Free and Public

User fees kill

This blog is made of short scenes because the woman’ story at the end is worth a thousand studies, statements, national or international policies.

Scene one 1986 DC
Economists do a lot of studies and extensive thinking on the critical issue of how to finance health care. They tell the world that governments cannot afford to pay for health care and that free care encourages overuse and therefore people must pay fee for services.

Scene two: October 2012 DC
Over the years mounting evidence demonstrates how user fees excludes poor people especially women from access to essential healthcare. Hundreds of NGOs send a letter to Jim Kim the president of the World Bank requesting the bank to support countries removing user fees.

https://www.oxfam.org/sites/www.oxfam.org/files/worldbank-cso-platform-on-health-open-letter.pdf

Scene 3: Dec 2013 Tokyo
Jim Kim the president of the World bank says: “Even tiny out-of-pocket charges can drastically reduce [poor people’s] use of needed services. This is both unjust and un-necessary “

Scene 4: March 2016 Cameroon
Newspaper published a horrific story of a pregnant women dying at the hospital door in Cameron simply because she could not afford user fees. Her niece tried to deliver the twins but both died.

https://www.naij.com/763152-doctors-refused-help-pregnant-lady-babies-cut-knife.html?utm_source=facebook&utm_medium=social&utm_group=free

Scene 5: still to come
Governments abolish user fees. Donors including the World Bank work with the governments to fully finance essential health care for all that are free at the point of use. In Cameroon women deliver attended by trained health workers without paying for the service.

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Last minute change to the UHC indicator for the SDGs is raising alarm bells! by Anna Marriott and Mohga Kamal-Yanni

303 organisations including NGOs, academic institutions, foundations and patients groups have reacted with alarm at a last minute proposed change to the indicator used to measure financial protection for health under the Sustainable Development Goal (SDG). We understand the World Health Organisation and World Bank are similarly concerned. While maybe sounding technical or trivial, if the new indicator for Universal Health Coverage (UHC) is left unchanged it could lead to more not less exclusion of women, marginalised groups and people living in poverty from the health care they need and have a right to receive. As such, those responsible for decision making within the SDG process have an urgent responsibility to act.

The hope is that the groups responsible for finalising the indicators and associated methodologies (the UN Inter-Agency Expert Group and UN Statistics Division) will take the opportunity of a meeting taking place tomorrow and until 11th March in New York to urgently review and amend this dangerous and counter-productive newly proposed indicator. Failing to do so could mean an enormous and unprecedented opportunity to advance Universal Health Coverage globally will be lost.

How did we get here?

The SDG target for UHC is to “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.

The WHO and World Bank worked intensively for three years in consultation with the health experts in governments, academia and civil society to define and measure UHC. This work included: data to be collected, how to collect it and the feasibility of collecting standardised data that allow measures to be compared across time, populations and countries.

It was agreed after a lot of haggling with different parties that UHC could be measured using a minimum of two indicators – one for coverage of essential health services and one for financial protection. Although the indicators developed by the WHO and World Bank were not perfect, there appeared to be a consensus across the global health community to accept and support the results of their work.

It therefore came as a shock that a radical and regressive last minute change was made to the proposed indicator for financial protection by the UN Inter Agency and Expert Group on Sustainable Development Goal Indicators (IAEG) at their most recent meeting at the end of February. The proposed indicator was changed from:

Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure”

to:

“Number of people covered by health insurance or a public health system per 1000 population”

A letter sent last Monday 29th February by 260 organisations (and now supported by 303 and counting) to the IAEG group members called for urgent action to revoke the proposed new indicator and revert back to the original indicator agreed by the WHO and World Bank.

What’s the fuss about?

The purpose of the financial protection indicator (number 3.8.2) is simple: to find out if there is progress being made regarding people accessing health services without falling into poverty (if they are not poor), or falling into deeper poverty (if they are already poor). The indicator must also be able to fulfil the SDG commitment to measure progress across disaggregated groups, especially for those on the lowest incomes and across marginalised groups.

The proposed new indicator is not just meaningless with regard to measuring financial protection for health, it’s also dangerous. In reality it could measure as so-called ‘progress’ an actual increase rather than decrease in impoverishing and catastrophic health expenditure by households.

Problems with using health insurance coverage as an indicator include:

  • Health insurance has no universal meaning or definition and therefore doesn’t work for cross-country comparisons;
  • Insurance is not a measure or guarantee of financial risk protection – in a number of countries the introduction of insurance schemes has not reduced out of pocket payments or provided protection against catastrophic health expenditure
  • What package of services is covered under an insurance scheme can vary enormously thereby potentially not protecting households against costs associated with a wide range of diagnosis, treatment and care services
  • There are numerous examples where insurance can widen inequalities (e.g. voluntary insurance that excludes people with pre-existing conditions or those unable to pay or social health insurance when only for the formal sector, thereby excluding the majority of people in low and middle income countries who work in the informal sector);
  • Dangerously the proposed indicator risks promoting voluntary insurance schemes against a large body of significant and robust academic evidence that such schemes do not advance UHC
  • Data disaggregation by income groups or other forms is not universally possible

Problems with using coverage by a public health system per 1000 population as an indicator include:

Whilst health insurance coverage as an indicator is dangerous, the alternative – ‘coverage by a public health system’ – is simply meaningless and not objectively measurable. Citizens in many countries may have a legal entitlement to a public health system but still have to make substantial payments to access services.

A colleague from India summed up the absurdity of the proposed new indicator better than I:

“This is quite ridiculous for a country like India. The ‘number of people covered by a public health system’ in India is always 100% as per government policy and programme plans! As regards coverage by health insurance, it is assumed that if covered by insurance all expenses are taken care of. It obviously is not often the case.”

The change we hope to see in the next few days

A series of meetings will take place in New York between 8th and 11th March where the members of the UN Statistics Division and the IAEG will aim to review and finalise the status of the indicators and the methodologies to measure them. We are hopeful that given the united call of so many organisations in support of the indicators developed by the World Bank and the WHO, that the members will review and amend indicator 3.8.2. This should not be a political issue but a methodological one – we need an indicator that measures improved financial protection for health. The current proposal fails to do that.

For those organisations wishing to sign on to our joint letter calling for action to revise this dangerous indicator please add your organisational name and contact details via the following link: https://www.surveymonkey.co.uk/r/2RZGMS7

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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.