Editorial

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/

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.

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.

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.