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Oxfam warns malaria subsidy is too risky to continue

A girl receiving treatment from a community health worker in Port-au-PrinceLast week in our new report ‘Salt Sugar and Malaria Pills’, Oxfam is calling for an end to a global malaria scheme; the Affordable Medicines Facility – malaria (AMFm).

Despite great successes in fighting malaria, many poor people continue to die of this treatable disease.  The majority of those dying in Africa are children. In fact in 2010, 86 per cent of malaria deaths were children under five.  So why are we not supportive of a scheme that aims to reduce the price of life saving medicines?

As you may expect – and hope – we have some very good reasons based on the evidence.

It is true that the AMFm has succeeded in reducing the price of ACT – the ‘good’ malaria drug – and increasing the number of medicines available in the countries where the subsidy operated. You don’t need a PHD in economics to understand that a subsidy will achieve these things. But that doesn’t mean the subsidy is helping the poorest families to get the treatment they need, and doesn’t take into account the public health risk of treating malaria in this way.

Firstly, there is no evidence that the poorest and most vulnerable have benefited. The AMFm’s own evaluation of the pilot phase, which has seen the subsidy rolled out in 7 territories, failed to measure this.  They don’t know who bought the medicines.  What we do know is that when medicines have even a low price, the poorest families cannot afford them.  Ordinary people have spent over 105 million USD buying these subsidised medicines in the pilot countries. This level of out of pocket payment is not what will allow the poorest people, living below the poverty line, to get the medicines they need.

But there is a far more fundamental flaw in the AMFm.  The scheme has mainly incentivised increased sales through small-scale private providers.  Which doesn’t sound like a problem, until you realise this doesn’t mean chemists or private doctors. It means shops.  The AMFm has put the majority of medicines in the hands of shopkeepers who don’t have any medical training, and can’t give medical advice to families or properly diagnose malaria.  Given that an estimated 60% of fevers are not malaria, distributing medicines in this way runs a real risk of wrong treatment for the majority.

We are not idealists either. We know that public health infrastructure in many countries cannot always provide a well trained doctor on the doorstep of the poorest people.  This is why our report also proposes a pragmatic solution that will have a far better chance of success than the AMFm.  Community health workers are based in communities, and can be trained to diagnose and treat malaria and non-malarial fevers.  When Ethiopia invested in 30,000 community health workers, they saw malarial deaths fall by half in just 3 years.  And the amount that has been spent so far on the AMFm could have trained and paid the first year’s salaries of 390,000 community health workers in sub-saharan Africa.  This is the opportunity cost of the AMFm that the Global Fund Board must bear in mind.

So ask yourself this. If there is a 2 in 3 chance your daughter who woke up this morning with a fever, doesn’t have malaria, but another life threatening disease, would you really take her to a shopkeeper without any medical training but with a financial incentive to sell you malaria pills? Or would you prefer to have a trained health worker in your community, who can diagnose and treat pneumonia and other diseases?

A child in Tanzania has the right to safe treatment, just like our own children do. The AMFm puts lives at risk in the poorest countries, and poses a dangerous distraction away from more effective interventions that can save the lives of the poorest and most vulnerable.

This is why we are urging the Global Fund who will meet in early November, to base their decisions on the evidence. To put an end to the AMFm, and free up the resources to invest in what we know works.

Emma Seery is Oxfam’s Head of Public Services and Development Finance team

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Une subvention pour lutter contre le paludisme qui, selon Oxfam, comporte trop de risques

Une subvention pour lutter contre le paludisme qui, selon Oxfam, comporte trop de risques

La semaine passée, dans notre dernier rapport “Des anti-paludéens à l’épicerie”, Oxfam suggérait que l’on mette fin à un projet mondial contre le paludisme Fonds pour des médicaments antipaludéens à des prix abordables (AMFm).

Malgré une avancée notable dans la lutte contre le paludisme, un nombre important de personnes indigentes meurent encore de cette maladie pourtant curable. La majorité des victimes en Afrique sont des enfants. De fait, en 2010, 86 pour cent  des personnes décédées des suites du paludisme avaient moins de cinq ans. Alors pourquoi ne sommes-nous pas en faveur d’un projet qui vise à réduire le prix de médicaments qui sauvent des vies?

Oxfam a de très  bonnes raisons d’exiger l’arrêt de ce mécanisme à la lumières de plusieurs  faits.

Il est vrai que le AMFm a réussi à faire baisser le prix des ACT – les meilleurs traitements antipaludéens à l’heure actuelle– et à augmenter la quantité de médicaments disponibles dans des pays où la subvention a été attribuée. Nul besoin d’un doctorat en économie pour comprendre qu’une subvention permette d’atteindre ces objectifs. Mais cela ne signifie pas pour autant que cette aide rend l’accès aux médicaments plus aisé pour les familles les plus démunies ni qu’elle prend en compte les risques de santé publique en traitant le paludisme de cette façon.

Tout d’abord, il n’existe aucune preuve que les plus pauvres et les plus vulnérables aient bénéficié de cette aide. La propre évaluation de l’AMFm lors de la phase pilote, durant laquelle la subvention a été déployée sur 7 territoires, n’a pu le mesurer et ils ne savent pas qui a acheté les médicaments. Mais ce que nous savons, c’est que même lorsque les prix sont bas, les familles les plus pauvres ne peuvent se permettre une telle dépense. Les gens ordinaires ont déboursé plus de 105 million USD pour ces médicaments subventionnés dans les pays pilotes. Pour autant, ce système de contribution personnelle ne permet pas aux plus nécessiteux, vivant en dessous du seuil de pauvreté, d’obtenir les médicaments dont ils ont besoin.

Ensuite, il existe un autre défaut encore plus fondamental dans l’AMFm. Le programme a essentiellement renforcé la hausse des ventes de petits prestataires privés. Ce qui ne semble pas poser problème, jusqu’à ce qu’on réalise que cela ne correspond pas forcément à des pharmaciens ou des médecins privés. Non, cela concerne plutôt des magasins. L’AMFm a mis la grande majorité des médicaments entre les mains de petits commerçants qui n’ont aucune formation médicale et ne peuvent donner aucun conseil à des familles, ni diagnostiquer correctement le paludisme. Dans la mesure où l’on estime que 60% des fièvres ne sont pas liées au paludisme, distribuer des médicaments de cette manière comporte un risque réel de distribuer des traitements inappropriés dans la majorité des cas.

Nous ne sommes pas idéalistes pour autant. Nous savons que les infrastructures de santé publiques dans de nombreux pays ne peuvent pas toujours fournir des médecins bien formés au plus près des plus démunis. C’est pourquoi notre rapport propose également une solution pragmatique qui aura bien plus de chance de réussir que l’AMFm. Les travailleurs de santé locaux basés dans les communautés qui peuvent être formés pour diagnostiquer et soigner le paludisme et des fièvres autres que paludéennes. Lorsque l’Éthiopie avait investi dans 30,000 travailleurs de santé locaux, les décès dus au paludisme avaient diminué de moitié en 3 ans. Or, le montant jusqu’à présent dépensé pour l’AMFm aurait pu servir à la formation et au salaire de travailleurs de santé locaux en Afrique sub-saharienne. Ceci est le coût d’opportunité engendré par l’AMFm que le Conseil du Fonds Global doit avoir à l’esprit.

Il faut se poser les questions suivantes : s’il y a deux chances sur trois que votre fille qui s’est levée ce matin avec de la fièvre, n’ait pas le paludisme mais une autre maladie qui mettrait sa vie en danger, l’amèneriez-vous vraiment chez un commerçant sans formation médicale mais financièrement incité à vous vendre des comprimés anti-paludéens? Ou préfèreriez-vous avoir un travailleur de santé formé dans votre communauté, qui pourrait diagnostiquer et traiter une pneumonie ou d’autres maladies ?

Un enfant en Tanzanie a le droit à un traitement sûr, au même titre que  le votre. L’AMFm met des vies en danger dans les pays les plus pauvres et risque de détourner l’intérêt général au détriment d’interventions efficaces qui peuvent sauver la vie des plus pauvres et des plus vulnérables.

C’est pourquoi nous invitons le Fonds mondial qui se réunit début novembre à prendre leurs décisions à la lumière de ces faits. Mettre fin à l’AMFm et libérer les ressources pour les investir dans ce qui, nous le savons, fonctionne.

Emma Seery, responsable de l’équipe Fonds de développement et Services publics à Oxfam

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Achieving universal health coverage in Ghana: why a premium-based health insurance model is not a better solution

Activists campaigning for universal access to healthcare in Ghana.Earlier in September this year, the Lancet published a special series on universal health coverage (UHC) which argued from ethical, political, economic, and health perspectives why a renewed effort to achieving UHC is necessary. The articles put forward many important policy propositions for achieving UHC, particularly on the need to abolish user fees for healthcare, and putting greater emphasis on public health financing and provision.

Indeed, the way health systems are financed is an important prerequisite for achieving Universal Health Coverage as this determines whether health services are available, and whether people can afford to use them. This link between financing and UHC is one which is clearly articulated in existing health policy documents in Ghana. However, with general elections less than two months away (December 7th), and as the different political parties articulate their visions and strategies for the health sector in particular, we ask whether the current modality of health financing in Ghana – the National Health Insurance Scheme (NHIS) – is an effective model for achieving UHC.

Up until 2003, the health financing model in Ghana was based on a fully fledged user fee scheme known as the Cash and Carry. Although vulnerable groups such as the poor people, pregnant women, and children were exempted from paying user fees, the policy had limited success in removing financial barriers to health services, as the exemption package was unclearly specified and inadequately funded. The system was also riddled with managerial and operational difficulties. As a result, the user fees policy denied many poor people access to the needed healthcare. 

The National Health Insurance Scheme (NHIS) was introduced as an alternative financing model in 2004 to ensure universal access to quality healthcare, provide financial protection and ultimately improve health outcomes. Membership in the NHIS is supposed  to be mandatory for all Ghanaians, and covers the direct costs of healthcare services and medicines for most common diseases in Ghana.  The scheme is financed from a range of revenue sources, notably, VAT revenue, payroll deductions from formal sector workers, and premium contributions from informal sector workers.

However, there are many challenges and shortcomings of the NHIS which makes it particularly ineffective for achieving universal access to healthcare. 

First, the way in which the NHIS is funded is unfair. This is because it is funded mainly from revenue generated from VAT which is regressive, and imposes a high tax burden on low income households. Ironically, despite being worse affected by VAT payments, low income households find it the hardest to afford the premiums required to enrol in the NHIS in order to benefit from the healthcare services it provides. Current enrolment rates on the NHIS stand at only 34% of the population (2010 data) mainly because of these high premium rates.

The second obstacle to achieving UHC under the NHIS is the high level of out-of-pocket (OOP) payments that still dominate healthcare financing in Ghana even eight years after the launch of the NHIS.  OOP payments accounted for just over a third (37%) of the total national health expenditure in 2009. Higher OOP payments at point of service have been noted to impoverish poor patients and limit access to live-saving care. In order for countries to reduce the burden of health expenditure on low income households, the WHO has recommended countries must reduce OOP payments to around 15% of total health expenditure. But Ghana’s OOP rate is about twice the recommended WHO threshold, and higher than that of other lower middle income countries.

The third challenge the NHIS faces with respect to UHC relates to the issue of sustainability. The World Bank has predicted the scheme would go bankrupt by 2013.  A large part of this problem is due to the inefficiencies of the scheme arising from poor premium and membership card administration. The cost of claims administration is estimated to have increased by around 40 folds since 2004.

The above are clear indications that the NHIS maybe a long way from achieving UHC. Maternal and child deaths rates in Ghana are among the worst in lower middle-income countries, with around one in every 280 pregnant women dying during childbirth, and about one in 15 children dying before their fifth birthday.  Also about three-quarters of the poorest 20% of pregnant women give birth without the presence of a skilled health worker. 

However,  as election day approaches,  it is encouraging to see all the major political parties being committed to pursuing UHC, though there are many loopholes in the policy plans they have put forward to achieve this.  These include the Convention People’s Party promising to  ensure universal health coverage, but without stated specifics as to how this will be achieved, to the New Patriotic Party committing to pursuing UHC but through public-private means that could in fact, lead to further exclusion of vulnerable people.  The current ruling party, the National Democratic Congress has promised to expand the benefit package and capitation system of the current NHIS system, but without specifics on how this will be achieved, and whether current system infrastructure could support its success.

In order to achieve UHC, policy propositions should be tailored to expanding access through the removal of financial barriers, while recognising the need to expand and improve health facilities.  On the demand side, payment by poor households can and should be abolished, with alternative and innovative means found to tax the higher income earners in order to fund quality health services. For instance, using property tax and scaling up the communication service tax (the ‘call tax’) could provide progressive forms of revenue to fund premium removal.  Another option could be to scrap the NHIS altogether and replace it with a national health service which will be funded from progressive tax revenue. Both of these options would improve coverage, and also provide efficiency savings from reduction in the cost of administering premiums. 

UHC is achievable in Ghana, but only when the financing policies are adopted!

Yussif Nagumse is a health policy officer at Oxfam-GB

Sidua Hor is the National Coordinator for the  Universal Access to Free Healthcare Campaign in Ghana

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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.