The World Health Organization (WHO) states in its constitution that it aims to achieve "the attainment by all people of the highest possible level of health.” The World Health Assemblies (WHAs) provide a key opportunity to engage on the achievement of this aim. Yet in an interesting study by Kitamura et al. in May 2013 in Health Policy reviewing the agendas of the WHAs between 1970 and 2012, the authors concluded that “agenda items of the WHA do not always reflect international health issues in terms of burdens of mortality and illness.”
So how are countries and stakeholders shaping the WHA agenda?
One way is through the WHO Executive Board (EB), particularly as it plays a role in setting the provisional agenda for the WHA. EB members are individuals nominated by countries with technical expertise in health. Of the 34 members of the Executive Board, seven are from the African region. Currently these are from Cameroon (2011-2014), Chad (2012-2015), Namibia (2013-2016), Nigeria (2011-2014), Senegal (2011-2014), Sierra Leone (2011-2014) and South Africa (2013-2016). As EB members, they are well-positioned to be heard and to bring concerns from their regions to the table. They can also block issues being discussed. The WHO secretariat also plays a role in agenda setting. Procedurally, the provisional EB agenda is proposed by the WHO Director-General. Getting issues on the agenda for the WHA is, however, not difficult. According to the rules of procedure, every proposal brought by a member state and any proposals submitted by the DG should be included in the provisional WHA agenda. So how are these policy levers being used?
Take the 2014 EB agenda for example. Many agenda items were not controversial as they are carried over from previous years, after broad agreement around their importance. This included non-communicable diseases (NCDs), neglected tropical diseases and reform of the WHO. Other agenda items may be more controversial. For example, when in 2012 the United States of America and Thailand successfully petitioned to include lesbian, gay, bisexual and transgender (LGBT) access to health in the WHO EB agenda for consideration it provoked debate, with Egypt and Nigeria, on behalf of their regions, asking for the item to be deleted.
This issue exemplified how health concerns can reflect and raise political division. Bringing health into diplomacy platforms, including that of the WHO, poses a challenge for how to avoid foreign policy concerns overshadowing health issues. The US delegate, Nils Daulaire, speaking about the demands for deletion of the LGBT item in 2012 said that it was “unprecedented for WHO member states to come together to attempt to remove an item legitimately placed on the Executive Board agenda by another member state. We believe it is important to afford each other the courtesy to discuss these important health items, even those with which not everyone agrees. Changing this deeply-established precedent risks politicizing all EB agenda items moving forward.” At the same time, countries are sensitive about health platforms being used to advance wider foreign policy agendas.
On the specific agenda item, a compromise position was reached to delete it and to ask the DG to consult with members on how to address the public health issues for future discussion. African diplomats in Geneva noted that the issue could continue to cause a stalemate unless the DG brings compromise solutions from her consultations within the regions. In the 2014 EB the item thus appeared as ‘[deleted]’ on the final agenda, and there was no discussion of it, as Member States had not agreed on a title or content of accompanying documentation for it. Until they do, the item will not be discussed.
Agenda setting can and does thus fall victim to politics and requires diplomacy to reach solutions that are acceptable to the membership. However African countries have successfully brought items to the WHA agenda, such as that of ethical recruitment of health workers. What may restrict both the inclusion and action on agenda item may be the limits set by the General Program of Work (GPW). The GPW is set for the organization every 5 years. Unless a suggested item falls within the GPW and has funding allocated to it, it is unlikely to make it onto the formal agenda. The Organization is currently working on its 2014-2019 GPW and bases its’ plans on a set of distinct categories in the GPW that have been agreed to by Member States - that is communicable diseases, non-communicable diseases, promoting health through the life course, health systems, and preparedness, surveillance and response. One reform of the WHO underway, according to the WHO website, is to “allow greater flexibility in allocating resources to priorities within these categories”, which may then give flexibility for new agenda items not yet covered in the GPW.
Even when issues make it to the WHA agenda, will they receive adequate attention?
The agenda of both the EB and the WHA have become longer and longer over the years. In May 2013, for example, the WHA agenda included numerous weighty issues, including health post 2015, NCDs, communicable diseases (including malaria and neglected tropical diseases), WHO reform, substandard/spurious/falsely-labelled/falsified/counterfeit medical products and a range of other issues. With such packed agendas, smaller delegations to the WHA face challenges in participating when equally important issues are being discussed at the same time. Dr. Emmanuel Makasa, health attache at the Zambia high commission in Geneva noted in one 2013 meeting in the region that African delegations have responded to this by working as a group: “We work together as the African Group of Health Experts in Geneva to tackle issues and engage as a group, which helps with our individual member state staff shortages and different professionals present at the meetings.”
A lengthening agenda may also reflect the widening reach of global factors and policies in health, or the widening range of concerns claiming for attention. Either way, countries need proactive strategies to get their health concerns onto the global agenda, to ensure that they obtain attention and are addressed. It implies long term thinking, preparing and collaborating with partners in advance to develop positions and organizing the evidence, expertise and alliances to raise and advance agenda items. As Chigas et al. highlighted in 2007 those who can early on “frame the definition of the problem and the terms of the collective debate, can have enormous influence on the subsequent negotiations and their outcomes.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The Centre for Trade Policy and Law is working with EQUINET on a research programme on GHD in association with the ECSA HC Strategic Initiative on Global Health Diplomacy. For more information on the issues raised please visit www.equinetafrica.org
Editorial
It is time to raise critical questions around the wide and growing enthusiasm for Universal Health Coverage (UHC), which is increasingly seen as a silver-bullet solution to health care needs in low- and middle-income countries. Although confusion still exists as to what UHC actually means, international development agencies typically define it as a health financing system based on pooling of funds to provide health coverage for a country’s entire population, often in the form of a ‘basic package’ of services made available through health insurance and provided by a growing private sector.
Global health agencies such as the World Health Organization, and international financial institutions such as the World Bank, are promoting this approach in response to the rise in catastrophic out-of-pocket expenditure for health services, and in the face of crumbling public health systems in the global South (both of which were precipitated by the fiscal austerity imposed by organizations such as the World Bank and the International Monetary Fund in the 1980s and early 1990s). In this new model, UHC prescribes a clear split between health financing and health provision, allowing for the entry of private insurance companies, private health providers and private health management organizations. The logic is that health care challenges require an immediate remedy, and since the public system is too weak to respond, it is strategic to turn to the private sector.
In short, the UHC model is built on, and lends itself to, standard neoliberal policies, steering policy makers away from universal health options based on public systems. Building and improving the public healthcare system is not part of this mainstream narrative, with the state generally confined to managing the system.
Although these programs are now zealously promoted by global health agencies, the evidence to support their implementation remains extremely thin. Giedion, Alfonso and Díaz in a review of existing evidence for the World Bank published in 2013 observed that reliable data upon which to evaluate their performance are hard to come by and methodologies designed to collect good evidence are singularly lacking, illustrated by the highly contested data of some early health reforms based on universal insurance in the South (e.g. Chile, Colombia and Mexico), which have nonetheless been used to legitimize the current UHC agenda.
In a paper recently published by the Municipal Services Project, we argue that secure finances for health care are a necessary but insufficient condition for systems that are equitable and provide good quality care. We analyze the reasons why finances need to be channeled through well-designed public systems if they are to be spent efficiently. We further argue that, in glossing over the importance of public provisioning of services, many proponents of UHC are actually interested in the creation of health markets that can be exploited by capital.
In Europe, 20th-century reforms have intensified health being delivered as a market commodity. The more recent experiences of Brazil’s SUS, India’s Arogyasri and Thailand’s Universal Health Care Coverage scheme all show features of this neoliberal model, within very diverse settings and reforms. They all show a persistence or expansion of private sector participation in provision of care, despite the fact that all are tax-funded health systems. In all cases, public funding does not match needs and this opens space for the progressive creep of the private sector into the larger health system. In Brazil, while the SUS has expanded public primary care services, hospital care remained largely publicly paid and privately provided. Despite a strong policy commitment to universal public sector health systems in Brazil and Thailand, the neoliberal ethos and its promotion of private provisioning appears too strong to shake off. Consequently all three countries have a powerful private for profit sector in health. This influences the functioning of the system as a whole, ratcheting up costs, jeopardizing the integrity of the public sector and drawing away resources, both financial and human, from resource-starved public facilities.
The three countries typify the challenges that LMICs face while attempting to construct universal systems that borrow from the internal logic of a UHC that is not based on public systems, where ideological pressures prevent the adoption of an entirely public system of care provision. The challenges of providing high quality and equitable health care are most acute in low and middle-income countries because of faster growing populations, higher prevalence of infectious diseases, and growing burdens of non-communicable illnesses. We would argue that re-imagining public health care – rather than the private sellout of health systems via a neoliberal agenda in UHC – is the only way forward in building truly universal health outcomes.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the Municipal Services Project website at www.municipalservicesproject.org and the MSP Occasional Paper, ‘Universal Health Coverage: Beyond Rhetoric’ at: http://www.municipalservicesproject.org/publication/universal-health-coverage-beyond-rhetoric.
When the news came of Nelson Mandela’s death messages came spontaneously on our list from colleagues from across the 16 countries in EQUINET. We can’t include them all but some are below. They signal the pride that Mandela gave to all in being African, the many facets of justice and wisdom he symbolized for people in the continent, his respect for power being located within the people and the inspiration that people drew and will continue to draw from his life. Hamba Kahle Madiba.
From Amuda Baba in Democratic Republic of Congo: It is a big loss for Africa. We have lost a symbol of peace, unity and humility. May his soul rest in peace.
From Severina Lemachokoti in Kenya: His wisdom was unique and his wise words will forever remain to build people of all races in the years to come.
From Moses Lungu in Zambia: We will draw lessons from him on equity, equal and social justice for all. Bless his family and nation
From Sam Wamani in Uganda: Mandela was and will remain a true love for all people of all colours. Africa and the world will always remember Madiba.
From Isabella Matambanadzo in Zimbabwe: He gave us an unmatchable sense of the dignity in being black Africans and of our humanness. ..May we always carry the best of you with us.
From Elisha Sibale in Tanzania: His lifelong commitment to social justice for all was a beacon to the world.
From Dennis Chibuye in Zambia: The world has lost of a true patriot and visionary leader. …Long Live Mandela Spirit.
From: Kingsley Chikaphupha in Malawi: An icon, statesman and a true son of Africa!!
From Wilson Asibu in Malawi: May his life inspire us all, especially the youth who have a great opportunity to sculpture their lives into greatness.
From Jacob Ongala Owiti in Kenya: Mandela had the unique ability to take power to the people - So, who will take up the Mandela's spear and move it forward?
From Fortunate Machingura in Zimbabwe: He said: “To be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others” he said…enhancing the freedom of others implies our joint action as a collective.…it’s now up to us Comrades… the struggle continues!
We wish all a 2014 in which our struggles for health and justice flourish.
If our health systems ‘listen’ better to people’s input, will this make them more responsive to people’s needs? Will strengthening people’s voice and role in decisions in health systems help overcome the significant inequalities that exist in east and southern Africa - and more widely - in access to and use of health services? What do we need to do to ensure that the substantial resources that flow to and in health systems reach the primary care and community level?
These were questions that we tackled at a recent regional joint workshop of the Community of Practitioners in Accountability and Social Action in Health (COPASAH) and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) hosted by TARSC in Zimbabwe. Thirty people attended this workshop, including community health activists, civil society organisations, health workers, academics and researchers from Kenya, South Africa, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe. As a group, they came from a wide range of contexts and experiences, working with or representing people living with HIV and AIDS, elderly people, women and children, health workers and people whose health rights had been violated. Participants came from organisations whose goals included supporting and strengthening community roles in monitoring health service delivery, and advocating for equity and quality of health services and increased resources for health.
Given the wide social inequalities in our societies, all who attended the meeting are working in some way to invest in and support community capacities to articulate their needs, present their conditions, negotiate for resources that improve their lives, and monitor the delivery on state commitments towards improving health. We agreed that, in order for this to happen and for it to have an impact upstream, beyond the more common ways that people support health services - such as caring for people who are ill or contributing their own resources or time to improve services - people also need to have a greater role in the planning, delivery and monitoring of their health services.
We brought our own stories of how greater citizen engagement with service providers, especially around social action on health and social accountability in services, makes for more effective and acceptable health services. For example, participants from South Africa, Kenya and Zambia noted that setting up community-health worker committees had helped to improve dialogue and collective action. Uganda CSOs reported on a randomized field experiment of community-based monitoring of public primary health care providers in Uganda by Björkman and Svensson in 2007 that showed how social accountability mechanisms led to large increases in utilization of services and improved health outcomes.
For this to happen, however, we see that the health system needs to change. When the health system itself does not give any authority to frontline workers, it is difficult for the same workers to respond to communities. Decentralisation of power and resources within the system to local levels, together with the capacities for it, is thus necessary if people at community level are to be effective in providing input to the organisation of services. The health system needs to make clear what entitlements people have, and what obligations service providers have, and to communicate this widely to health workers and the public as a prerequisite for delivering health rights and building social accountability. If our health systems are to become more people-centred, they need to not only develop skills, knowledge and procedures around technical issues, but they also need the skills, knowledge and procedures for health workers and managers to facilitate meaningful community engagement and involvement, including in decision making. And these are most needed where the communities enter the system, that is, at the primary care level. To build ‘people centred’ health systems it is essential that resources, including medicines and skilled health workers, reach the primary care level.
This touches on the power dynamics within health systems. The inequalities in health systems are not just inequalities in relation to resources, or to access to services. There are also inequalities in power: between service providers and communities, between different kinds of health personnel and between different levels of the health system. This is an issue that is largely invisible but that has impact on the participation in and use of health systems by more marginalised groups. So a great part of our meeting tackled the sort of mechanisms and processes that can address this power imbalance. For example, mechanisms such as community prioritising of health needs, monitoring service delivery using community score cards, community- health centre meetings and community action planning, can help to make service providers more accountable to communities, and can potentially support and improve interactions between communities and frontline service providers. This strengthened interaction can then, if based on a mutual listening and understanding, lead to alliances between local health workers, managers and communities in negotiating with higher level authorities for improvements in services.
One of the ways of embedding a shift in power relations and to strengthen that alliance and interaction between communities and primary health care actors, is through using participatory reflection and action (PRA) approaches. PRA uses a variety of visual and verbal methods to provoke discussion, analysis and planning for action in such a way that it can strengthen the power that people have to change their own lives, their communities and the institutions that affect them. For the last 10 years, the pra4equity network in EQUINET has been exploring how this approach can support the strengthening of a people-centred health system. At our meeting we built on this to examine how PRA can be used to shift attention and resources towards the primary care level of the health system, to make those at higher level more accountable to the needs of communities, and to ensure the capacities of frontline services to deliver on those needs. In reviewing some of the blocks and deficits raised in our current health systems, we concluded that PRA does have a role to play in improving transparency, improving dialogue between rights holders and duty bearers, and establishing platforms for feedback and consultation.
This was a unique opportunity to bring together and build synergies between two bodies of work, on PRA approaches and on social accountability. It also raised the potential for PRA approaches to position our engagement on accountability within a dialogue between communities and their frontline health workers, for both to listen to and engage with the realities and experience of the other. We already have evidence, in the work of the pra4equity network published on the EQUINET site, that this improves local service quality for both health workers and communities. The question we are yet to test, and will be exploring in our follow up work, is whether this shared power is able to address imbalances in institutional resources and power within the health system, so that the resources, skills, commodities and authorities reach the primary and community level services, where they are most needed.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on the issues raised in the oped can be found in the report of the meeting and other publications on the EQUINET website at www.equinetafrica.org and in the COPASAH website at www.copasah.net
At the 3rd Global Forum on Human Resources for Health, Recife, Brazil, November 2013 a group of civil society organisations and regional networks produced a statement of commitment on the key role of health workers in universal systems. The statement from EQUINET, European Public Health Alliance, Health Poverty Action, Health Workers for All and All for Health Workers, Latin-America Association of Social Medicine ALAMES , Medicus Mundi International Network MMI, People’s Health Movement PHM, Public Services International PSI, The Centre for Health Sciences Training, Research and Development CHESTRAD and WEMOS is shown below.
The health workforce crisis remains a core barrier to achieving the Millennium Development Goals (MDGs) for health with only 31% and 12% respectively of 75 Countdown countries likely to attain MDGs 4 and 5. Despite donor and country commitments at the 1st and 2nd Global Forums on Human Resources for Health, the global health workers’ shortage persists. Of the 57 countries identified as falling below the WHO target only 19 have seen an improvement in their aggregate health worker density. Earlier commitments to increase domestic resources or external aid, as well as implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, remain largely unfulfilled.
National and international funds have been channelled to strengthen health workforce programs, like task shifting and the scaling-up of community health worker’s programmes. However, too little investment has been targeted at the recurrent costs of health workforce development, for instance on salaries, education and social protection measures for health workers. The inequitable distribution of health workers through increased mobility and migration within and between countries adversely affects access to health.
Health workers and a robust health system are essential for universal health coverage (UHC), and realizing the right to health through universal health systems.
Therefore at the 3rd Global Forum on Human Resources for Health in Recife, Brazil, we, the undersigned representatives of civil society organizations hereby commit that we will:
• Help amplify the voices of health workers, especially those at the lower levels of care and support their work to influence national and global health policies and plans.
• Assist local civil society organizations to ensure their voices are heard in global and national health workforce policy discussions.
• Assist in strengthening the capacity of patient groups to advocate for equitable and quality services staffed by sufficient, competent and equipped health workers at all levels of care.
• Recognise the gender dimensions of the health workforce and champion the rights of women health workers, and
To catalyse a strong movement for health workers, we will:
• Advocate for governments at all levels to institute plans and allocate adequate resources for human resources for health (HRH) to ensure that every person has access to a trained, supported and equipped health worker.
• Press bilateral and multilateral organizations and civil society actors to increase health workforce development efforts and financing, including of national training institutions, in alignment with government plans.
• Work with training institutions, professional and regulatory bodies to achieve quality in health worker education, including on the social determinants, so that every health worker is competent to provide quality care and accountable to the populations they serve.
Strengthen the advocacy of health workers and civil society for improved infrastructure, support and working conditions
• Support the development of a strong, motivated, public workforce to counter some of the ill- effects of an increasingly globalised, inequitable and unstable economy and rapidly changing health and demographic patterns.
• Commit our own resources and expertise to assist in converting HRH policy and plans into action.
To ensure accountable HRH systems at national and global levels, we will:
• Work with governments, the Global Health Workforce Alliance, the World Health Organization, and other stakeholders to develop mechanisms to measure progress towards improved and equitable access to competent health workers
• Monitor and report on progress of public HRH commitments made by global actors and governments.
• Assist citizens and health workers in developing strategies to enhance accountability of national and global actors and challenge inequitable policies that impact on HRH development.
• Increase transparency of our programmatic and technical contributions to national HRH strategies and attempt to reduce onerous reporting requirements placed on countries. We will commit ourselves to supporting a strong public sector for health workforce development and be accountable in our own funding and technical programs to mitigate the ‘internal brain drain’ from the public to the private sector.
We will hold donors, government and multilateral actors accountable to:
• Ensure that economic governance arrangements and fiscal space enables the development of a strong national health workforce as a long-term investment in the wellbeing of the people and the economy of a country. The return on investment to employ a health worker is many times higher than to bail out a bank.
• Provide the leadership, resources and stewardship needed to fulfil commitments made to urgently and effectively address the health workforce crisis and ensure improved and equitable access for every person to competent health services.
• By 2015, develop, finance, and implement HRH action plans, including strengthening national training institutions, with concrete targets and integrate them into national health plans.
• Ensure that health workers and civil society organizations are active partners in the health workforce policies, planning and development.
• Promote equitable access to health care by investing especially in health workers at primary and community levels and in community structures to facilitate citizens’ voices.
• Improve investment in health workforce development, including salaries and social protection, and in national training institutions in order to rapidly increase numbers of HRH.
• Assist in development of robust HRH information systems to facilitate improved planning and management and
• Respect and implement the Global Code of Practice on the International Recruitment of Health Personnel including additional enforceable legislation and redistribution mechanisms to compensate for the international ‘brain drain’ that exacerbates global health inequalities.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
Google the words “universal health” and in under 3 seconds you’ll get 165 million results. There is a crescendo of talk on universal health coverage. But has it been translated into terms that can engage social debate? The two editorials in this month’s newsletter and several of the papers suggest that such debate across all of society is critical, given how deep the consequences for society of the choices made. In the first editorial, Latin American social medicine and health scientists warn of the negative impacts of segmented insurance options. The second editorial, drawn more from African experience, argues a similar case. Both urge for exploration of tax funding, particularly given that universal systems are a right of all citizens not a benefit of particular employees or contributors. There are clearly debates and choices- are they reaching the people who will be most affected by them?
ALAMES and CEBES, in the framework of the Second Brazilian Congress of Policy , Planning and Management in Health of the Associacao Brasileira de Saúde Coletiva (ABRASCO) affirm that the path to full exercise of the right to health for the peoples of Latin America involves building, strengthening and developing universal public health systems (the ‘SUS’), as opposed to the campaign launched by international financial institutions and neoliberal governments around ‘universal health coverage’ based on the expansion of different forms of insurance, with a limited package of services for the poor and through promoting private investment in health.
This position is based on the following considerations:
• Universal health care systems are expressions of public and social commitment in each country to implement the principles of universality, equality, integrity and non-discrimination in relation to peoples’ health needs. They are part of state policies aimed at ensuring social rights.
• A single universal and public health system (a national health service) contributes to the implementation of universal policies, in the context of social and human development, that break with the social inequalities and inequities that are inherent in the logic of the market. Their management and financing can be sustained through fair tax policies that promote a fairer distribution of wealth.
• The neoliberal reforms in various countries in the region to date demonstrate that systems of health insurance based on targeting and limited service packages have deepened social differences in care by placing at the core of their design alleged financial constraints and greater private sector roles in health services.
• The momentum that agencies, foundations and corporations are giving to the debate and implementation of so-called ‘universal health coverage’ is an expression of an interest in locating health as a key field of capital accumulation. This can rob countries of resources that are vital for health and reproduces injustices and inequities in health care.
We should be alert to the efforts being made to deepen exclusionary insurance systems and loss of health rights in Peru, Colombia and Mexico.
We call on the Latin American and global movement for the right to health to express their rejection of deepening processes of market insurance and privatization that are advancing right now in Peru, Colombia and Mexico.
• In Peru, using a questionable granting of legislative powers to the Executive Branch to drive the process that bypasses the Congress, the Ministry of Health and Ministry of Finance intend to introduce new laws that seek to deepen market participation in the health sector through the promotion of public-private partnerships, contracting of services and deregulated insurance. This lowers the possibility of equalizing the access to comprehensive health care and social security that only a third of Peruvians currently enjoy. The first laws passed under these legislative powers have violated the labour rights of health workers, undermining their security of pay, with further uncertain implications. This is despite a constant demand from social movements and professional associations in health in most parts of the country to build a reform based on universal principles.
• In Colombia, universal coverage based on insurance has had disastrous consequences, with the collapse of national insurance funding declared by government itself to be a national health emergency. Despite this, the reform initiated today merely changes names on the same entities and processes that have for twenty years undermined access to health, blocked avenues for claiming the right to health and subordinated claims on the right to health to macro-economic considerations. The reforms do not address any of these underlying factors and despite the flow of funds, the health system is literally dismembered. The fact that health is only a business for insurance companies has been associated with a rise in corruption and paramilitarism in the sector.
• Mexico is currently presented as a promising example of neoliberal reform. However, claims in the reform of having achieved universal coverage hide the fact that a significant share of the insured population has no real access to care, that there has been a reduction in benefits covered by insurance, and that the introduction of private insurers seeking to make profits in the sector is raising the risk for millions of people of losses in social security health benefits.
All countries need universal health systems.
• Recognizing the complexities and particularities of each country, it is urgent that social movements drive and ensure the formation of Universal Health Systems, understood as an inalienable responsibility of the state and society, to build institutions that guarantee the right to health universally and equally outside the logic of the market and profit. This requires progressively overcoming the fragmentation of sub-systems through innovative management and through a commitment to sustainable financing.
• We recognize the national health system (the ‘SUS’) in Brazil as an example of social momentum based on universalist principles, and call for its defense and for deepening it in all necessary areas. We especially support popular demands to allocate 10% of the gross federal revenue to support the expansion of the SUS and to limit the growth of private services. We defend Brazil's SUS as a source of inspiration and an example of the real possibility of reversing the expansion of an individualist model of health insurance that breaks the concept of and responsibility for public health.
• In this regard we urge the Brazilian government to publicize and defend the SUS internationally, presenting it as an alternative to guarantee the right to health of the people.
For the right to health, universal public health systems for all countries of Latin America!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For the original declaration in Spanish see http://www.alames.org , entry two for October.
Social health insurance schemes, introduced in the name of universal health coverage (UHC), are excluding the majority of people and leaving the poor behind. So argues a new report from Oxfam ‘Universal health coverage: why health insurance schemes are leaving the poor behind’.
The growing momentum for universal health coverage (UHC) is certainly cause for celebration. But in some cases health financing reforms are widening inequality by prioritising already advantaged groups in the formal sector and leaving the most poor and marginalised people – especially women – as last in line to benefit.
This raises the question of why there is an almost exclusive focus on contributory-based health insurance schemes as the way to achieve UHC. Although no country in the world has achieved anything close to UHC using voluntary insurance, private and community-based voluntary schemes are still being promoted by governments and external funders. India’s voluntary India’s voluntary Rashtriya Swasthya Bima Yojana insurance scheme for people below the poverty line is widely praised as a success. However evidence cited in the Oxfam report indicates that the scheme offers limited financial protection against impoverishing out of pocket spending on health and has skewed public resources to curative rather than preventative care.
For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries. However attempts to replicate the same kind of employment-based models in low- and middle-income countries have proved unsuccessful. Even high-income countries struggled to achieve rapid scale up via SHI. In Germany UHC took 127 years to achieve using a SHI model. Surely people in low and middle income countries (LMICs) should not have to wait that long!
In low and middle income countries SHI schemes are typically characterised by large-scale exclusion. Ten years after the introduction of SHI schemes in Tanzania, according to a National Health Insurance Fund 2011 report, coverage had reached only 17 per cent. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans. Ghana’s National Health Insurance Scheme (NHIS), widely promoted as an SHI success story, covers only 36 per cent of the population.
Hopes that insurance contributions from those outside of formal employment would raise significant revenue have not been realised. In Ghana, cash premiums paid directly by those in the informal sector contribute just five per cent towards the cost of the NHIS, that also draws funds from earmarked tax and other sources. Governments also face huge bills to cover the SHI contributions of their workers. According to 2010 National Health Insurance Fund Tanzania and WHO evidence cited in the report, the Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.
Instead of importing inappropriate health financing models from high-income countries, governments in LMICs should surely learn from the increasing number of home-grown UHC success stories in other, more comparable countries.
The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency and not on employment status or financial contributions. While their specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. Crucially, the 2009 report of a Task Force on Global Action for Health System Strengthening found that the only low-income countries to achieve universal and equitable health coverage did so by relying mainly on tax financing. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population.
The growing momentum for UHC is welcome, exciting, and challenging. UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. But rather than focus efforts on collecting contributions from people who are too poor to pay, governments and external funders should focus on financing options that will work to deliver universal and equitable health care for all. The preoccupation with health insurance as the ‘default’ UHC model has left the crucial question of how to generate more tax revenues for health largely unexplored. This blind spot should be urgently addressed.
At its core, UHC is about the right to health. This means moving away from the idea of an employment or contributory basis for entitlement. People must be entitled to receive benefits by virtue of their citizenship and/or residency and not because they are formally employed or have paid to join a scheme. Women and men living in poverty must benefit at least as much as the better off every step of the way.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the Oxfam report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ at www.oxfam.org/uhc
Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to implement equitable pathways towards UHC by including appropriate targets and measures in the post-2015 development framework. These are the main messages of a joint report titled ‘Universal Health Coverage: A commitment to close the gap’ launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO and available at http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage.
Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. Research implemented for the report reveals that the deaths of 1,8 million children under-five and 100 000 mothers could be averted each year by eliminating wealth related inequities that occur within countries in the coverage of essential maternal and child health interventions in 47 of the 75 countries where more than 95% of all maternal and child deaths occur (http://www.countdown2015mnch.org/). If in 2013 to 2015 all groups were able to reach the coverage levels of the highest fifth of people by wealth, this would reduce maternal and child mortality by almost one-third and one-fifth respectively.
We present evidence in the report that more equitable health financing saves lives. Pooled funding comes from prepayments and pooling makes it available to distribute to those with higher need. If the share of health financing that is pooled were to increase by ten percentage points, while keeping total health expenditure constant, we estimate in the report that there would be fifteen fewer deaths in children under five years of age for every 1000 live births in the same 75 countries on average. This could enable thirteen countries that are currently off-track to achieve their Millennium Development Goal (MDG) 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, the reduction in child deaths may be even greater.
It is thus possible to make huge improvements in health outcomes and access to health care. It is possible, for instance, to reduce by almost half the number of children who die each year when compared to the rates in 1990. Despite this, too many people are denied their right to health. In 2012 for instance, 6,6 million children died before the age of five and most of these deaths could have been prevented. High levels of out-of-pocket payments (cash at point of care) for health care act as a barrier for poor people to access the care they need or can lead to an increase in poverty due to health spending. About 150 million people are estimated to incur catastrophic (impoverishing) expenditures for health care each year. This is a scandal that must be addressed.
The health system’s response to this challenge must be Universal Health Coverage – which we define as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement the policy reforms for UHC.
In the report we identify a number of policy lessons for equitable pathways towards UHC in low- and middle-income countries, particularly in relation to health financing. One policy lesson is that countries increase equitable funding for health through mandatory, progressive prepayment mechanisms, including revenues from taxation, and eliminate out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. A universal benefit package should be designed for all, and delivered in a manner that meets the needs of the poorest and most vulnerable in society, through strategic purchasing of services and through providing incentives that ensure health providers promote quality of care. The policy lessons point to the importance of taking a ‘whole-system’ approach to UHC, and for coordinating reforms across health system building blocks such as financing, health workers, commodities, social participation and others. To overcome pervasive inequities in the coverage of quality health services and to ensure that people are not impoverished from health spending we need to also act on the wider social determinants of health. Political will and strong mechanisms for effective accountability are critical for implementing the measures needed for equitable pathways towards UHC.
As the MDGs have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, with clear indicators of and targets for such measures that strengthen health systems and close the equity gap.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed visit www.savethechildren.org.uk/resources/online-library/universal-health-coverage and www.equinetafrica.org
As she walks away from the clinic Sarah’s back is straight and she has a smile on her face. She has heard confirmation from the nurse that there have been no cases of cholera in her area this year, unlike in previous years, when many died of the disease. She can’t wait to get back to tell the others - “we did it!”
This is not a fiction. It was achieved, for example, in parts of Lusaka district, Zambia, after the joint activities of health literacy facilitators, communities and health workers. At a time of scarce resources and mounting disease we may overlook that our health systems have one of the most critical resources in abundance - people.
The power and ability that people and social groups have to know, act on and direct resources towards promoting health and addressing their health needs are key contributors to health. Health systems that are organised around social participation and empowerment create powerful constituencies to protect and advance public interests in health. Aware and organised communities support early detection of and response to problems and uptake of services, reducing the need for costly treatment of advanced disease. Despite high levels of poverty, East and Southern Africans have high literacy levels and strong social capabilities and social networks that are all assets for health.
But do we effectively tap these assets? We praise the benefits of social participation in health, but do we really practice it? Are there national scale programmes for ensuring that the population is not only literate but ‘health literate’? Do we recognize in law and invest in the capacities and functioning of mechanisms for dialogue and joint planning by health workers and communities as a core part of health systems? Do we ‘lecture’ to and ‘mobilise’ communities, or work in a way that builds on their experience and facilitates their own learning, reflection and collective action?
Studies carried out in the pra4equity network in EQUINET over the last decade suggest that our health systems don’t have strong or sustained investment in these social roles and mechanisms, give limited incentives for health workers to put time into them, have top down planning and weakly address barriers and facilitators to health service uptake and adherence, leading to resource inefficiencies.
Investing in health literacy should, however, be as central to our health systems in the region as supplying medicines or training health workers. Health literacy is a process that empowers people to understand and act on health information to advance their health and improve their health systems. It isn’t only about sharing information, however. Literacy implies functional capacity. Health literacy draws on local experience, encourages reflection on that experience, identifies shared problems, and draws in new information on those problems for community level diagnosis and action on health.
Work on health literacy (HL), co-ordinated through TARSC, has been implemented in the pra4equity network in EQUINET over the past five years. HL addresses the major health issues faced at all stages of life, and includes information on how the health and other sectors are (or should be) organized to address these issues and on social rights and organization. Health literacy was initiated in Zimbabwe, where the Community Working Group on Health now covers nearly half of all districts with the programme. It then spread to Malawi, Botswana, Zambia and Uganda. After pilot work in Uganda in 2011, with Cordaid support, five civil society organisations formed a network co-ordinated by HEPS Uganda to extend health literacy into new areas and communities. Organisations such as the National Forum for People Living with HIV and AIDS (NAFOPHANU) are building health literacy onto work on treatment literacy, with actions taking place on prevention of malaria, typhoid and brucellosis. In Zambia, the Lusaka District Health Office first implemented health literacy in selected communities in the city, building on participatory work strengthening communication between health workers and communities. After realizing the impact the programme had achieved in reducing diseases such as cholera, the Ministry of Health officially adopted the programme for national scale up in 2012.
The work in the past year has highlighted the potentials of scaling up HL and the challenges to be addressed.
HL brings together a wide range of stakeholders, including health workers, community leaders and members, youth and vulnerable groups. This demands facilitation that is sensitive to inequalities in voice and power in these groups. However the discussion and analysis of health problems and their causes across these groups can lead to a deepening understanding of the different experiences and views in communities, and build shared decision making that leads to more inclusive action. CEHURD HL sessions with youth and health workers in Uganda revealed for example a perception amongst students that health workers only interact with students when the school administration wants to identify those who are pregnant for expulsion. Dialogue between health workers and youth in the HL sessions helped to strengthen their mutual relations and opened discussion of ideas from each on how to strengthen youth friendly health services. In Zambia, the HL programme has overcome past suspicions and built communication between communities and health workers, with both working together and with local authorities to clear waste dumps that had grown over years, to improve safe water and sanitation, food hygiene and other public health issues. Healthy environments are often identified as high priority by communities.
From the work in Zambia and Uganda we have seen features of HL programmes that would seem to be essential for any efforts to scale HL to national level. They include national political and technical support; a core of experience and capacities in participatory reflection and action; HL materials that integrate regional good practice with national content; and a co-ordinating group that is able to plan, review and support the horizontal roll out of HL activities, mentor and evaluate the work and share learning. Perhaps the most central feature are young, old, male, female, urban and rural HL facilitators that recognize local knowledge and creativity, are able to use participatory methods to support people to explore, discuss and plan their health actions, and that are evidently passionate about health! The work in Zambia has shown that the best way of scaling up is through a bottom up and horizontal roll out, where communities can take leadership and facilitators in existing areas can mentor in new areas. This can take time, but it also yields more sustainable results.
Like any element of a functioning health system, building a health literate population calls for policy support, planning, resources, organization and capacities to be applied. Surely an informed, active and organized population is too valuable an element of the health system to leave to ad hoc inputs and external funding? Its time all countries in the region followed Zambia’s example and adopt health literacy as a core activity of national health systems!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org