Earlier this year, the International Rescue Committee (IRC) released its position paper on access to healthcare and user fees, drawing on their work in the Democratic Republic of Congo (DRC). The IRC found significant evidence that user fees, which it describes as “regressive” and amounting to a “consumption tax on health services”, reduce poor people’s access to healthcare. They argue that only the abolition of user fees will guarantee improved access to life-saving healthcare in post conflict countries like the DRC.
Since 2009, the IRC has worked in partnership with the Ministry of Health to roll out free healthcare for pregnant women and children under-5 in 10 health zones in the DRC. Drawing on this experience, the IRC position paper describes how even in post conflict countries where health infrastructure is weak, the removal of direct payments for services results in significant health gains. For example, over a period of just 3 years, average healthcare utilisation rate in Orientale Province increased by 121% – from an average of 1 consultation in every 3 years to just under 1 consultation per year. Similar trends were recorded in other provinces, including Kasa Occidental and South Kivu.
The case of DRC is not unique; there have been many other examples of where user fee removal has increased uptake of health services and improved population health. In Mali, the removal of fees for obstetric and child health care resulted in significant decline in maternal and child deaths. In Sierra Leone, healthcare utilisation by children increased more than two-folds and maternal mortality declined by 61% after user fees were removed for maternal and child healthcare. Similar outcomes were recorded in Haiti where health care utilisation increased by 302% following the introduction of free healthcare.
The IRC position paper is explicit about the importance of investing in health systems in order to maximise the benefits of free health care. Good quality services, health infrastructure, adequately paid staff, and reliable drug supplies are all key to success. The IRC’s experience in the Democratic Republic of Congo demonstrates that user fee removal can be financially sustainable and does not necessarily weaken the administrative capacity of the health system as critics have often claimed.
The call by the IRC could not be any clearer: governments in developing countries should make healthcare free at the point of use to improve access and achieve universal health coverage. This should be complemented by sustained investment in the health system in order to expand and improve service delivery. Donor agencies also need to provide developing countries with sustained financial and technical support to enable them to remove healthcare user fees to save lives.
Yussif Nagumse is a Health Policy Officer at Oxfam-GB
Plus tôt dans l’année, le Comité International de Secours (IRC) a publié son document de prise de position sur les frais restants à la charge des usagers pour accéder aux services de santé en se basant sur son travail en République Démocratique du Congo (RDC). Sur la base de preuves significatives, l’IRC affirme que le paiement direct des soins par les usagers -décrits comme “régressifs” et assimilable à “une taxe à la consommation sur les services de santé” – réduisent l’accès des personnes indigentes aux soins de santé. Il soutient que seule la suppression du paiement direct garantira un meilleur accès aux soins de santé vitaux dans des pays en situation de post-conflit tels que la RDC.
Depuis 2009, l’IRC a travaillé en partenariat avec le Ministère de la Santé afin d’étendre les soins de santé gratuits aux femmes enceintes et aux enfants de moins de 5 ans dans 10 zones de santé de la RDC. Fort de son expérience, le document de position de l’IRC affirme que même dans les pays sortant d’un conflit et où les infrastructures sanitaires sont insuffisantes, la suppression des versements directs pour des prestations entraîne des améliorations significatives en termes de santé publique. Par exemple, sur une période d’à peine 3 ans, le taux moyen d’utilisation des moyens de santé en Province Orientale a augmenté de 121% – on est passé d’une moyenne d’une consultation tous les 3 ans à presque une consultation par an. Des tendances similaires ont été observées dans d’autres provinces, telles que le Kasaï Occidental ou le Sud-Kivu.
Le cas de la RDC n’est pas unique; nombreux sont les exemples où la suppression du paiement direct a eu pour conséquence une utilisation accrue des services de santé entraînant une amélioration de la santé publique. Au Mali, la suppression des frais de santé obstétriques et infantiles ont été synonymes d’une chute importante de la mortalité maternelle et infantile. Au Sierra Leone, l’utilisation des services médicaux par les enfants a plus que doublé et la mortalité maternelle a chuté de 61% après que la suppression du paiement direct des soins pour les soins maternels et infantiles. Des résultats identiques ont été enregistrés en Haïti où le recours aux services de santé a augmenté de 302% après l’introduction de la gratuité des soins.
Le document de prise de position de l’IRC est explicite quant à l’importance d’investir dans les systèmes de santé de façon à maximiser les retombées positives des soins gratuits. Des services de bonne qualité, des infrastructures sanitaires, du personnel correctement payé, et un approvisionnement fiable en médicaments sont autant d’éléments nécessaires au succès. L’expérience de l’IRC en République Démocratique du Congo montre que la suppression du paiement direct par les usagers peut être viable financièrement sans pour autant affaiblir la capacité administrative du système de santé ainsi que certains critiques l’ont souvent prétendu.
La demande de l’IRC est on ne peut plus clair: les gouvernements des pays en voie de développement devraient faire en sorte que les soins de santé soient gratuits au point d’usage afin d’en améliorer l’accès et parvenir à une couverture sanitaire universelle. Cette politique devrait être complétée par des investissements constants dans le système de santé de façon à étendre et améliorer la prestation des services. Les bailleurs de fonds doivent également fournir un soutien financier et technique constant aux pays en voie de développement afin de leur permettre de supprimer le paiement direct et ainsi sauver des vies.
Yussif Nagumse est responsable des politiques de santé pour Oxfam Grande-Bretagne
Over the past two decades, health sector reforms in Ghana have transformed how health care is financed and delivered in the country. The most significant of these reforms was the introduction of health sector cost recovery and liberalisation in 1980s and, more recently, the National Health Insurance (NHI), which was introduced in 2004. A key objective of the NHI is to ensure equitable access to healthcare services for all Ghanaians. I was recently involved in a study which considered the issue of equity in relation to the financing and delivery of health services in Ghana.
The study examined the current range of health financing mechanisms in Ghana including general tax revenue, national health insurance contributions and out-of-pocket payments (OOP), as well as the distribution of healthcare benefits among various socio-economic groups in the country. We found that while general tax revenue is a progressive source of financing, insurance contributions by informal sector workers and out-of-pocket payments are regressive. We also found that the benefit incidence from using services in Ghana is largely pro-rich.
General tax revenue is the second major source of healthcare financing in Ghana, contributing around 40% of total healthcare financing. There are five main streams of general tax revenue (personal income tax, corporate tax, VAT, import duty, and fuel levy) and our study findings showed these to be mainly progressive, with the exception of a levy on fuel to which poor people contribute relatively more than the rich.
We found that while the National Health Insurance contributions are mildly progressive overall, this is only true when these are considered collectively. Contributions made by informal sector workers alone were very regressive. This was partly because while contributions by formal sector workers were graduated according to their income level, informal sector workers paid a flat-rate premium. Though the NHI premiums paid by informal sector workers are highly subsidised, a substantial number of people (about 40% of the population) can still not enrol due to poverty. This is not surprising given that around one-quarter of the population of Ghana still lives below the poverty line and 18.5% in extreme poverty. The informal economy employs over 80% of the working population in Ghana, but only around 35% of those registered for the NHIS belong to this group. There have also been numerous practical challenges, just as in many other low income countries, at targeting the poor for premium exemptions, including errors of inclusion and exclusion and high transaction costs.
Although the National Health Insurance (NHI) was introduced to reduce reliance on out-pocket payments (OOPs) for health services, our research found that OOPs are still very substantial, and constitute almost half (45%) of the total healthcare financing in Ghana. The high incidence of OOPs was mainly due to the inability of informal sector workers to afford NHI premiums, as well as the continuous reliance of NHI members on private providers for services not provided under the NHI.
Out-of-pocket spending was found to be the most regressive because the majority of the burden of payment fell on the poor. If Ghana is to achieve Universal Health Coverage it is essential to reduce out-of-pocket payments. Evidence from other countries has shown repeatedly that not only do direct payments for health care deny poor people access to essential services, they also push them into deeper levels of poverty. A 2008 ILO Briefing paper reported that in countries such as Kenya, Senegal and South Africa, between 1.5 and 5.4 per cent of households fall below the poverty line as a direct result of paying for health services. For 2005 alone this amounted to over 100,000 households in Kenya and Senegal, and about 290,000 households in South Africa.
In addition to equity issues relating to how health care is paid for, our study pointed to huge inequities in the distribution of benefits of health services in Ghana. The rich enjoyed double the health benefits of the poor, although the latter had greater healthcare needs. These inequities were found to have been driven largely by unaffordability, inaccessibility and unavailability of healthcare services for poor people and rural populations. However, lower level public health facilities (and services) such as community health centres and district hospitals were found to promote equity and benefited poor people more than higher level facilities.
The inequities in the distribution of healthcare benefits suggest the need to increase investment to improve the availability of healthcare services, especially at the grassroots level. More specifically, efforts ought to be directed at removing geographical barriers, increasing staff and equipment capacity, and addressing operational inefficiencies in health facilities. In doing this, the government can leverage the NHI provider payment system to ensure equitable distribution of healthcare services and personnel across the country.
Our study demonstrates that while financing from general taxation is progressive, OOP spending on health and insurance contributions from the informal sector are regressive. Policy makers, thus, need to direct more attention at general tax financing if they are to make real progress at achieving equitable and universal health coverage. The ultimate aim for policy makers should be to create a health system that guarantees equitable access to adequate essential health services for everybody in Ghana.
James Akazili (PhD) is a Health Economist at the Navrongo Health Research Centre in Ghana. This blog is drawn from the article, “Progressivity of health care financing and incidence of service benefits in Ghana”, which was published in the Journal of Health Policy and Planning.
As the 19th AIDS conference drew to a close last week, I left Washington DC with mixed feelings of hope and despair. Advances in science gave me hope for the day we can cure HIV, yet pharmaceutical companies’ fierce fight for control over existing and emerging technologies remind me of the battles ahead. I was optimistic about the commitments made by Jim Kim, the new president of the World Bank, to invest in health systems that work for the poor, but worried that declines in donor funding will slow down progress. Above all, I was energised by the activists in the North and South who have for decades demanded action. Yet I felt frustrated at the lack of high-level commitment to address prejudice, stigma and discrimination. Here I reflect on my three greatest hopes and the three battles in the struggle to end AIDS.
REASONS FOR HOPE
1. THE SCIENCE IS MOVING TOWARDS ENDING AIDS
Great strides have been made by the scientific community and the goalposts have clearly shifted – instead of “fighting AIDS” we now talk about “ending AIDS”. Scientific advances in prevention and treatment have saved lives and turned the deadly disease into a chronic condition. Medicines for those who develop resistance or side effects are more effective than ever before and scientists are on track to find a cure. There are new lab techniques to test and closely monitor people living with HIV in order to improve treatment. The evidence is clear that treatment is an effective method of prevention and new studies show that early treatment results in far better health outcomes. Therefore, there is a strong recommendation to start treatment as soon as a person is diagnosed.
2. BOLD COMMITMENT FROM THE WORLD BANK
In his opening remarks, the new World Bank President Jim Yong Kim stated that the World Bank would play a pivotal role in ending AIDS by focusing on what it does best: building health systems. I strongly believe that investing in health systems (including infrastructure, health workers, drug supply chains, and health information systems) is a critical prerequisite to ending AIDS. To achieve Jim Kim’s vision I hope that the World Bank will increase its support to developing countries (with help from other donors) to invest in free public health care and support community-based care. Access to free treatment has been critical in the struggle against HIV and we must learn from this lesson.
3. THE POWER OF ADVOCATES
In his speech Jim Kim reminded delegates that at every point in the history of the epidemic, it was the HIV activists who have led the way – putting pressure on politicians and drug companies to act. The 2012 conference brought together the veteran fighters who broke the silence on HIV decades ago and the young activists who are driving the movement today, demanding their rights and creating new societal norms in difficult contexts, such as the Middle East.
THE THREE BATTLES
1. PHARMA: THE DE JA VU PHENOMENON
As new medicines come on stream, there are signs that pharmaceutical companies are taking the same path they took decades ago when the first ARVs became available and advocates fought tirelessly to demand access to new treatment. Now as then, the pharmaceutical companies want to control of the Intellectual Property for these medicines in order to maintain absolute control of the market. For example, companies such as Johnson & Johnson and Merck are refusing to license their medicines to mechanisms like the Medicine Patent Pool (MPP), an initiative which would enable widespread generic competition and hence expand access to medicines. Some companies have cynically claimed that they are refusing to work with the MPP because they want to ensure patient adherence – as if a patent monopoly would allow them to monitor every patient! Others claim that the market for their products is so small that it cannot bear more than 2 to 3 producers: the company itself and those it decides to provide voluntary licenses. Such licenses tend to have very limited geographical coverage and their standards are not open for public scrutiny (unlike the MPP license which has transparent policy and is mandated to negotiate wide geographical coverage). Besides, generics companies, which understand the dynamics of the generics market, are best placed to determine whether it is worth producing a generic version after the entry of 2 or 3 generics producers.
2. DECREASED FUNDING
There is no doubt that donor funding for HIV and health is decreasing. The global financial crisis has been blamed for this decrease. Yet it is not possible to end AIDS without investment in massive scale-up of prevention and treatment efforts, especially via the Global Fund. Last year, the Global Fund cancelled Round 11 causing difficulties in programmes in a number of countries such as Malawi and the Democratic Republic of Congo.
This year the Global Fund is discussing a new funding model to replace the Round system. We activists are concerned that the “financial crisis” will dictate a model that dampens country demand. Allocating budgets to countries, as has been proposed at the Global Fund, will induce “self-censorship” whereby countries go for what they can buy with their allocated funds rather than what they actually need. I hope that the Global Fund board rejects such top-down approaches and maintains the principle that it prides itself on: country ownership. To enable the serious work to end AIDS to continue donors will also need to fulfil their funding commitments.
3. WOMEN AND VULNERABLE GROUPS
The initiative to have a HIV free generation via stopping mother-to-child transmission is to be applauded. Yet the lack of commitment of donors and governments to treating women before and after birth is appalling. Also, the lack of high-level political commitment from country leaders to tackle prejudice, stigma and discrimination threatens to undermine the goal of ending AIDS.
In a nutshell, the science, the advocates, and the new World Bank give me reason for hope. It’s now time for pharma, donors, and governments to play their part. Activists will not wait for long to act!
Mohga M Kamal-Yanni works for Oxfam as a Senior Health & HIV Policy Advisor