Much attention has recently been given to raising an adequate level of resources for health, especially to achieve goals of universal coverage. But if these resources are to reach those who need them, we also need to allocate resources fairly. This is particularly important given the very different access different social groups have to health care. In spite of the recognition by many countries for needs based resource allocation, including my own country, Zambia, our experience suggests that we still face many obstacles to put this intention into practice.
Data in Zambia shows, for instance, that although the allocation formula was radically revised with policy support in 2004/5 to incorporate deprivation and population weights, the new formula has still not been fully implemented. We realize that applying a formula to redistribute resources on the basis of need is not just a technical issue, but has significant political implications. We found in our research in 2007 and 2010 that applying a formula that takes deprivation into account in Zambia implies a loss of over 30% of revenue for the wealthiest districts, if immediately implemented. This raised considerable resistance towards an immediate implementation of the revised formula from key stakeholders such as district health management teams, as well as from the political leadership in the affected districts.
Allocating a fair share of health care resources to those with greatest health need is not only an ethical issue. It also makes public health sense to reduce the burden of disease, improve the uptake of health care and reduce avoidable inequalities in health. It makes economic sense in terms of poverty reduction and improved productivity, Needs based allocation of resources combines with other elements of priority setting in health, including the setting of basic entitlements and ensuring the effectiveness of health interventions. So why have we faltered in achieving this goal?
A common explanation is that the available resources are too limited to allocate equitably. How do you distribute an unfair total amount fairly? Prior work in EQUINET has shown that it is easier to reallocate new resources equitably when budgets are increasing than to redistribute static or shrinking budgets. In 1995 to 2006 in Zambia, according to the Ministry of Health, the total health expenditure per capita ranged from $17.50 in 1999 to $58.00 in 2006, but the government share was only between 8 – 14 per cent of this. The resource allocation formula was applied only to the recurrent budget, and between 2004 and 2009, the per capita recurrent budgets to districts ranged between only US$1.50 and US$ 4.14. How much impact can be achieved on inequalities in access and coverage health when such limited resources are being reallocated? So even though fair resource allocation is a demand that arises from the scarcity of health care resources, it is itself limited by that scarcity. Breaking this vicious cycle would be important for equity.
It is thus a problem that the significant resources that come from external funders are not themselves subject to a needs based resource allocation formula. National Health Accounts data in Zambia show that 44% of health finances are spent on district health services comprising the district health management offices, district hospitals and health centres, and 20% on provincial and tertiary facilities. Of these expenditures, the share of external funding was 42%, and funding earmarked for HIV/AIDS made up almost 25% of this. These funds are disbursed as vertical funding for specific targeted programmes and purposes. The funds are distributed primarily to achieve geographical coverage, with less concern for equity, as has been the case for Prevention of Mother to Child Transmission and general ante-retroviral treatment programmes that command significant resources.
While the adequacy of funds available for reallocation and the segmentation of external funds may weaken resource allocation, there is a deeper issue: Priority setting - and thus allocation- has not been strongly grounded in ethical values or social norms. It makes a difference whether financing decisions, including those related to the allocation of resources, are based on the pursuit of equity and social justice, on utilitarian issues of efficiency, including economic efficiency, or on an egalitarian liberalism that aims for steadily improving coverage, complemented by individual actions to enhance uptake.
The lack of a shared ethical premise supporting resource allocation may be the most significant constraint to advancing the fair allocation of resources. Experiences of resource allocation in Zambia suggest that reforms aimed at enhancing fairness in resource allocation falter more easily when they are not protected, or demanded, by a strong expression of social norms and values. It could thus be the key factor leading to uncertainty, and sometimes failure to implement resource allocation in a consistent and committed way for the effective strengthening of the health system in low resource settings. So while we build the technical measures and institutional capacities to more fairly allocate the resources for health, we also need to ensure that the ethical foundation it is based on is clear, shared and strong enough to sustain implementation on the face of the other blocks we face.
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, and reports on equity in resource allocation please visit the EQUINET website at www.equinetafrica.org.
Editorial
This month's editorial draws our attention to the shift the profile on universal coverage has brought in the international debate on global health. Much of this dialogue on universal coverage has been focused on financing issues. However universal policies cannot be only technical, or financial. A December 2010 World Conference on Universal Social Security Systems in Brazil put it simply - universal policies are the means to deliver on rights based guarantees that citizens are entitled to and that states have a duty to ensure, including access to health care. At national and global level there is a huge gap in how this is delivered on. Researchers from Africa, Asia and the Americas observed in a statement at the final plenary of the first Global Symposium on health systems research: “Equity is the central goal. Universal health coverage is the means of achieving equity”. As experience has taught in many places, closing this gap, nationally and globally, calls, beyond technical options, on political leadership and social power and action. What we say and do within and across all our different constituencies will be pivotal in realising universal policies in health. We wish you a safe, healthy and peaceful new year and look forward to our interaction towards equity in 2011.
Today, over 100 million people are cast into poverty each year because they have to pay for health care services “out of pocket”. The lack of adequate social protection in health and the lack of health care coverage in case of ill health, plays a decisive role in the scandalous inequity in access to proper health care - challenging all countries, not least those in Africa.
On November 22-23, 2010, on the occasion of the presentation of the World Health Report (WHO) Report for 2010 on ‘Health Systems Financing – the path to Universal Coverage’, the German Federal Government, together with the WHO, convened an International Conference in Berlin. The gathering was attended by almost thirty Ministers of Health from all over the world together with government officials, politicians, some researchers and a few non government organisations.
Everyone agreed on the aim to achieve universal coverage. Remarkably the model that was presented by WHO concerning this doesn’t speak about just going for “some coverage” or essential minimum packages for the poor, but demands from all countries to do their utmost to set up pooled funds that cover three dimensions: expanding the number of people covered, expanding the scope of services and reducing cost sharing (direct payment such as user fees).
WHO General Director Dr Margaret Chan who addressed the audience at the beginning raised the demand to get rid of user fees, because "user fees punish the poor". All countries have people who are too poor to contribute financially to health care. They need to be subsidised from pooled funds, generally tax-based health systems. Out of pocket payments have to be reduced by promoting prepayment and pooling systems (tax-based or mandatory social heath insurance). All agreed that there is no ‘silver bullet’ that serves as a solution for all countries. There is no global scheme that has to be "adopted" by all countries, but the need is to “adapt” a way to move forward in the three dimensions (population covered, the scope of services expanded and cost sharing reduced) at national level. Universal coverage cannot be achieved by connecting access to health care with individual purchasing power, but only by solidarity. This means that people who are richer also contribute to the health needs of those who are poorer. By articulating these principles, WHO has opened space for national adaptations. This provides civil society organizations with the opportunity to continuously engage and challenge their governments on their delivery on these principles, such as what they are doing to expand the scope of services.
With exception of few participants nobody mentioned private companies as relevant actors. Achieving universal coverage requires the strengthening of health systems. Ensuring affordable access to health was ultimately seen to be a public responsibility and not to be relegated to private insurance companies. Participants from Africa reiterated the 2001 Abuja Declaration to allocate at least 15% of annual government domestic spending to the improvement of the health sector.
To ultimately realize the right to health, governments have to create the needed fiscal space. In this regard, the 2010 World Health Report mentions as possible new sources of revenue: a special levy on large and profitable companies, a currency transaction levy, a financial transaction tax, and the so-called sin-taxes (alcohol, tobacco). No reference was made to ‘for profit Public-Private-Partnerships’.
In the context of global responsibilities, the report states that countries providing overseas development aid should do more to meet their international commitments, by providing a more predictable and long-term flow of aid.
We should not be surprised to find that a ministerial conference also produces nice and bubbly words. Some of the presenters mixed up risk-sharing with solidarity-actions. And when it came to actions many preferred to be vague in their statements. Nevertheless, there is an interesting shift in the international debate on global health. Thirty two years after its first use, the concept of ‘Health for all’ is back on the agenda.
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 2010 World Health Report, www.who.int/whr/2010/en/index.html , the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/
When the first Global Symposium on Health Systems Research, held under the theme "Science to Accelerate Universal Health Coverage" ended a week ago, after hearing the concluding statement (included in this newsletter), many people went back to heavily fragmented health systems with very different experiences of access and service for different social groups. The two editorials in this newsletter take the issue of universal coverage to the real time of the policies and interests being negotiated at country level in South Africa. The discussion by Di McIntyre on national health insurance in South Africa points to the importance of perspective and clarity on the long term implications of choices being made in the current debates on national health insurance; while the report by Jacky Thomas of SANGOCO points to the measures civil society are taking to move from issue specific to common platforms, to challenge unhealthy divisions in systems and in society. Together they raise the challenge of twinning perspective with knowledge, and knowledge with organisation, to build universal, integrated health systems.
There has been considerable media debate about the proposal to implement a National Health Insurance (NHI) in South Africa. This editorial attempts to unpack the options that face South Africa by painting scenarios of where we could head. These scenarios focus on two key elements of current debates: firstly whether this major health system reform will be ‘affordable’ and ‘sustainable’; and secondly, whether we are able to achieve an integrated health system or are destined to continue to have a highly fragmented health system.
It appears that we have essentially four scenarios for the South African health system:
1: the ‘no go’ option
2: the unsustainable, ‘divided forever’ option
3: the sustainable, ‘second rate’ health system with fragmentation option, and
4: the integrated, ‘healthy nation’ option.
The starting point for considering what health system changes would be helpful is to be clear about the path on which we are currently set. Our health system is heavily fragmented. A key division is between those that are medical scheme (private insurance) members (16% of South Africans) and those that are not (the remaining 84%). Health service access is very different for these two groups.
Our current health system is ‘second rate’ in many ways. For increasing numbers of families, medical scheme cover is just not affordable. In the early 1980s, medical scheme contributions for a family took about 7% of average formal sector wages and salaries. This had increased to a staggering 30% by 2007. The challenges facing the under-resourced public health sector are well known. There is no question that change is needed, and needed soon.
If this is not the direction in which we want to head, where do we want to go? Some argue that we need to pursue ‘social health insurance’ (SHI) – the ‘divided forever’ scenario. It is proposed that everyone who is formally employed and who earns more than the income tax threshold should be required to have medical scheme membership. The problem is that this scenario is a very expensive option. R1 in every R10 spent in South Africa would have to be spent on medical schemes alone, for the benefit of less than 40% of South Africans.
This scenario is called ‘divided forever’ because it will entrench a fragmented two-tier system between the haves (those that have insurance cover and access to any health service they desire) and the have nots. Proponents of this path argue that SHI is a logical step towards universal coverage. But experience in other middle-income countries, notably many Latin American countries, shows that it is very difficult to overcome the divisions created by SHI once they have been entrenched.
Many believe that, instead, an integrated system is needed. What is so prized about such a system? The global call for progress to universal health systems is based on the following two principles:
That no one should have their livelihood threatened because they have to pay for health care, i.e. that all citizens should be provided with financial protection from health care costs; and
That all citizens should be able to access the health care they need.
In order for these principles to be realised, an integrated health system is needed. It simply doesn’t work to have all the richer, healthier people contributing to and benefiting from one funding pool (or worse, a number of fragmented pools) and all the poorer, sicker people in a completely separate funding pool. You end up having a lot or most of the money for health care going to serve a relatively healthy minority and very little money available to provide health care for those who bear most of the burden of ill-health.
One way of pursuing an integrated system is to attempt to cover everyone using the current medical scheme model. However, this would result in more than R2 in every R10 that is spent in South Africa going to cover the entire population via medical schemes. For this reason, this scenario has been called a ‘no go’ – no country in the world has such a system and it is not something worth even considering for South Africa.
I believe that it is possible to achieve an affordable or sustainable and integrated system. Everyone agrees that the first step is to substantially improve services in the public health sector. There is much to be done, both in terms of improved management and resourcing. Some say: “why not just focus on improving the public sector”. The most valuable and scarce resource in the health sector is that of health professionals. We could be utilising the human resources we have far more efficiently and equitably than at present. However, this is only possible if we have a large integrated pool of public funds that can be used to purchase health services from public and private providers for the benefit of all South Africans. It is not simply a matter of focusing on improving the public sector. We need to change the way in which health services are funded if we are to effectively use the health professional resources in South Africa so that everyone can access health services on the basis of their need for care and not on the basis of their ability to pay.
Ensuring affordability in a universal health system requires other changes. Two things are particularly important. First, it is critical to have high quality primary level services and for primary care providers to determine access to specialist and hospital inpatient care. Second, we need to change the incentive structure for health care providers. At the moment, we pay private doctors and hospitals a fee for every service delivered; the incentive is to provide as many services as possible. International experience clearly demonstrates that changing the way of paying providers is necessary to secure greater value for money.
The ‘healthy nation’ scenario is what I believe public debate should focus on. Surely we can all agree that we do not want to continue on the current path (the ‘second rate system’)? Instead of saying that health system change is unaffordable, let’s focus on how we can achieve a sustainable, integrated health system that benefits all. A health system that brings our nation together rather than dividing us further.
This editorial has been modified by the author from a longer version published in the South African Independent Online media – the Mercury, the Star and the Argus. 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 the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
While individual organisations in civil society in South Africa are known for their struggles to ensure access to medicines, access to water, land shelter and other rights, September 2010 provided an opportunity for civil society across platforms and constituencies to build wider solidarity around poverty and inequality.
Since 1997, civil society in South Africa has gathered every two years to learn from each other, dialogue and debate, propose input into government policies and programmes and strengthen civil society’s role in challenging poverty and inequality. In 2010, this ‘NGO Week’ was on 20th-25th September in Cape Town under the banner of “Building Solidarity to Fight Poverty and Inequality” starting on Monday, 20th September 2010, ending with a Heritage Day Festival on Friday, 24th September 2010.
The week brought together a range of existing civil society campaigns, such as The Right to Health Campaign, The Peoples’ Budget Campaign, 16 Days of Activism for No Violence against Women and Children, Amplifying Feminist Voices and Building a Popular Education Movement. amongst others. The organisations that came together involve and work with a range of constituencies, including women, organised workers, health workers, people living with HIV and religious groups. The organisations included those that advanced issue based campaigns, like the Treatment Action Campaign, Feminist Forum, Women on Farms and the Learning Network, broad sectoral movements like Popular Education Movement and People’s Health Movement and membership based umbrella organisations like the South African Council of Churches (SACC), or the Congress of South African Trade Unions (COSATU). The gathering provided an opportunity for dialogue, self-organized workshops and sharing of case studies across the different groups, to build shared understanding on challenges and approaches to dealing with socio-economic rights. For example the campaign for the right to health, that includes the right to healthy living and social conditions and to access health care, was adopted by all groups as a common cause for all.
Over five hundred and fifty participants from civil society used the discussions and interaction to build and strengthen the kind of cross-cutting civil society platforms needed to tackle the multidimensional nature of poverty and inequality. Resolutions were made on actions that would benefit individual platforms but also have wider and more general impact, such as ensuring an enabling environment for the non-profit sector, or strengthening community action and participation around rights to health. These wider platforms call for strong networking across sectors, with strong leadership and accountable, transparent, democratic governance. Civil society organisations (CSOs) agreed that this calls for partnerships to build knowledge and learning between civil society and other institutions. Hence civil society was encouraged to partner with the twelve Higher Education and Research Institutions in the country, particularly the five in the Western Cape Province.
As a result of the deliberations of the week, the CSOs involved developed a number of resolutions on joint action (see http://www.sangocowc.org for the full resolutions). For example, as one outcome, CSOs are now interrogating and making input to the African Peer Review Mechanism (APRM) Report from South Africa. These reports have been adopted at African Union level to report on developments in governance on the continent. The CSO contribution in South Africa will feed into the draft of the Second Report on the Implementation of South Africa’s APRM Programme of Action, and through this into the wider continental discussion. Civil society resolved on a range of platforms to strengthen their role as a watchdog, to widen networks, to include champions from key stakeholder groups and to support and monitor our own programmes of action. The week ended with a cultural festival on the final day to commemorate ‘Community House’, which has a rich history as a hub of radical civil society organisations and trade unions.
The South African Non-Governmental Organisation Coalition (SANGOCO) was tasked to co-ordinate and monitor the implementation of the resolutions. SANGOCO is a coalition of civil society networks and organisations. It originated in 1997 to re-build civil society and the society at large within the context of a world where social justice and civil liberties are under attack. It aims to establish a strong and vibrant civil society that has capabilities and policy influence in the interests of people, especially poor people. SANGOCO seeks to hold government programmes and policies accountable for the extent to which they effectively serve the needs and interests of poor people. SANGOCO was mandated by the CSOs to coordinate sectoral and cross-sectoral working groups to take forward the resolutions over the next two years 2012.
It was important for us that civil society representatives from other countries in east and southern Africa participated in the events of the week, including groups from Namibia, Mozambique, and Malawi, as well as people from civil society centres as far afield as Denmark, USA and India. The lunchtime cultural events provided an interactive marketplace where people from civil society from across different countries discussed and exchanged experiences on common struggles. The South African organisations urged their counterparts in other countries in the region to also strengthen their umbrella bodies and networking on common platforms.
Poverty has many dimensions and inequality exists across a range of social and economic factors. South African civil society has recognized that while issue specific platforms help to raise profile and draw attention to specific areas of deprivation, we need to bring civil society together around common agendas to address the many dimensions of poverty and causes of inequality. Even more so do we need to bring together civil society across East and Southern Africa to tackle the much deeper levels of poverty and inequality in the region, given the degree to which our economies, societies, labour markets and trade are interlinked. The policy dialogues and debates that were held during NGO Week 2010 in South Africa have helped strengthen these cross cutting coalitions in South Africa. We hope that they spread throughout the region.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For further information on SANGOCO or the NGO Week please contact sangocowesterncape@telkomsa.net or visit www.sangocowc.org
Archbishop Ndungane, president of the African Monitor, commented after the United Nations (UN) Summit on the Millennium Development Goals (MDGs) in September 2010 on the gap between the concrete commitments made and clear plans for how they will be implemented. A bottom line for this is money.
Even before the Summit the UN Secretary-General in his March 2010 report had observed that unpredictable and insufficient international financing was blocking progress on the MDGs. Health needs alone at global level have been estimated to cost up to US$76 billion annually by 2015. The UN Non government Liaison Service reported this year that the financial deficit on resources to meet the MDGs could reach between US$324 - $336 million in 2012-2017, including a shortfall of about US$168-$180 million in official development assistance (ODA).
Which country and community you live in and what income group you are borne into affects your chances for health and for accessing the resources for health. This leads to an unacceptable global inequity. African countries, with the highest rates of mortality and ill health globally, are also most disadvantaged by widening gaps between rich and poor countries, by diminishing commodity prices and by outflows of key resources, such as skilled personnel. The financial crisis triggered by the US and European banking crisis has exacerbated this shortfall, creating a budget revenue hole of $65 billion in low and middle income countries. According to Development Finance International, aid has filled only one-third of this hole in revenue.
So African countries and people have a significant interest in debates on how global commitments will be financed.
ODA has been one way of releasing immediate resources for global priorities. Almost all low income countries could absorb much more aid without negative economic consequences, whereas they have much less space to borrow or to raise taxes. Attention has thus grown on how far the international community has fulfilled long-standing aid promises and improved aid effectiveness. A 2009 Mutual Review by the UN Economic Commission for Africa and OECD noted the welcome increase in commitments made at G8 and other summits. These include commitments to 0.7% of Gross national income to ODA in 2002; to an increase of $25 billion annually in aid to Africa in 2005; to an additional US$60bn to fight infectious diseases and strengthen health systems in 2006; to US$22bn to raise productivity of smallholder farming and $30bn for climate change mitigation in 2009; and to support for Universal access to HIV prevention and treatment. At the 2010 UN Summit an additional $40bn was pledged for the Global Strategy on Women’s and Children’s Health. The UN ECA and OECD report also noted that while progress was being made to the target of 0.7% ODA, it was still at 0.43% of combined GNI, with improved ODA largely related to debt relief flows in 2005/6. OECD reports indicate that less than half the $25bn promised in 2005 has been delivered and shortfalls exist on other pledges made.
The UNECA / OECD report points out that the most significant source of development finance in Africa is domestic revenue, making up 75% of its development financing. It indicates therefore that for African countries to raise the domestic revenue to deliver on development commitments, multilateral trade negotiations need to yield more substantial and faster improvements in market access and returns, and progress needs to be made in investment in areas such as energy access, technology transfer, infrastructure and climate adaptation. A further response to the resource gap is to reverse the net transfer of financial resources out of Africa. For example, Global Financial Integrity (2010) estimated that between 1970 and 2008 the outflows from Africa due to trade mispricing alone were as great as ODA inflows.
Unpredictable, inadequate aid flows and the slow progress in improved returns from the global economy have raised doubt whether business as usual will be enough to raise the funds needed to meet global goals. President Nicolas Sarkozy of France and Prime Minister Jose Luis Rodriguez Zapatero of Spain both raised in their addresses to the 2010 UN Summit the need for new approaches to financing global commitments, especially through a new tax on international currency transactions. President Sarkozy stated in his address to the Summit: “We can decide here to implement innovative financing, the taxation of financial transactions. Why wait? Finance has been globalized. Why shouldn’t we demand that finance contribute to stabilizing the world through a minuscule tax on each financial transaction?”
When a similar call was made by Nobel prize-winning U.S. economist James Tobin in 1972, and by UN panel chair Ernest Zedillo in 2000, it met strong opposition. However since then, a range of innovative development financing options based on levies have been established: UNITAID, an international facility for the purchase of drugs to combat HIV/AIDS, malaria and tuberculosis launched by Brazil, Chile, France, Norway and the United Kingdom in 2007, has raised US$1.5 billion in three years, 65% of which came from a micro-tax scheme on air tickets. In 2009, as a result of a Task force in Innovative Financing, a number of new facilities were introduced, including a US$1 billion expansion of the International Finance Facility for Immunisation (IFFIm); a new mechanism for making voluntary contributions when buying airline tickets, expected to raise up to US$3.2 billion by 2015; US$360 million worth of debt conversions in the Global Fund's Debt2Health Initiative; a VAT tax credit pilot scheme called De-Tax, expected to raise up to US$220 million a year in VAT resources; and a commitment to explore a second Advance Market Commitment for life-saving vaccines. In March 2010, the UN with country partners and the American Society of Travel Agents, launched ‘MASSIVEGOOD’ an offshoot of UNITAID, that provides travellers in the United States the option of making a voluntary contribution of up to $50 when purchasing tickets, booking a hotel room or renting a car online. This is expected to bring in up to US$1 billion in four years to support treatment for children with HIV, for tuberculosis and insecticide treated bed nets. Such funds bring significant new resources, and raise challenges for how they support the financing of systems and improve the production of domestic revenue.
These financial innovations, the impending deadlines for action on global commitments and a funding gap that is not being met through current approaches has brought new demand for the introduction of an international multi-currency transaction tax. Sixty countries in the Leading Group on Innovative Financing for Development (LGIFD) support it, and the potential financial contribution is significant. Financial flows have increased sevenfold since 2000, with a volume of transactions worldwide of about $3.6 trillion daily for foreign exchange, of $210 billion daily for bonds and $800 billion for stocks. At a session on 21 September at the Summit, Bernard Kouchner, foreign minister of France, held up a five-cent coin saying: ‘This will be the tax on a 1000-dollar transaction. It is impossible not to accept that. Especially when you have in mind that the result of such a tax would be 40 billion dollars a year..'.
An approaching deadline to account for global goals and an economic crisis may be a challenging situation for global social commitments, but it may also be an opportunity to implement the possible - to advance sustainable and equitable ways of financing them.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on this issue and the UN 2010 Summit can also be found in the Health Diplomacy Monitor www.ghd-net.org.
The editorials in this newsletter comment on two global events, two months apart. The first is the 18th International AIDS Conference held in Vienna in July, and the second the UN Summit on the Millennium Development Goals being held in New York in September. Both conferences have triggered a wealth of ideas, debates and publication, some of which we include in the newsletter. Both deal with heads of state commitments, made in prior conferences: The first to universal access to treatment for AIDS, the second to the eight MDGs. In the first editorial Sharonann Lynch reminds that after the “talk and spectacle”, many conference participants go back to work in impoverished realities. She suggests concrete people-centred strategies for delivering on treatment commitments in these conditions. In the second, Ranga Machemedze asserts that many living in the most impoverished realities have not yet benefited from the MDGs, even when progress has been made at national level, and asks what the UN Summit will do to close the gap. For both, the test of the global talk is the concrete local improvement it produces for the most disadvantaged communities.
After the 18th International AIDS Conference (IAC) has wound down in Vienna, the word in the hallways is that the science is in: earlier initiation of treatment and improved antiretroviral (ARV) drug regimens are better for individual patients and communities, and may even ultimately reduce transmission of HIV. Some of the new data presented at the conference come from MSF's project in Lesotho, where I worked from 2006 to 2009. In a two-year study of 1,128 patients from rural Lesotho, where the government has adopted new World Health Organization (WHO) guidelines, patients starting treatment earlier (at CD4 count <350) were 70% less likely to die, 40% more likely to remain in care, and >60% less likely to be hospitalized compared with those started when their disease was already advanced (CD4 <200).
After all the talk and spectacle, many of us—people with HIV/AIDS, clinicians, researchers, and activists—will have to go back to reality: to townships and rural villages still ravaged by the virus; to congested clinics with waiting lists for treatment; and to rich country capitals where donors are ignoring the science and retreating from their commitment to fully fund universal access to treatment, telling us to get used to this new reality—we are in the midst of global economic recession, after all.
At the conference there was a lot of talk about cost-effectiveness and efficiency as a means to mitigate funding shortfalls. Sure, we need to avoid waste and the obscene number of consultants and reports that sit on shelves in Washington, Geneva, and London. But how do the actual people fit in to these crude calculations? What is the cost-benefit to their lives, families, and communities?
We are advocating for a different vision: for patient-centered efficiencies that will increase access to treatment and reduce the burden on patients in taking toxic drugs, reporting excessively to health facilities, and traveling great distances to seek care. We also want efficiencies to reduce the requirements on the health system, for example through task-shifting and community-based, out-of-facility approaches to drug dispending and social support. And economists are telling us these sorts of efficiencies will even be cost-saving in the long run.
So how do we build on Lesotho's example and get more patients on treatment? Here are some forward-looking ideas that could change the game:
* Invest in rigorous research and pilot projects to explore the feasibility and impact of "treatment as prevention." Treatment is increasingly understood to have major prevention benefits, in addition to reducing HIV- and TB-related illness and death.
Support research to radically simplify and optimize the package of ARV treatment, including:
* Dose optimization: If shown to be effective, reducing the dose of some ARVs could potentially treat up to one-third more patients without a cost difference.
* New drug development: Develop new ARV drug delivery platforms and slower-releasing drugs, which could help to decrease the burden on patients as well as the cost per patient per year.
* Accelerate commercialization of point-of-care diagnostics: new instrument-free, point-of-care CD4 cell count blood tests, once available, could be rapidly deployed to the field for use in identifying more patients at the lowest levels of care, while we redouble efforts to develop a point-of-care viral load test.
And additionally;
* Create and implement a financial transaction tax (FTT): billed by some as the "Robin Hood tax" (including activists at IAC dressed up in feathered green hats and bows and arrows), a tiny tax of 0.005% on foreign currency transactions could generate an estimated $33 billion per year for global health needs and other issues affecting the developing world. Such a "tax and treat" strategy could deliver the sufficient, regular, and predictable funding to pay for scale-up, provided donors make good on their existing commitments to the Global Fund and other financing mechanisms.
* Ensure an enabling policy environment to usher in these new innovations, including aggressive use of Trade-Related Aspects of Intellectual Property (TRIPS) flexibilities and an effective patent pool.
If we want to bend the curves of the HIV epidemic, we should seriously consider and put into action radical game-changers such as these.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This article is Open Access and was reprinted freely under a Creative Commons license. http://speakingofmedicine.plos.org/2010/07/23/msf-beyond-vienna-possible-game-changers-for-scaling-up-optimal-aids-treatment. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see MSF's website at http://aids2010.msf.org.
According to UN reports, sub-Saharan Africa has the world’s highest rate of child mortality, with one in seven children dying before their fifth birthday. The region has witnessed a 22% decline in the under-5 mortality rate since 1990, although significant variation exists between countries. Although rates of infant mortality have declined since 1990, 17 of the 20 countries with the highest infant mortality rates are African. Maternal mortality is the health indicator that shows the widest gaps between rich and poor, both between and within countries. While data is scarce, WHO estimates that 900 women die per 100 000 live births in Africa. The continent, with the exception of Namibia, is identified by the UN as experiencing high or very high maternal mortality. Sub-Saharan Africa is also the region most affected by the HIV/AIDS epidemic, with over two thirds of all people living with HIV worldwide, and nearly three-quarters of AIDS-related deaths. There are some positive signs: the rate of new HIV infections has slowly declined, and 44% of adults and children in need of antiretroviral therapy had access to treatment, up from 2 % five years earlier. Efforts to combat malaria have progressed: the use of insecticide treated nets by children in 26 African countries rose from 2% in 2000 to 22% in 2008.
African countries have developed numerous strategies to reach the goals. In 2006, the African Union endorsed the Maputo Plan of Action on Sexual and Reproductive Health and Rights, and 22 countries have since set Maternal and Newborn Health Road Maps to improve sexual and reproductive health through laws, policies and health systems. The AU’s African Health Strategy 2007-2015 proposes to strengthen equitable health systems; the AU’s 2005 Gaborone Declaration commits to universal access to HIV prevention, treatment and care; the 2001 Abuja Declaration commits African states to allocate 15% of their national budgets to health and the 2008 Ouagadougou Declaration commits to advancing Primary Health Care and Health Systems in Africa. The 2010 African Union summit held in July in Kampala, passed a number of resolutions, including a renewed commitment to the 15% budgetary allocation to health; and CARMMA- the Campaign for the Accelerated Reduction of Maternal Mortality in Africa.
The African Union and its member states must, however, go beyond rhetoric to implement the promises set out in their declarations and produce tangible results. For example, the Global Fund has reported that as of 2007, out of 52 African countries (no data was available for Somalia), only three (Botswana, Djibouti, and Rwanda) had met the 15% target for health budgets, while three more (Liberia, Malawi and Burkina Faso) surpassed this target.
The UN report, Keeping the Promise – United to Achieve the Millennium Development Goals for the 2010 MDG summit being held in late September in New York has a paragraph on Africa stating that the continent is lagging behind on many of the MDGs, that progress has been made in some African countries but that the poorest ones remain “a grave concern, especially in the wake of the hard hitting financial and economic crisis”. The UN note in the report that while aid to Africa has increased in recent years, it still lags far behind commitments made. Will the Summit produce the resources called for by the UN through delivery of these commitments? Will the UN MDG Summit in September go beyond rhetoric to action? Will it unleash the resources to move from the many strategies to practice?
After all is said and done in September, one sign of that must be the extent to which whatever is said is translated into local level interventions and reaches vulnerable groups. This needs to be tracked, but the UN only collects MDG data aggregated at the national level, making it difficult to track how far this is being achieved. There is no provision in country reports for disaggregation of country-level data to assess sub-national progress on the MDGs. The reports do not therefore capture the stark inequalities among different regions, socio-economic, ethnic, racial and cultural groups within countries on accessing the resources for health or achieving the MDGs.
And should we be measuring targets or rates of progress? The World Bank noted in 2010 that uniform goals like reducing infant mortality by two-thirds, maternal mortality by three-quarters can underestimate progress in poor countries and communities. Why? Because the greater the distance to the goals from low starting points in poor countries, the greater the improvement needed to reach the targets. Is it the rate of progress, or the likelihood of achieving the targets that should be evaluated? While the target is the outcome we are aiming for, Fukuda and Greenstein argued in 2010 that the rate of progress tells more about the likelihood of achieving it along the way, and would place more pressure on governments to do more.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This editorial has been edited from the original that appeared in the Health Diplomacy Monitor Special Issue on the UN Summit on the Millennium Development Goals, Vol 1 Issue 3. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see the Global Health Diplomacy website at www.ghd-net.org.