funding of the programs as well as thinking about new approaches to improve the effectiveness of HIV program, including many of the approaches that you are describing.

The following comments are broadly aligned with the three points you make.

(1) The drafting of the report was completed in late 2010, and incorporates a large number of references published in 2010. Additonally, I have incorporated  during the editing process the data which were released in end-2010 by UNAIDS in the context of the Report on the Global AIDS Epidemic. Your comment that the report “relies almost exclusively on pre-2009 data” is clearly wrong, and I am puzzled as to what might have given rise to this misconception. I also disagree on your claim that the report disregards “greatly enhanced efficiencies in AIDS programming.” For example, the unit cost of treatment in South Africa were based on a very elaborate analysis of providing ART through the public health system as of 2010 conducted on behalf of the Department of Health.
Two more points on your comments regarding the latest evidence in the analysis:
(a) One of the challenges in incorporating the latest evidence from empirical research is the fact that costs differ substantially across countries – superimposing empirical findings from recent research, which are to some extent country-specific, over current or recent national data is a source of great errors. Using the best available data shared by the national HIV/AIDS programs therefore is legitimate and useful, and helps anchoring the analysis with the ongoing policy dialogue.
(b) At this time (and especially a year ago when the book was written), the evidence on “treatment-as-prevention” is not advanced enough to support the epidemiological modeling the fiscal analysis in the book is based on. I know of substantial current efforts to take this further, to translate the evidence into population-level modeling, but expecting that this fiscal analysis should outsmart and upstage the very complex epidemiological modeling efforts that are going on now specifically in this direction is unfair and inappropriate.

(2) I largely agree with your comments regarding “investments now in treatment scale-up and in diffusion of scaleable prevention methods.” This is exactly the reason why the book places so much emphasis on the costs of meeting the demand for HIV/AIDS-related services caused by new infections. Quantifying these costs is a tool for motivating investments in prevention methods such as the one you mention – to convince a Minster of Finance or donor to provide funding, e.g. for “male circumcision, condoms, and needle-exchange,” it is useful to have estimates of the resulting financial savings (and, of course, of the obvious health benefits) at hand.

(3) The four reports combined in this book take a country-specific perspective, and was written to inform specific governments. Irrespectively of donor commitments, these governments are accountable to their citizens to meet the demand for public services. Assuming that “innovative global financing” or the Global Fund (which itself is in a financial crisis) would pick up the bill would be irresponsible from the perspective of the national HIV/AIDS program. However, I would hope that the analysis of the situation in countries like Swaziland and Uganda (where the estimated costs of the response to HIV/AIDS exceed any debt relief received) will help securing global HIV/AIDS funding.
The report does not argue “that the costs of treating people infected now and of those newly infected (discounted to present value) show that treatment expansion is ‘unsustainable.’” It uses a comparison with debt sustainability analyses conducted by the IMF and the World Bank to highlight the financial burden countries like Swaziland and Uganda are facing. But this burden needs to be interpreted against the extraordinary health challenges facing these countries, which means that simply looking at the costs of the HIV program would be grossly inappropriate. Moreover, by linking the scale of the financial costs to criteria which have been used in the past for allocating debt relief, the analysis offers concrete tools for soliciting external funding that can be used for negotiating external support.

Finally, I am – as you hope – confident that “the Bank (will issue) a more hopeful report, responsive to recent development and cognizant of the power of new investments to end AIDS.” However, I am not so optimistic regarding the immediate gains from the innovations you are describing. In the countries the report looks at, about one-half of the estimated burden of financing the HIV/AIDS program addresses the needs of people already living with HIV/AIDS (and the other half the costs of projected infections), and even a steep decline in HIV incidence would have very little impact on the funding needs of the HIV/AIDS program over the next decade. With all the “exciting new science” you quote, it would nevertheless be irresponsible to lose sight of the need to secure the funding of the existing HIV/AIDS programs.

 

Response from Professor Brook K. Baker to Dr. Markus Haacker

Thanks for your public response.

I agree with your point 1 that there are some references to 2010 publications, but the bulk  are earlier.  Adding 2010 UNAIDS data is certainly useful, but from the vantage point of 2012, 2011 was a very big year.

I don’t agree with your point 1(b) that it was unfair or inappropriate to suggest that the paper could have at least mentioned the emerging evidence on treatment as prevention.  Although it may not have been possible to redo the analysis in light of the complicated recalculations you describe, the idea that treatment as prevention might impact the fiscal analysis you offer is something that paper must address, especially since the paper seems to place treatment and prevention in opposition, once again.

With respect to your point 3, it’s a little hard to interpret your report, the World Bank press release, and all the mainstream press about the paper as not suggesting that treatment scale-up is unsustainable.  That conclusion is stated in summary terms, although I agree that there is also much more detailed and sophisticated analysis in the four country studies.

I certainly understand the importance of the Report’s focus on HIV prevention – it is something that AIDS activists have fought for for generations.  The problem is that “prevention” has often been presented as an oppositional concept to treatment – very directly during the 1990s and even thereafter.  Likewise, the Report’s discussion of treatment scale-up really presented treatment, now in March 2012 when published, as a separate category from prevention.  Given stunning developments in the scientific validation of treatment-as-prevention over the past two years (Haiti study and then HPTN 052 and frankly observationally even earlier than that), it certainly would have been appropriate to mention treatment as now being even more synergistic and intertwined with prevention.  That is not to say that the paper couldn’t have urged countries to know their pandemic (as it did) nor that it shouldn’t have urged countries to be alert for further developments on the prevention front (something that could have been clearer).  However, by leaving your recommendation for prevention open-ended – without any real specification of evidence-based prevention successes like male circumcision, treatment-as-prevention, etc. – the paper risked being interpreted according to the old behavior-change prevention/treatment binary.

Admittedly, the Report did encourage both more investments – by donors and by countries – and greater efficiencies.  But the headline conclusion of the Report, as I said above, was fiscal unsustainability.  It may have been your intention to ensure country self-reliance on domestic resources (after all you say below that countries shouldn’t count on innovative financing or the Global Fund), but cautious ministries of finance, already acculturated to an ideology of macroeconomic fundamentalism, will read the Report very pessimistically.  In my estimation, they are likely therefore to encourage less rather than more scale-up, especially since treatment will be understood according to the Report as being oppositional to prevention in terms of resources.  Anything the authors and the Bank could do to clarify and prevent this kind of interpretation would be helpful.

Professor Brook K. Baker is a professor of Law at Northeastern University School of Law.  He is also a policy analyst for Health GAP (Global Access Project).

Dr. Markus Haacker is co-author of  ”The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda”. Dr Haacker is a growth and development economist,  and  currently an Honorary Lecturer at the London School of Hygiene and Tropical Medicine. He also works as a consultant to the World Bank and UNAIDS.

This article was originally posted on the European Aids Treatment Group website (posted on 22/03/2012).  It has been adapted and reproduced here with permission from Professor Brook K. Baker and Dr. Markus Haacker.

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One important step forward for access to medicines in India, but are two giant steps backwards just around the corner?

Last week, the Indian Patent Office took a major step to decrease the price of a previously unaffordable life-saving medicine by issuing a ‘compulsory license’ on Sorafenib, a medicine used for the treatment of kidney and liver cancers. But such welcome action is unlikely to be repeated if the EU and Novartis have their way.

Up until now Sorafenib has been sold exclusively by Bayer, the German drug firm, at a very high price that nearly no one in India could afford. The new compulsory license permits Indian pharmaceutical manufacturers to make and sell low-cost copies of the medicine while paying royalties to Bayer, the patent owner.

The Indian Patent Office stated that Bayer had failed to make the medicine “available to the public at a reasonable price”. Through the manufacture of generic versions, the price of the medicine will fall drastically and ensure it is more affordable. News reports suggest that only about 49 patients were placed on treatment last year. So the impact will be significant.

A compulsory license is a basic safeguard, enshrined in global trade rules, whereby a country can override a drug patent to enable production or importation of a generic medicine needed for public health purposes in the country (and to a limited extent, for export). Although drug prices have been shown to be consistently too high in developing countries, and in spite of the increased public health demand for new medicines to address diseases, very few countries have issued compulsory licenses to date. This is due mostly to political and corporate pressure placed on developing country governments.

For example, Thailand issued a number of compulsory licenses for medicines to treat HIV, cancer and heart disease in 2006 and 2007. In response, both the EU and the US sent strong messages to the Thai government requesting they cancel its compulsory licenses. At the same time, Abbott, a drug company, withdrew registration of seven medicines, including a critical, heat-stable version of an HIV and AIDS medicine, to retaliate against the Thai Government.  It was an unprecedented action.

Pharmaceutical companies, supported by rich nations, have tried to also stem (or even abolish!), the use of compulsory licensing to very limited circumstances (e.g. only to address an epidemic or emergency or to only treat HIV and AIDS). Yet WTO rules make clear that compulsory licensing should be a tool available for all medicines needed for the benefit of public health. With an ever growing burden of cancer and other non communicable diseases (NCDs) in developing countries [about 70% of all cancer deaths in 2008 occurred in low- and middle-income countries and NCDs are responsible for 53% of all deaths in India] it is crucial to ensure that effective new treatment is available and affordable to patients in these countries. 

Given the disappointing number of compulsory licenses issued to date, India has clearly made an important step in the right direction. Yet the good fortune for India’s people may be short-lived. Through the rest of 2012, the Indian government will face at least two serious challenges from rich countries and drug companies that could threaten the country’s ability to manufacture affordable generic medicines. Firstly, the EU is putting enormous pressure on India to introduce new IP rules through a free trade agreement whose negotiations should be completed this year. 
At the same time, and for the second time since 2005, the drug company Novartis has hauled the Indian Government through its own court system to force changes to the country’s intellectual property law – alleging that in its current form it is not compliant with global trade rules. The Indian law being challenged was introduced in 2005 and plays a critical role in keeping down the price of medicines by discouraging the practice of ever-greening. To take action on the Novartis case visit: http://sumofus.org/campaigns/novartis-lawsuit/

Despite meeting all its obligations under global trade rules, India faces tremendous pressure to tighten its intellectual property rules. If either the EU or Novartis gets its way the impact will be catastrophic, blocking access to affordable medicines for millions of people in India and across other developing countries.

India’s actions, whether it be issuing a compulsory license, or pushing back against the aggressive pressure of the EU and Novartis, are especially important because India is considered the ‘pharmacy of the developing world’. Since India has stuck out its neck to issue a compulsory license, hopefully others will follow suit. Conversely, if the Indian government cedes to the pressure of the EU and Novartis it will be a huge set back to other countries fighting for affordable medicines. 

Let’s hope India keeps taking steps in the right direction.

1. Rohit Malpani is a campaigns advisor at Oxfam and leads the organization’s access to medicines campaign

2. Mohga M Kamal-Yanni works for Oxfam as a Senior Health & HIV Policy Advisor

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Poor people benefit from government subsidy for skilled birth attendance in Burkina Faso

In an effort to address life threatening financial barriers to skilled birth attendance in Burkina Faso, the government launched a national policy in 2006 to subsidise the cost of child delivery. Our research in Ouargaye district found an increase in the use of maternal health services by poor women and a substantial reduction in the cost of deliveries.

The subsidy package introduced in 2006/7 includes: a 60% – 80% subsidy for the direct cost of deliveries (with full exemption for indigent women), as well as a 100% subsidy for the cost of transportation for caesarean referrals. The findings from our research are as follows:

The number of poor women using maternal health services increased: Before 2006/7, user fees meant that women in higher income groups used obstetric care more than poor women. Following the introduction of the subsidy, service utilisation increased substantially across all income groups and especially so for poor women. However, inequity in access to care still exists because relative to their health needs, women from lower income groups have less access to obstetric care. This is partly explained by the facts that, with the exception of the very poorest, women still have to pay at least 20% of the direct costs of delivery. Poor women also face significant geographical barriers with services being much easier to reach by those in higher income groups. Removing these remaining barriers (i.e. geographic and financial) will make access to obstetric care more equitable.

Substantial reduction in the cost of deliveries for poor women: The average medical cost of deliveries reduced significantly by 65% after the introduction of the subsidy. Also, average total expenses for deliveries went down from $18 in 2006 to $11.6 in 2010. Women in the poorest income bracket benefited most from the reduction. The distribution of benefits from the subsidy was progressive in the sense that it resulted in a decrease in medical expenses for women in the lower income group (-14%) and an increase in the cost of care for those in the upper income bracket (+15%). However, there were still a significant number of women (about half of all the women interviewed) who were paying more for normal delivery than the official cost of $1.80. The main cause for this was the purchase of medical products and medicine.

Risk of catastrophic medical expenditure significantly reduced: The proportion of households at risk of obstetric care-related excessive medical expenditure reduced considerably for all women – down from 6–12 % in 2006 to 1-2.5% in 2010. The reduction in risk of catastrophic expenditure was felt more by poor women living near a medical centre (demonstrating the importance of geographical barriers). Overall, only a small portion of the population was found still to be subjected to excessive medical expenses after the introduction of the policy.

The number of women receiving 100% exemption increased though about half  of all eligible indigent women could still not benefit from it. The distribution of the benefits was progressive because the majority of the beneficiaries were poor women. The relative success of the exemption policy is partly due to  an action research project that was carried out in the Ouargaye district which faciliated the indentification of eligible indigent women. However, the fact that many eligible indigent women are still not beneffiting from the exemption suggests that such targeting is still problematic.

Despite the success of the subsidy policy, poor women in Burkina Faso still face significant financial barriers in accessing obstetric care. While many indigent women are eligible for 100% exemption, many still cannot access it; most women have to pay at least 20% of the direct cost of delivery services; and all (with the exception of those referred for caesareans) have to bear the indirect cost of transportation.

To make the child delivery subsidy policy more effective and equitable, the government needs to remove the remaining financial barriers by making obstetric care free for all women at the point of use as promised by the President of the Republic in early 2010. The government should also consider alleviating non-medical costs related to obstetric care for poor women, including transportation, so that everyone can benefit equally from the healthcare subsidy policy.

Policy makers from other countries can learn from the Burkina Faso example. Removing user fees for health care (or subsidisation) is an effective strategy for reducing inequalities in access to healthcare and alleviating catastrophic health expenditure. User fees removal should be seen as a positive step forward that needs to be matched with efforts to strengthen and improve the quality of the healthcare delivery system. Countries that continue with user fees need to recognise the enormous barrier to access such fees present and that efforts to remove fees and improve the healthcare delivery system can work to enhance the health of their population, avoid unnecessary death, and avert household poverty.

Valéry Ridde, Ph.D., is a professor of public health at the University of Montreal, a researcher at the CRCHUM, a CIHR New Investigator, and Associate Research at the IRSS/CNRST Burkina Faso. To read further on Valéry’s other publications, visit: http://www.pum.umontreal.ca/ca/fiches/978-2-7606-2278-4.html

Acknowledgements
This blog is drawn from the research programme “L’abolition du paiement des services de santé en Afrique de l’Ouest” (“The abolition of user fees for health services in West Africa” financed by IDRC/AFD). For further information on the project visit http://www.lasdel.net/gratuit%E9.htm or http://www.vesa-tc.umontreal.ca/ressrc.htm

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Les personnes pauvres au Burkina Faso bénéficient d’une subvention gouvernementale pour les accouchements médicalisés

Une des stratégies les plus efficaces pour réduire la mortalité maternelle consiste à permettre un accès aux accouchements médicalisés ; néanmoins, de nombreuses femmes dans les pays pauvres n’ont toujours pas les moyens de s’offrir ce service essentiel.  Afin de régler les problèmes posés par ces barrières financières, le gouvernement du Burkina Faso a lancé une politique nationale en 2006/2007 dans le but de subventionner le coût des accouchements médicalisés. Notre étude de 2010 visant à mesurer l’impact de la politique dans le district d’Ouargaye a montré une augmentation de l’utilisation par les femmes pauvres des services de santé maternelle, ainsi qu’une réduction importante du coût des accouchements (notamment un risque moins élevé de dépenses catastrophiques). Vous trouverez ci-dessous les principaux résultats et les leçons politiques extraites d’un document de recherche sur la politique de subvention.  

L’enveloppe de subventions introduite en 2006/2007 comporte les éléments suivants : une subvention à 60-80% du coût direct des accouchements, une subvention à 100 % du coût de transport des femmes devant subir une césarienne, et une exonération intégrale des coûts directs des accouchements pour les femmes démunies.   

Un nombre plus important de femmes pauvres utilisent les services de santé maternelle : avant 2006/2007, à cause du paiement direct, les femmes appartenant aux groupes de revenus plus élevés utilisaient plus les soins obstétriques que les femmes pauvres. Suite à l’introduction de la subvention, l’utilisation des services a augmenté de manière importante dans tous les groupes de revenus, et tout particulièrement chez les femmes pauvres. On ne peut pas dire pour autant que les femmes dans toutes les fourchettes de revenus bénéficient du même accès aux soins obstétriques. Si l’on compare le taux d’utilisation des soins obstétriques dans les différents groupes de revenus aux besoins respectifs de ces groupes en matière de soins de santé, on se rend compte que les femmes appartenant au groupe de revenus les moins élevés conservent un moins bon accès aux soins obstétriques. Ce résultat s’explique en partie, car malgré la politique de subvention, il reste encore d’autres obstacles à franchir, notamment le coût des soins (environ 20 % du coût de l’accouchement) et les barrières géographiques qui font que les personnes riches sont plus à même d’utiliser les ressources en matière de santé que les personnes pauvres. Si ces barrières restantes (ex. géographiques et financières) étaient supprimées, l’accès aux soins obstétriques serait plus équitable.        

Réduction importante dans le coût des accouchements pour les femmes pauvres : le coût médical moyen des accouchements a baissé de 65 % après l’introduction de la subvention. Les dépenses totales moyennes pour les accouchements sont passées de 18 $ en 2006 à 11.6 $ en 2010. Les femmes appartenant à la tranche de revenus la moins élevée ont le plus bénéficié de cette réduction. La distribution des bénéfices a également été parfaitement graduelle :  la politique a entraîné une baisse des dépenses médicales pour les femmes dans la fourchette de revenus la plus basse (-14 %), et une hausse des coûts de santé pour celles appartenant au quintile le plus élevé (+15 %). Cependant, un nombre encore important de femmes (environ la moitié des femmes interrogées) payent encore pour un accouchement normal une somme supérieure au coût officiel de 1.8 $. L’achat de produits médicaux et de médicaments est le principal responsable de cet état de fait.     

Le risque de dépenses médicales catastrophiques a baissé de manière significative : la proportion de foyers représentant un risque de dépenses médicales excessives dans le domaine des soins obstétriques a considérablement réduit dans tous les groupes de femmes – elle est passée de 6-12 % en 2006 à 1-2.5 % en 2010. Les femmes qui vivent à proximité d’un centre médical ont plus souvent tendance à ressentir la réduction du risque de dépenses catastrophiques (ce qui montre le problème toujours actuel des barrières géographiques). D’une manière générale, seule une petite portion de la population subit encore des dépenses médicales excessives depuis l’entrée en vigueur de la politique.

Le nombre de femmes bénéficiant d’une exonération de 100 % des frais a augmenté, même si la moitié des femmes démunies éligibles n’arrivent toujours pas à obtenir cette exonération. La distribution des prestations a été graduelle parce que la majorité des bénéficiaires sont des femmes pauvres. Le succès relatif de la politique d’exonération est en partie dû à un projet de recherche-action réalisé dans la région d’Ouargaye qui a facilité l’identification des femmes démunies éligibles au programme. Cependant, comme de nombreuses femmes démunies éligibles ne peuvent toujours pas bénéficier de l’exonération, il est nécessaire de mettre en place des mesures plus efficaces pour identifier les personnes pauvres.  

En nous basant sur les résultats ci-dessus, nous pouvons conclure que la politique de subvention du Burkina Faso a été efficace pour réduire les dépenses médicales (y compris le risque de dépenses catastrophiques) associées aux accouchements. De fait, la politique a été plus efficace dans ce sens que d’autres politiques similaires instaurées dans certaines zones de l’Afrique subsaharienne (ex. Ghana, Kenya ou Sénégal). De plus, toutes les femmes ont profité de cette politique, et notamment les plus pauvres d’entre elles. Le succès relatif de la politique de subvention s’explique en grande partie parce que le Burkina Faso possède un meilleur système de soins de santé maternelle et d’accouchement, et plus de ressources humaines que les autres pays de la sous-région, ce qui permet au système de prestation des soins de santé de gérer la hausse des demandes en soins de santé maternelle.
 
Malgré le succès de la politique de subvention, les femmes pauvres du Burkina Faso rencontrent toujours des obstacles financiers importants dans l’accès aux soins obstétriques. Elles doivent toujours s’acquitter des coûts indirects des soins (ex. coûts de transport), et la plupart payent 20 % des coûts directs. Environ la moitié d’entre elles payent leur accouchement plus cher que ce qu’elles devraient, et de nombreuses femmes éligibles à l’exonération de 100 % n’y ont toujours pas accès.
 
Afin de rendre la politique de subvention des accouchements plus efficace et équitable, le gouvernement devrait retirer les obstacles financiers restants, en rendant les soins obstétriques gratuits pour toutes les femmes comme promis par le Président de la république au début de 2010. Le gouvernement devrait également envisager d’alléger les coûts non médicaux des soins obstétriques – comme les coûts de transport-  pour les femmes pauvres, afin que chacune bénéficie de manière équitable de la même politique gratuite de soins de santé.

Les décideurs politiques des autres pays peuvent apprendre de l’exemple du Burkina Faso; la suppression du paiement direct des soins de santé (ou leur subventionnement) est une stratégie efficace pour réduire les inégalités d’accès aux soins de santé, pour améliorer la santé, et alléger les dépenses médicales catastrophiques. La suppression du paiement direct doit être vue comme un pas en avant positif, qui doit être accompagné d’un système de soins de soin de santé efficace et de qualité. Les pays qui utilisent encore le paiement direct comme stratégie de financement de la santé se doivent de reconnaître le caractère insurmontable des barrières financières pour l’accès des plus démunis aux services médicaux vitaux. En outre, les gouvernements doivent réaliser qu’en supprimant le paiement direct et en améliorant le système de santé, ils peuvent sensiblement améliorer la santé de leurs populations, éviter des décès inutiles, et de surcroît limiter la pauvreté des ménages.  

Remerciements
Ce blog s’inspire du programme de recherche « L’abolition du paiement des services de santé en Afrique de l’Ouest », financé par l’IDRC/AFD. Pour plus d’informations sur ce projet, rendez-vous sur les sites http://www.lasdel.net/gratuit%E9.htm ou http://www.vesa-tc.umontreal.ca/ressrc.htm.

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Universal Health Coverage for India?

These are exciting times for health care reform in India. Last year in his Independence Day Address the Prime Minister declared that health would be accorded the highest priority. Going a step further, the government outlined plans to increase public financing of health from 1.2% of India’s GDP to 2.5% and there have been many recent press statements on this. Of course actions will speak louder than words.

In November 2011 the High Level Expert Group submitted its report to the National Planning Commission, describing a vision where every citizen should be entitled to essential healthcare services that will be guaranteed by the Central government. The report shows how it is feasible for India to establish a UHC system within the next ten years. In response the PM has let it be known that he wants the Planning Commission to take steps to help the government offer free universal health care, as proposed by the group.  Very welcome plans are already apparently in motion  to provide free medicine for all through Public Health Facilities under the National Rural Health Mission.

The Public Health Foundation of India has just launched a dedicated website to drive forward progress on Universal Health Coverage (UHC) in India. The website showcases the recent groundbreaking report of the Planning Commission’s High Level Expert Group on Universal Health Coverage. It features background documents, commentary, and expert interviews and serves as an interactive space for UHC publications as well as national and global events.

The High Level Expert Group report includes the following key recommendations:

  • Increase public expenditures on health to at least 2.5% by the end of the 12th plan, and to at least 3% of GDP by 2022
  • Ensure availability of free essential medicines by increasing public spending on drug procurement
  • Expenditures on primary health care should account for at least 70% of all health care expenditures
  • Use general taxation as the principal source of health care financing
  • Do not levy fees of any kind for use of health care services under the UHC
  • Do not go the insurance route – all government funded insurance schemes should be integrated with the UHC system.

The UHC India website could not have been launched at a more appropriate moment. This month the National Advisory Council, led by Sonia Gandhi, will consider the recommendations of the High Level Expert Group, which is indicative of a key milestone in the push for a system where all Indian citizens, regardless of their economic, social or cultural backgrounds will have the right to affordable, accountable and appropriate health services.

For UHC to succeed political and financial commitment will be essential and much hard work is needed. This new website is an excellent resource for anyone committed to making this aspiration a reality.

 

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.