Free and Public

Saving a program that saves lives: A rejoinder

In November 13th edition of the New York Times, Professor Kenneth Arrow (a  Professor of Economics at Stanford University)  published an article in which he reiterated the rationale for establishing the Affordable Medicines Facility – malaria (AMFm), and asked for the Global Fund to modify and scale it up. 

The AMFm model was conceived by a team of researchers led by Professor Arrow.  The idea was to establish a global subsidy which would reduce the price of Artemisinin-based Combination Therapy (ACT) – an effective malaria treatment. The AMFm model also sought to make ACT affordable and available and as well as drive out artemisinin monotherapy (AMT), a cause of Malaria drug resistance. In 2010, the AMFm model was piloted by the Global Fund to expand access to ACT through delivery at local shops. 

Our main argument against the implementation of the AMFm model is that using shops to sell malaria treatment is dangerous to public health.  Shopkeepers may wrongly diagnose malaria and consequently provide the wrong treatment.  In many low income countries shopkeepers who sell medicines lack the needed skills to diagnose and administer malaria treatment correctly. Particularly, shopkeepers often struggle to appropriately deal with negative malaria test. The usual outcome of shop treatment is that a patient is taken to the hospital late in their illness, potentially putting their life at risk and causing their family unnecessary financial and emotional distress.

Professor Arrow’s article also asserts that “diagnosis makes sense only if treatments that follow are both affordable and accessible”. This obviously carries some truth, however,   it is also important that people who provide treatment are able to diagnose and prescribe properly.  The effective and indeed efficient treatment of malaria therefore requires using trained health workers. Although the article seems to suggest that public health service systems in low income countries, particularly in rural areas are unable to deliver on this, there is mounting evidence that Community Health Workers (CHWs) can be effective at providing healthcare in rural and remote areas. For example, Zambia and Ethiopia are two countries that have made remarkable progress at controlling malaria with strong emphasis on public sector facilities and the use of trained CHWs to administer malaria treatments. Recent evidence from Uganda confirms the ability of CHWs to diagnose and treat both malaria and pneumonia. Also,   studies have shown higher utilization of CHWs in remote areas and small villages, and by poor people.

CHWs have many advantages for providing healthcare in remote and rural areas.  As members of the community, they have insights into local beliefs and culture and can therefore provide appropriate and acceptable care.  Their presence in local communities typically reduces transportation costs and allows for wider reach of rural and remote population. Finally, CHWs training also equips them to provide referral services so that patients who have non-malarial fevers can get the right treatment from an appropriate healthcare provider.
 
However, continuing and building on the successes of CHWs require greater investment to provide them with the needed training and support. It is not too expensive to provide such training and support.  For example, our calculation shows that the AMFm subsidy could have trained 1.7 million CHWs in Africa.  Therefore, there is a great need to build public health systems, particularly at decentralized levels in order to provide much needed supervision and referral services for primary providers.

Finally, we question the relevance of the AMFm model for controlling malaria. As of 2004 when the AMFm model was first put forward,   the malaria landscape was already changing. This process of change has continued, and the current realities eight years on are strikingly different.  This means that approaches that seemed good at controlling malaria then, are not necessarily relevant today. The following landmark changes are worth nothing: 
1.  The WHO issued guidelines in 2010 that treatment of malaria has to be based on correct diagnosis. Since then Rapid Diagnostic Tests (RDTs) have been increasingly available and are used by health workers in many countries.
2. The incidence of malaria is decreasing in most countries and therefore the likelihood that a child with fever has pneumonia or other diseases is high. A recent study (i)   in Tanzania puts malaria as a cause of only 10% of children’s fever. Applying AMFm means that 90% of the children with fever will get medicines they do not need and thus delay diagnosis of killer diseases. Parents will pay precious money for useless drugs.
3. There is mounting evidence that shows that other providers are more effective than informal shops. Community health workers (CHWs) are able to diagnose and treat malaria and pneumonia more effectively. 
4. The AMFm evaluation showed a great difference in implementation between and within countries and therefore the idea of a global model that fits all is not valid. 
5. The evaluation showed that AMFm had no effect on monotherapy because governments’ regulations had already done the job of decreasing monotherapy in the market.

Our above arguments show that modification and scale up, as proposed by Professor Arrow, require a careful consideration. The recent decision by the Global Fund to modify the AMFm to allow countries to decide on how best to tackle malaria is welcomed. However, to focus on shopkeepers as the vehicle for malaria treatment is dangerous and short-sighted. It is important to support solutions that are proven to effectively control malaria and other causes of fever, like investing in community health workers.

Reference

(i)  Valerie D’Acremont, Mary Kilowoko, Ester Kyungu, Sister Philipina, Willy Sangu, Judith Kahama-Maro, Christian Lengeler, Blaise Genton ( Forthcoming),  Etiology of fever in children from urban and rural Tanzania

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

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110 civil society organizations call on the World Bank to advance universal health coverage



A 30 year old mother of 3 Selina receiving care in  a hospital in GhanaSource: Oxfam Words & PicturesAs part of the growing global movement for universal health coverage (UHC), civil society groups met with World Bank president Jim Yong Kim at the World Bank annual meetings in Tokyo earlier this month asking that he support developing countries to achieve universal health coverage.  Health was a theme of this year’s meetings.

They presented Dr. Kim with an open letter signed by 110 organizations from 40 countries, including the Ghana Universal Healthcare Campaign, World Vision, and Oxfam asking him to ensure the World Bank assists all people, especially the poorest and most vulnerable, to access quality health services. 

The clear message of the letter – underlying all its demands – is that strong and equitable health systems are the key to achieving universal coverage.  It emphasized that universal coverage should not just mean protection from catastrophic expenditure; it must mean that all people, especially the poorest and most vulnerable, are able to access quality essential health services when they are needed.  To achieve this, the right kind of health systems must be built – systems that promote health services of good quality through investment in health workers, facilities, information systems and quality generic medicines. Health systems must also be structured and financed in a way that ensures all people, especially the poor, can access care that is free at the point-of-use. 

That is why the letter’s first “ask” is for the Bank to help countries remove out-of-pocket fees, an essential component of any attempt to achieve UHC in developing countries, where evidence clearly shows that fees block access to healthcare for the poor, especially women.  For too long, the Bank pushed user fees in developing countries as a way to recover costs and ration care.  Next year marks the 20th anniversary of the Bank’s seminal 1993 World Development Report, “Investing in Health,” which – building on a previous publication (1)  – made the case for cost recovery through user fees.  The messages in this report, amplified by World Bank policy advice and technical assistance, influenced policies in scores of developing countries over the ensuing decades.

Encouragingly, President Kim has recently said that poor health and high out-of-pocket healthcare expenditures are leading causes of poverty.  The tide at the World Bank on this issue is slowly turning, as evidenced by the recent example of Sierra Leone, where the Bank played a helpful role, alongside other donors, in providing financial support to the country’s successful free care policy for pregnant women and children. However, there is wider demand for this type of support: 12 countries (2)  in sub-Saharan Africa have made healthcare free at the point-of-use specifically for maternal and/or child health services over the last decade.  The Bank is still too slow to provide assistance to most of these countries and to others who are interested in pursuing broader fee removal policies.

In order to help countries achieve UHC, the letter also calls on the World Bank to take additional steps, such as providing support to expand public financing; offering balanced policy advice that does not privilege private sector solutions over publicly financed and delivered health systems; ensuring space for civil society involvement in national health policy development; and collaborating with the World Health Organization and other global health institutions.

With a health expert committed to evidence-based policy-making at the helm of the World Bank, and strong leadership from the Bank’s health sector team, there has never been a better time to make progress on this issue.  And as this letter demonstrates, there is also overwhelming demand from civil society for action from the World Bank to make universal access to quality healthcare a reality for all.

References

(1) World Bank, (1987) “Financing Health Services in Developing Countries: An Agenda for Reform”1
(2) Benin, Burkina Faso, Burundi, Ghana, Kenya, Madagascar, Mali, Niger, North Sudan, Senegal, Sierra Leone, Zimbabwe.    Source: Sophie Witter (2010) HLSP Institute, ‘Mapping user fees for health care in high-mortality countries: evidence from  a recent survey.’

 Katie Malouf Bous is a Policy Advisor for Education and Health at Oxfam International

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110 organisations de la société civile en appellent à la Banque Mondiale pour faire avancer la couverture santé universelle

Selina receiving healthcare in a hospital in Ghana Dans le cadre du mouvement mondial en faveur d’une couverture santé universelle (CSU), des groupes de la société civile ont rencontré le mois dernier le président de la Banque mondiale Jim Yong Kim lors des assemblées annuelles de la Banque mondiale à Tokyo, pour lui demander de soutenir la mise en place d’une couverture en santé universelle dans les pays en développement. La santé était en effet l’un des thèmes de l’assemblée cette année.

Une lettre ouverte signée par 110 organisations provenant de 40 pays, dont Ghana Universal Healthcare Campaign, World Vision et Oxfam, a été présentée au Dr Kim pour demander à la Banque mondiale d’aider les populations, notamment les plus pauvres et vulnérables, à accéder à des services de santé de qualité.

Cette lettre, ainsi que l’exprime clairement l’ensemble des demandes formulées, appelle la Banque à soutenir la mise en place de systèmes de santé solides et équitables seuls à même de permettre l’avènement d’une véritable couverture universelle. Celle-ci ne doit pas seulement prendre en charge les dépenses de santé dites « catastrophiques », mais également établir le principe selon lequel les populations, en particulier les plus pauvres et les plus vulnérables, doivent pouvoir accéder à des services de santé de base en cas de besoin. Pour y parvenir, il convient de mettre en place des systèmes de santé appropriés, capables de promouvoir un bon niveau de qualité à travers des investissements en personnels de santé, installations, systèmes d’information et médicaments génériques sûrs. Les systèmes de santé doivent également être structurés et financés de manière à offrir l’accès gratuit aux centres d’accueil et dispensaires, en particulier des populations les plus pauvres.

C’est pourquoi il est demandé en premier lieu à la Banque d’aider les pays à supprimer le paiement direct, une étape essentielle à toute politique de prise en charge universelle dans les pays en voie de développement. Ces frais constituent la première barrière financière à l’accès aux soins des plus pauvres, notamment des femmes. Depuis trop longtemps, la Banque a incité ces pays à s’appuyer sur le paiement direct des soins par les usagers pour compenser les coûts des soins de santé. L’année prochaine marquera le 20e anniversaire du Rapport mondial sur le développement de 1993, « Investing in Health », élaboré à partir d’une précédente publication (1), qui a établi le principe de la récupération des coûts sur les frais restant à la charge des patients. Les messages envoyés par ce rapport, amplifiés par les recommandations et l’assistance technique de la Banque mondiale, ont considérablement influencé les politiques des pays en voie de développement au cours des décennies qui ont suivi.

Fait encourageant, le président Kim a récemment déclaré que la mauvaise santé et le coût souvent élevé du paiement direct des soins sont les causes principales de la pauvreté. L’approche de la Banque mondiale est toutefois en train d’évoluer doucement, comme en témoigne l’exemple récent de la Sierra Leone où la Banque a apporté un soutien financier déterminant, aux côtés d’autres donateurs, au programme national de gratuité des soins pour les femmes enceintes et les enfants. Il existe cependant une demande bien plus large pour ce type d’initiatives : 12 pays (2) d’Afrique sub-saharienne ont en effet mis en place la gratuité des soins dans les dispensaires ces dix dernières années, en particulier pour les services de santé maternels et infantiles. La Banque répond encore trop lentement aux demandes d’aide de la plupart de ces pays comme des autres nations souhaitant aussi renforcer leurs politiques d’abolition du paiement direct.

Afin d’aider les pays à mettre en place une CSU, la lettre appelle également la Banque mondiale à prendre des mesures supplémentaires, comme soutenir le développement des financements publics, offrir des recommandations équilibrées qui ne privilégient pas les solutions du secteur privé au détriment des systèmes financés et organisés par les pouvoirs publics, veiller à ménager un espace pour l’engagement de la société civile en faveur des politiques de santé publique et collaborer avec l’Organisation mondiale de la Santé et d’autres institutions mondiales de la santé en faveur de la couverture universelle en santé.

Avec, à la tête de la Banque mondiale, un spécialiste de la santé engagé à élaborer des politiques fondées sur des données probantes et un leadership fort de la part de l’équipe en charge du secteur, le moment est plus que jamais propice aux avancées dans ce domaine. Et comme le démontre cette lettre ouverte, il existe une demande considérable de la société civile appelant à une action de la Banque mondiale pour que l’accès universel à des soins de qualité devienne une réalité pour toutes et tous.

Références
(1) Banque mondiale. « Financing Health Services in Developing Countries: An Agenda for Reform – 1 » (1987)
(2) Benin, Burkina Faso, Burundi, Ghana, Kenya, Madagascar, Mali, Niger, Nord Soudan, Sénégal, Sierra Leone, Zimbabwe.  Source : Sophie Witter. HLSP Institute. « Mapping user fees for health care in high-mortality countries: evidence from  a recent survey. » (2010)
Katie Malouf Bous est conseillère en politiques d’Éducation et de Santé chez Oxfam International

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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.