The number of people in the global South without access to adequate basic services is staggering, not least in Africa. For more than two decades, international financial institutions have prescribed private sector participation as the remedy, often with disastrous consequences. Recently, critics of this approach have given new visibility to ‘alternatives to privatization’ to counter this trend.
Although the debate about alternatives to privatization in the water sector has been particularly dynamic, the health sector has been slower to recognize and promote new models. Similarly, Africa has developed fewer alternatives than Asia and Latin America – although the African health sector has seen some innovative community health insurance schemes and reliable non-state provision on a not-for-profit basis.
The Municipal Services Project (www.municipalservicesproject.org) is at the forefront of such research and action, and is releasing a new book this February – Alternatives to Privatization: Public Options for Essential Services in the Global South – in an effort to stimulate further debate and research in this field. The authors who contributed to this book address questions of what constitutes alternatives to privatization, what makes them successful (or not), and what lessons are to be learned for future service delivery debates. The analysis is backed up by a comprehensive examination of initiatives in over 50 countries in Africa, Asia and Latin America, looking at three sectors: electricity, health care and water/sanitation. As the first global survey of its kind, it provides the most rigorous platform to evaluate alternatives to date, and compares them across regions and sectors.
We conceive of alternatives to privatization as those involving public entities that are state-owned and operated, or non-state organizations functioning on a non-profit basis. We propose a normative set of ‘criteria for success’ to make sense of case studies because we believe that some universal claims are necessary if we are going to have a coherent global dialogue about the kinds of service delivery alternatives we want to promote. We have focused on current efforts to make public services more democratic, participatory, equitable, transparent and environmentally sound.
Equity emerges as an important criterion for alternatives because inequity is arguably the single largest concern with privatization, leaving scores of marginalized groups with little or no access to health care and other services. We are particularly interested in equity along class, gender and ethnic lines, and how public services have attempted to overcome these disparities.
Our aim has been to construct a bridge between universal criteria (such as equity) and the particularity of different locations. We recognize the unique realities of each region and the fact that there are no ideal models (in opposition to the neoliberal approach that sweeps away differences and pushes a one-size-fits-all solution). Uganda is not Uruguay is not Ulan Bator, but there are core values and objectives that underscore our definitions of what it means to provide a successful public service and consistent ways to evaluate this success.
Africa may be the weakest region in terms of such successful initiatives, as identified by our researchers, but there is robust popular resistance to privatization and it may play to the continent’s advantage that lessons can be drawn from experiments in other parts of the world.
In the chapter on alternatives to privatization in the African health care sector – African Triage – Yoswa Dambisya and Hyacinth Eme Ichoku identify and evaluate promising models for more equitable health systems. First, they explore community-based health insurance schemes (or mutuelles de santé), which aim to extend benefits to populations excluded from traditional social protection programs and operate on voluntary and non-profit bases, promoting principles of mutual aid, solidarity, and pooling of risk. These systems offer protection from catastrophic health costs and facilitate cross-subsidization. In Rwanda and Tanzania, it appears that such schemes would increase the chances of seeking assistance from formal health care providers rather than opting for self-medication or traditional healers. Ghana also developed an interesting alternative at the community level, sending nurses to live in villages to reduce barriers to geographical access, and setting up local health oversight committees. However, these schemes can also suffer from limited revenue due to low population coverage and can result in a situation where the poorest cross-subsidize the less poor. In short, these types of insurance models can complement, but not substitute, strong government involvement in health system financing.
Second, Dambisya and Ichoku review national health insurance schemes. These are more formal than community-based models but also allow pooling of risk and cross-subsidization of health services, equalizing financial access. Important shortcomings are that they do not erase geographical barriers, leaving rural populations at a disadvantage, and that they cover those in the informal sector last – even though these groups are probably the neediest. Further, such initiatives may not be viable where there is rampant corruption and high mistrust of authorities, as the failure to implement plans for national health insurance in Uganda and Zimbabwe may indicate.
Finally, faith-based organizations emerge as the largest single health care provider outside of government in most of Sub-Saharan Africa. Mission hospitals appear to offer the best quality care, generally operate in an efficient manner, and have stood the test of time. What may be more problematic is the issue of accountability and community participation. Policy makers should look into ways of better integrating these large players into national health systems.
Findings from Latin America and Asia present a very different picture of alternatives to privatization in the health sector, however, and offer some intriguing lessons for Africa, as do lessons from the water and electricity sectors in all regions studied. But despite the differences it is the commonalities that are most encouraging, highlighting a commitment from policy makers, frontline workers, activists and academics to a world that is not dictated by the demands of the market, celebrating public systems that work and pushing for innovative reforms where they don’t.
In the end, the book is just a start and the final chapter concludes with a series of future research and activist priorities, pointing to a long-term and exciting challenge for those committed to a world of social and economic equity.
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 read the book Alternatives to Privatization: Public Options for Essential Services in the Global South published in Africa by HSRC Press and available at http://www.hsrcpress.ac.za.
Editorial
In recent years, many low and middle-income countries have removed user fees in their health care sector. However providing free health care is more complex than it is usually thought.
Researchers have studied these policies in Afghanistan, Burundi, Burkina Faso, Mali, Nepal to see what lessons can be learned from them. These country experiences highlight that decisions to remove user fees are often taken by authorities at the highest level in countries, sometimes during electoral campaigns. Many countries are opting for selective free health care, such as for children under five years, free delivery for mothers. This aligns access to areas of the Millennium Development Goals. It is probably reasonable, given the costs to governments of free health care policies. Leadership developed by African leaders in favour of vulnerable populations such as young children and pregnant women has to be praised. Good outcomes for these groups however require a long term commitment in terms of public resources and policies which are sound from a technical perspective.
The country assessments found, for example, that when these decisions are taken in a hasty manner, without sufficient consultation of stakeholders, including of the technicians working for the concerned ministries, health systems may experience a shock. They are found to have difficulties with coping with the increase in patients and drug shortages. Lucy Gilson, Professor at the London School of Hygiene & Tropical Medicine and at the University of Cape Town said “As leaders take important decisions to strengthen health systems for the benefit of the poorest, their engagement with communities, health workers and technicians is vital in bringing those decisions alive in the day to day practice of health care delivery”.
In contrast, when the policies are well-designed, implemented with the appropriate accompanying measures and sufficiently funded, they can improve access to health services. Funding levels are important. Insufficient funding may lead to a situation where the increased utilisation of services by the population after fees are lifted paradoxically leads households to spend more for their treatment. This happens, for instance, when there are drug shortages in free public health facilities, so that households have to buy their drugs in private pharmacies.
There are different ways to reduce financial barriers to health care. Free health care is one option. Another option is to introduce health insurance, so that any changes are paid in advance and people are charged according to their ability to pay and not their health need. Any good solution, that works for both vulnerable people and for the public budget requires a certain level of complexity. It is therefore important that leaders consult their technicians who plan and deliver services. They can help leaders to build fair, efficient and sustainable health care systems.
External funders, aid agencies and Northern Non-Governmental Organizations were also found in the country studies to play a role, such as in assisting countries to monitor and evaluate their policies, a step overlooked in too many countries. It is however important to note that any involvement of international agencies should be in full respect of sovereign choices made by low-income countries. Abdelmajid Tibouti of UNICEF New York observed for example that equity is a major challenge in many countries. “Technical and financial partners have probably a stronger support role to play, in full respect of course of options chosen by countries themselves. A first track is to network countries implementing similar policies”.
In this respect, there are some positive trends. African experts working on these issues have organised themselves in a community of practice and are using information and communication technology to share their experience and knowledge. An African regional meeting was held in Bamako in November 2011 where those involved from 10 Anglophone and Francophone countries gathered to review free care policies in maternal health. This direct exchange between countries in such communities of practice provides a critical means for learning by doing, as countries face the complex challenges of providing free health care.
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 http://heapol.oxfordjournals.org/content/26/suppl_2.toc to access the Health Policy & Planning supplement with the findings of the studies. You can contact the Financial Access Community of Practice at cdp.afss@gmail.com.
We always hear that maternal deaths are avoidable, yet they remain a main cause of mortality. Whenever a woman dies while giving birth, we absorb the fact as though it was normal, despite the pain caused to her family, her children and her partner. Silence engulfs the mourners and after burial, the deceased woman is registered into the records and included in public health statistics.
These are the facts: According to Cook, Dickens and Fathalla in 2003, every year more than 500 000 women die from pregnancy complications or childbirth globally, and 99 percent of these deaths occur in developing countries. According to the Road Map for Accelerating the Reduction of Maternal and Neonatal mortality and morbidity in Uganda 2007-2015, sixteen women die every day in Uganda due to maternal mortality. This means that 6000 women die every year and leads to an estimated maternal mortality rate of 345 per 100 000 live births.
This tide of death due to pregnancy and childbirth occurs for various reasons. The health sector is chronically underfunded compared to health need, leading to lack of available, well supervised trained midwives in services close to communities. Referrals for complicated cases face problems of lack of ambulances and of emergency obstetric care in referral hospitals. Health workers may be demoralized in such conditions and show poor attitudes to clients. Within communities, partners may give women inadequate support and resources to make timely use of services, especially when poorly equipped local services mean that they have to travel some distance to facilities. Participatory research carried out by HEPS (Uganda) in 2008/9 found that women get weak support in maternal health issues from their male partners.
These problems have contributed to the deaths of many women, especially the poorest women, who constitute a large share of the population. These women are also the bread winners of and carers for many rural families. The Ugandan government acknowledges in its Road Map for Accelerating the Reduction of Maternal and neonatal mortality and morbidity that maternal mortality occurs because of the three delays. The first of these is a delay in making the decision to seek care. The second delay is in identifying and reaching a medical facility, while the last is in receiving of adequate and appropriate treatment. It is a duty of government to address these delays, including any shortfalls in funding of the health sector that may be connected to the weaknesses in service delivery that lead to these maternal deaths.
In 2011, building on civil society advocacy on these three delays, the Centre for Health, Human Rights and Development (CEHURD) took a further step of petitioning the constitutional court, seeking declaration(s) that the non-provision of healthcare in government health facilities leading to the death of mothers is an infringement on rights to life and health.
The petition draws on maternal death reviews from government hospitals, where the cause of death has been cited as lack of facilities, equipment or consumables. Health workers cite that they did not have equipment for monitoring the deliveries in the theatre and labour suites, including materials like gloves, and noted that there were inadequate trained heath workers.
When complications happen, if women report late to services this reduces their chances of survival. However, the reported shortfalls in health care services have meant that even when they arrived early at hospitals, when labour pains started, women were still at risk. Two cases were cited in the petition. In one, a young woman arrived at 8:00am and died at around 9:00pm when her uterus ruptured, due to obstructed labour. In the second, the woman went to a government Health centre first before being taken to a government district hospital. She could not be saved after she had a retained twin. This woman was reported to have arrived at 2:30pm but to have not been attended to by health workers until she died just after midnight at 12:30am. In both instances, the hospital reports point to lack of basic equipment and supplies for deliveries and lack of staffing.
The petition contends that these deaths, arising from the non-provision of basic maternal health care services in government hospitals, is a violation of the right to life guaranteed under Article 22 of the Constitution of Uganda. The petition contends that the right to health under Objectives XIV and XXII is violated when government health workers and government fail to provide the required essential care during the period before and after childbirth. This happens when there is inadequate staffing for maternal health, specifically midwives and doctors, frequent stock-outs of essential drugs for maternal health and lack of Emergency Obstetric Care Services at Health Centres III, IV and hospitals.
In taking on this public interest litigation case, CEHURD, and the wider civil society groups who support the petition have acted for a wider concern in society on unacceptable levels of maternal death. Principal State Attorney Patricia Mutesi was reported on Sunday 23 October’s Monitor (www.monitor.co.ug) to have argued that a court determination would amount to usurping of power of the Executive and the Parliament to determine on economic policies. However, Mr David Kabanda, the petitioners’ attorney, said the State objection was misconceived because the matter before court is seeking for court interpretation whether the acts and omissions at the various health centres contravene the Constitution. Irrespective of its outcome, the petition has widened awareness of the right to health and social expectations on maternal health. Uganda National Health Consumers Organisation (UNHCO) has raised advocacy on the issue (http://unhco.or.ug/news) and a coalition of over 35 civil society organizations has since been formed on maternal health, which is taking up wider health issues, including budget monitoring. This coalition is providing learning and networking on health rights generally, building social activism using evidence from the real situation in health services and the social concerns in communities.
The petition sets a precedent on one of the ways of progressively realising the right to health in a resource constrained setting. It may inform the way we address other obligations and entitlements, like access to medicines. Social action through constitutionally set channels is one way society can act to prevent unacceptable death in vulnerable women and to advance health equity in Uganda.
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 CEHURD website: www.cehurd.org
The WHO and Government of Brazil sponsored Conference on the Social Determinants of Health held in late October turned out to be a case study of how expectations materialized in a war of brackets added to the text of the original Rio Political Declaration on Social Determinants of Health (www.who.org ). The rich countries’ brackets and ‘toning-down-relativisation-adjectives’ won, despite fierce debate. This begs the question: Are United Nations declarations predictable?
The frustration in the halls ran so high that no less than three alternative declarations made it to the floor of the final day. One from the Peoples Health Movement (www.phmovement.org ), one from the Latinamerican Association of Social Medicine (www.alames.org ) and one from the International Federation of Medical Students’ Associations (www.ifmsa.org).
Dr Michael Marmot, chair of the Commission on Social Determinants of Health that produced the 2008 report said: …”Closing the gap in a generation is a rousing call. Did the World Health Organization’s Commission on Social Determinants of Health really believe it to be possible? Technically, certainly. …the evidence suggests that we can make great progress towards closing the health gap by improving the conditions in which people are born, grow, live, work and age. …..In the three years since ‘Closing the Gap in a Generation’ was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; climate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequalities….”
The weaknesses were clear. WHO Member States were reluctant to discuss or redress the power relations that year-in-year-out reproduce health inequalities. The social determinants of health cannot be addressed by just fixing policy coherence and inter-sectoral action in health as is being called for. Obscuring these realities of power under platitudes about inter-sectoral action and policy coherence across sectors only helps to perpetuate the continuing violation of the right to health. In fact there is significant policy coherence across sectors, including the health sector, influenced by currently dominant conservative economic policies which have also promoted a market approach in health care financing. Irrational global trade liberalization, capital flight and a continued unfair regime of patents, especially of medicines are clearly maintaining health inequalities. Comprehensive primary health care, with proactive community involvement, is the fundamental guide for an equitable health system. The progressive privatization of health care provision over the last three decades has seriously weakened capacities to organise comprehensive primary health care.
It is thus the stubborn combination of poor social policies and programmes, unfair economic arrangements, and bad politics that are depriving large numbers of people of opportunities to lead healthy lives. Reducing health and nutrition inequalities is critically dependent upon changes in the functioning of the global economy. Differences among countries; between social classes; between men and women; between corporations and communities result from the interaction of the different axes of power which end up critically determining which actions will be taken and which will not on the social determinants of health and nutrition. A willingness to transfer real power to communities is thus key to deal with the existing unequal power relations and with the measures taken to tip them in favour of dire community needs.
Despite the committed role all representatives of the Brazilian government and civil society in bringing out the deficiencies above, in the final Declaration, no mention was made of redressing the unequal power relations that lie at the base of the determinants. The Declaration thus proposes an apolitical agenda. In this respect it is a step back from the recommendations of the WHO Report on the Social Determinants of Health.
Peoples Health Movement and Alames in their declarations insist that the institutions, corporations and governments which promote the current state of affairs need to be confronted if there are to be any shifts in the way the social determinants of health are addressed. These declarations make specific proposals for how to do this. For example, WHO has led the way in developing a global regulatory regime for tobacco control and should do the same for the food industry. The financial sector needs to be held accountable for the economic crisis and contribute to addressing the vast resource gap in health by paying a small tax on financial transactions.
The Conference at best served for leaders to acknowledge social determinants of health as an ‘issue’. But it leaves us with the lingering question: Can the health and nutrition sector take upon its shoulders the tackling of the social determinants of health? We are the sector that picks up the pieces of a sick society. Putting our own house in order will not be enough.
The declarations referred to in this editorial are included in the newsletter. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The views expressed in this editorial are the authors. For more information on the issues raised in this op-ed please visit the website of the World Conference on Social Determinants of Health http://www.who.int/sdhconference/en/ and of Peoples Health Movement at www.phmovement.org
The September 2011 UN High-Level Meeting on Non-Communicable Diseases (NCDs) has come and gone. The political declaration adopted by governments, is included in this newsletter. It points to the need for multi-sectoral public policies that create equitable health-promoting environments. It calls for action across government sectors and partnership across government, civil society and private sector to implement these policies. It mandates WHO to develop for consideration ‘voluntary global targets’ and indicators for monitoring by 2012, for accountability on the declaration. The Commonwealth issued a statement on 21st September welcoming the declaration as a commitment to deal with NCDs. Others, some included in this newsletter, raised concerns about the absence of clear commitments on funds or targets, such as on access to medicines or on regulations to curb trade in unhealthy products. Questions were raised on what can be achieved through a reliance on partnership and voluntary arrangements, with a call for stronger exercise of public health authority. The High level meeting on NCDs opened a window into the competing influences of politics, commerce, social movement and science on global health negotiations. While evidence of health need and feasible strategy is persuasive input to these competing influences, Thomas Gebauer asserts in this month’s editorial that ethical principles, such as solidarity, are fundamental to health, and must be applied in global negotiations that affect the human right to health.
In view of the wealth existing in today's world, the prospect of Health for All must not be an illusion any longer. The world doesn’t lack the resources for health; it requires a fair use of what is available, in other words: the redistribution of wealth guided by the concept of solidarity. The world is awash in money. What is missing is the political will of those in power and – to challenge ourselves – the public pressure to make change happen.
The struggle for Health for all starts with challenging the prevailing neoliberal paradigm. It is well known that globalisation has widened health inequalities. However, more emphasis should be given to the fact that the transformation of health services into commodities, the linkage of access to health care to individual purchasing power and the dismantling of public health systems has only been possible in the context of a specific ideology - an ideology that has widely affected even those who are suffering the negative consequences of neo-liberalism, the global poor.
At the core of the neo-liberal ideology is a concept that replaces social values and institutions such as solidarity and common goods by self responsibility and individual entrepreneurship. “There is no such a thing as society”, Maggie Thatcher said in the early 80’s - paving the way for the cynical credo of neoliberal politics: If everyone takes care for him/herself, then ‘all’ are taken care of.
Although there is plenty of evidence that health is primarily a political matter determined by the social environment, neo-liberalism has succeeded in pushing the responsibility for health away from public and state institutions to private actors and individuals, including individuals perceived as business entrepreneurs in a liberalised market. Even spheres of societies that traditionally do not belong to the field of business, such as health, education and culture, have been increasingly penetrated by market values.
It was the French revolution – calling for Liberty, Equality and Fraternity – that came up with the first comprehensive list of Human Rights in 1789. ‘Fraternity’, the revolutionary agenda’s third pillar, may be equated with ‘solidarity’ in today’s discourse. It has been under permanent siege during the last decades. Millions of people have been excluded from health and social care as a consequence of neglecting the social principles that nurture the cohesion of society. Only by revitalising solidarity – both as an ethical principle and in its public institutions –can health inequalities be tackled and Health for all achieved. Indeed, there is such a thing as society.
It is a fact that there are always and everywhere people too poor to afford adequate health care out of pocket. Even in a perfect world, in which all the social determinants of health are respected, people will fall ill and will be in need of support. Therefore Health for all requires the presence of a permanent and institutionalised redistribution of wealth. Those who are in the position to pay more should also pay for those who are in need. This balancing is exactly meant with the principle of solidarity. It is perhaps the most important key to establishing an effective health care system.
In this context it doesn’t matter whether a system is tax-financed or based on the idea of social insurance schemes. Both are socially agreed funding schemes guaranteeing that even members who are not in a position to contribute a single shilling or cent financially to national budgets or social insurance will receive the same services as all the others members when they need them. While individual contributions (in terms of taxes or insurance contributions) are dependent on financial capacities, the entitlement to and claiming of services however, is only determined by needs.
It is preciously the principle of solidarity that disconnects access to health care from individual purchasing power: those who are wealthier support those who are poorer, younger, or elderly; and those who are economically active support those who are unemployed, retired and children.
Thus, the principle of solidarity goes far beyond what is usually meant when solidarity refers to empathy and charity. The principle refers rather to an institutionalised solidarity that organises a fair burden sharing. It is fundamental to the “social infrastructure” of societies. Like the hard infrastructure, like transportation, energy, administration, law enforcement, police, and so on, the social infrastructure also needs to be publically regulated and funded. The term social infrastructure stands for an ensemble of common goods, such as effective health care services, proper education systems, social protection schemes, food security, and so on. In other words, it covers social institutions that are essential for the social cohesion of societies that should therefore accessible for everybody, independent from an individual’s purchasing power.
In view of the global poverty affecting one third of the world’s population fiscal policy-making should again focus on the redistribution of wealth. At an International Conference on “Strengthen Local Campaigns for National and International Accountability for Health and Health Services” held in Johannesburg in March 2011 delegates in their statement also called for “the principles of social solidarity that are an accepted part of governance within many nations to be extended to the international level”. That sounds quite radical, but even the World Health Organisation (WHO) makes this argument. The World Health Report 2010 invites WHO member states to introduce new fiscal measures to enhance governmental revenue capacities. The report particularly points to the taxation of large and profitable companies as one of the key policy instruments to widen the fiscal space, as well as a levy on currency transactions and a financial transaction tax. The latter would only make sense if it is agreed internationally as a global resource to enable all states to adequately finance health services, including countries in the north facing persistent health sector cuts and sale of public health care services.
Health care systems based on the principle of solidarity still exist. In countries like my own, Germany, they form part of the foundations of the society. Most likely these systems can only be defended by extending them to the international level. In fighting back neo-liberal extremists who are persistently posing deadly threats to societies by dismissing solidarity institutions as a proof of “devilish socialism”, it is crucial to again struggle for solidarity. This struggle needs to be waged at national level, but it also includes an international dimension, such as in the call for an “International Fund for Health” that serves as an international equalisation payment scheme to balance existing financial gaps. For this, countries with higher incomes that can support those at lower incomes would be obliged to contribute to the health budgets of poorer countries. Taking the principle of solidarity forward internationally is not a question of money. It is rather a question of the political will to create a new international treaty regulating that richer countries with higher fiscal capacity are obliged to transfer funds to poorer countries, as long as these are lacking adequate fiscal capacity. It is this principle of solidarity that will realise Health for all and other social rights.
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 EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/healthfund
In 2007, the International Finance Corporation (IFC) of the World Bank Group released a report that observed that over half of health care funding in Africa comes from private sources and that there is considerable spending on private health care providers. It proposed that, if rapid economic growth in Africa is expanding the middle-class, it is also increasing the demand for private health care. The report encouraged investment in the private health sector as one of the top five areas for investment in Africa. Subsequently, the World Bank introduced the “Africa Health Fund”, supported by the IFC and the Gates Foundation, amongst others, to fund efforts to expand the private health sector in Africa.
Should development aid be used to support the growth of for-profit private providers and private health insurance, as the IFC suggests? Should African governments encourage growth of private for-profit health services? Is this as healthy a partnership as the World Bank and IFC would suggest?
These questions need to be answered in all countries in East and Southern Africa, as the private sector already exists, or is growing, in all. While the not-for-profit private sector, such as faith based services, has had a long presence and co-operation with governments in the region, growth in the private-for-profit sector appears to be a new trend.
There are many examples. In the hospital sector, the Indian hospital group, Fortis Healthcare, and African Medical Investments (which is based in the Isle of Wight in the UK) have initiated investments in high-end ‘boutique’ hospitals that target the high-income domestic, expatriate, diplomatic and medical tourism markets in Kenya, Mauritius, Mozambique and Tanzania, while South African private hospital groups are expanding into other African countries. The US-based hedge fund Harbinger Capital Partners has bought a controlling stake in African Medical Investments which aims to become a leading operator of high-end hospitals.
An alliance between two pharmaceutical manufacturers, the South African company, Aspen Pharmacare, and the multinational, GlaxoSmithKline, is leading expansion into many countries in the region. Private health funders are also spreading. The Tanzanian private health insurer, Strategis, is set to expand rapidly with the sponsorship of the “Health Insurance Fund”, supported by the Dutch Ministry of Development Cooperation. This fund provides a mix of public, donor and private funding to stimulate private health insurance companies as a critical step in creating demand for private health care provision. PharmAccess, a Dutch NGO appointed to manage the Fund, is developing models and contracts to facilitate private health insurance elsewhere in Africa. The “Investment Fund for Health in Africa” established in 2007, also from the Netherlands and with Pfizer amongst its shareholders, provides private equity to invest in private health care providers. In 2010, it purchased a 20% stake in a private insurance scheme, AAR East Africa, that is based in Kenya but operates in many other countries in the region.
Such initiatives bring immediate investment resources to the region, and provide services to some of the population However, the experience of South Africa, the country with the longest and most extensive experience of the formal private sector in the region, raises questions about the impact these sorts of activity have on the equity and sustainability of the wider health system.
In South Africa, after de-regulation of the private health sector in the late 1980s, there was the same growth of private health insurers and providers now being proposed in other parts of Africa. As McIntyre shows in EQUINET Discussion paper 84, this was accompanied by increasing costs of health insurance, rising fees charged by private providers (especially hospitals) and low and shrinking coverage of the population. In 1981 an average household with only one member working in the formal sector devoted just over 7% of its wages to medical scheme contributions for the family. By 2007 this stood at almost 30% of average wages. Monopolies emerged, as the same company involved in private hospitals would also buy into ambulance services and a range of other health care activities. Private beds consolidated over the years within three large private hospital groups. This limited the competition that was supposed to reduce costs and decreased, rather than increased, consumer choice. While this expansion was taking place the private sector also received various public subsidies. At the same time it attracted skilled health professionals trained at considerable public cost away from the public sector.
These trends have proved very difficult to reverse in the 2000s in South Africa, despite considerable efforts by government to re-regulate the sector. It has made it more difficult to develop policies to achieve universal coverage. The experience is a warning signal for other countries in the region of the political and economic costs of a private-for-profit health sector expanding in a relatively unregulated environment.
Governments and communities cannot be mere spectactors of these developments. They, together with external funders, should be asking questions before they open the door to such trends elsewhere in the region: Who will benefit from the expansion of the private for-profit sector? What consequences will the expansion have on health service prices, resources, services and coverage? Will it support national health policy goals? What regulations and capacities exist in the state to manage this process?
There is at present inadequate evidence to provide clear answers to these questions, not least because it is difficult to obtain financial and other information from the private sector. Given their duty to protect the health of the whole population, Ministries of Health should thus remain cautious about fostering the expansion of the for-profit private sector and entering into public-private partnerships without getting clear information about the effects on the equity and sustainability of the wider health system.
While arguments are being put forward about the investment and profit potential of the private health sector, Ministries of Health need to make clear to their government colleagues not only the advantages, but also the potential pitfalls of encouraging for-profit private sector expansion as part of their economic growth policies. The opportunity costs of supporting the for-private health sector as opposed to developing the public health system need to be made visible. If private investments in the health sector are proposed, it is a duty of the state to require prior independent health impact assessments, especially where public subsidies from government or development aid funds are involved. The assessments should cover issues such as the impact on health care coverage for low income groups, projections of costs and affordability, impacts on public sector resources, the viability of the entire health system, and so on.
Ministries of Health and the public cannot allow private sector expansion to take place in a vacuum. Government needs to develop comprehensive policies and a robust regulatory framework for the private sector that protects against the development of monopolies and unethical business practices and aligns investments to national policies and core social objectives, particularly for improving the coverage of appropriate, good quality services in rural areas and low-income populations. Health ministries need to ensure that they have departments and capacities to engage with the private sector and to carry out the basic functions of ‘due diligence,’ including co-ordination, monitoring, regulation, management, inspection and enforcement of sanctions.
And as a bottom line, if governments are to gain support for their efforts to manage the for-profit private sector in line with national goals, they must inject resources into the public health system so that it can provide an equitable, effective and good quality alternative to private care.
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 read EQUINET Discussion paper 87 and other materials on the EQUINET website at www.equinetafrica.org and visit the Health Economics Unit website at http://heu-uct.org.za/
Many children across Malawi experience severe diarrhoea caused by a virus called rotavirus. Rotavirus kills more than 500 000 children under the age of five years around the world each year—almost 1 400 deaths each day—the vast majority of them in sub-Saharan Africa and South Asia. In Malawi alone, rotavirus was estimated by Ministry of Health in Malawi to be responsible for nearly 5 000 deaths every year. Rotavirus attacks our families and threatens our nation’s future by targeting our most precious resource—our children. It spreads through the faecal-oral route, via contact with contaminated hands, surfaces and objects, but is not easily eliminated by improved sanitation. Those with the diarrhoea require oral rehydration and if properly rehydrated have a good chance of recovery. Death is usually through dehydration. .
The tragedy is that much of this death and suffering could be prevented right now, if children in Malawi had the same access to life-saving vaccines as children in industrialised countries. In the United States, rotavirus vaccines have been widely available for five years. Before the vaccine was introduced over 2.7 million cases of rotavirus gastroenteritis occurred annually, 60,000 children were hospitalised and around 37 died from the results of the infection in the USA. After the vaccination programme was introduced these rates went down dramatically. In Malawi, where the need is much greater, this vaccination is not yet widely available for children.
Vaccines are one of the best long-term investments to prevent disease and give children a healthy start to life —a few shots or drops can protect a child for a lifetime. And they are one of the most cost effective interventions to prevent illness in a country like ours Malawi many competing health priorities. With rotavirus (A), existing oral vaccines have been shown to provide significant protection against the disease. It is estimated that broad access to rotavirus vaccines in low-income countries could save up to 225 000 children annually. In fact, the World Health Organization strongly recommends including the rotavirus vaccine in all immunisation programmes because of its potential life-saving impact. But even the most effective vaccines will only have an impact if they are made available to people who need them. Yet rotavirus vaccines have been too expensive for low income countries, where health resources are scarce, and external funders have been hesitant to support the vaccine until costs come down.
In June, there has been new cause for optimism. Children in African countries could finally access the same vaccines for rotavirus as children living in high income countries. On June 6, the GAVI [the Global Alliance for Vaccines and Immunisation], an international organisation that supports the rollout of vaccines to low-income countries, announced it had been offered a significant price reduction for rotavirus vaccines from a pharmaceutical company, reducing the cost by a third to US$2.50 a dose. By comparison, measles vaccine still costs a lot less, at 19 to 30 cents a dose. So the cost is still relatively high. GAVI, which supports vaccine programmes in Malawi, now plans to rapidly accelerate its financial support for rotavirus vaccines, to scale up access. Malawi was one of the handful of countries that hosted clinical trials demonstrating that rotavirus vaccines save lives. The country is now planning to roll out new vaccines for pneumonia later this year—with the potential to give children protection against another big childhood killer. These signs of leadership give cause for optimism in a situation where the longer we wait, the more lives are lost.
At the same time, if this is to be sustainable, costs must be brought down even further. There is report of new, more affordable rotavirus vaccines on the horizon that will sustain our efforts to save children’s lives for the long-term. When GAVI announced the price cut for the existing rotavirus vaccine, it disclosed that an Indian rotavirus vaccine candidate – which should be available around 2015 – will cost US$1 per dose. While manufacturers in other parts of the South like India are developing vaccines that will assist in improving access and affordability, we should also be asking what we are doing to expand capabilities for vaccine production in Africa. Vaccines alone will not eliminate rotavirus or solve all of our persistent health problems. We still need to focus on long-term challenges such as improving sanitation, adequate water and strengthening health systems, to prevent faecal borne disease, and ensuring wide knowledge on and access to oral rehydration to prevent child mortality from diarrhoea. But in my view, ensuring access to rotavirus vaccines is a simple prevention measure that we can and should take today.
An earlier version of this oped appeared in the Daily Times-Malawi 13 June 2011 and the New Era Press Namibia 2 June 2011. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full please visit Health Rights and Education Programme (www.hrep.org.mw/) or EQUINET (www.equinetafrica.org).
The world has become a very small place for some. Globalisation and the movement of people and goods mean that it’s possible on the same day to wake up in Asia and go to sleep in America. Farm products grown in an Africa can be on shelves in Europe within days. Yet it can take the same time or longer for a woman from that African country to get to a hospital with a midwife to access maternal health services. Clearly, the benefits of the increasingly rapid movement of goods, services and information across countries are not obtained by all. How have women in low-income rural and urban communities in Africa experienced the impact of globalisation?
A workshop held in Nairobi in May 2011 reviewed this experience and the implications for research on globalisation and health in Africa. The workshop was convened as part of a research programme on globalization and women’s health in east and southern Africa co-ordinated by Karolinska Institute and TARSC. The research programme found, through analysis of the Millennium Development Goals (MDG) database, that African countries are becoming more integrated with world markets and that women’s occupational roles are changing, but with inadequate disaggregation of global databases like the MDG data to assess the impact of these changes on women’s health and nutrition. A review of literature on existing studies suggested however that while globalisation related economic and trade policies have provided urban employment and social opportunities for women, they have also been associated with time and resource burdens for them that have had negative consequences for their own and their families’ health and nutrition.
Examples of research presented at the workshop similarly suggested that women’s involvement in export oriented coffee production in Uganda and in urban export processing zone (EPZ) factories in Tanzania had brought improved incomes for the women workers, but with longer working hours and weaker social protection. Improved incomes in both groups had not translated to better nutrition or dietary outcomes compared to women working in non EPZ factories or in farms producing food for local markets. For countries seeking to make a link between economic activity and improved health outcomes, this lack of improvement from globalisation related changes is a problem, especially given the context of Sub-Saharan Africa having the highest level of maternal mortality globally, with 900 maternal deaths per 100,000 live births, a level well above the targets aimed for in the MDG commitments. While globalisation has been associated with information, research and technological advancements and a wider demand for equity and rights for women, delegates also heard evidence that it has been associated with commercialised health care and reduced public funding, creating barriers to use of health services by poor women. Further, recent features of global markets - the 2008 financial crisis and the increased price of food and fuel – were raised by delegates as likely to intensify food insecurity, particularly for those already vulnerable to nutritional stress. Poor women in urban areas are likely to suffer more due to reliance on food purchases. A new trend of purchases or long-term leases for agricultural land by foreign investors for food exports and bio-could further threaten the local agricultural systems that commonly involve small scale women farmers, widening inequities in nutrition, health and access to livelihoods.
In discussing this evidence, delegates to the meeting identified that research on globalisation and women’s health in Africa needs to address three broad gaps, if the interests of low-income African women are to be better reflected in economic policies associated with globalisation:
i. to bring local evidence and voice into global policy processes;
ii. to highlight gaps between global policy commitments and local realities; and
iii. to ask the “what if?” questions, to explore and inform alternatives that would be more health promoting for African women and their livelihoods, and countries.
There are many specific areas of research that emanate from these three areas. For example, in the first, evidence on the experience and effect of global processes - whether IMF conditionalities, land grabs, commercialisation of services or other areas - needs to reach and be made accessible to national level and to those negotiating in global forums. Delegates noted that there is already evidence at local and regional level that could be useful for this, if reviewed and appropriately organised. This includes bringing together evidence from evaluations of global programmes and transnational activities in the different countries of the region.
However delegates also called for a shift in agenda formulation, with locally driven evidence and perspectives having greater influence on international agendas. Examples were given of research that explores such alternatives. For example, IDRCs Ecosystem and Human Health Programmes has supported work in Malawi to assess the effects of local production of nitrogen containing legumes. This was found to have not only improved soil fertility and reduced reliance on imported chemicals, but to also have improved the quality of diets and nutritional outcomes. Delegates concurred that this type of work had the potential of building partnership across actors, disciplines and countries, including with affected communities, that would better connect local level initiatives and evidence with global level processes and policies. While globalisation has raised attention to the injustice of the huge inequalities in women’s health globally, responding to these injustices calls for responses that strengthen the organisation of ideas, evidence and practice from the community level and their influence at national level, as a basis for the engagement in global processes.
For further information on this issue please read the background papers at http://sjp.sagepub.com/content/38/4_suppl and the report of the meeting available in the annotated bibliography at http://tinyurl.com/6zeeod5 at www.equinetafrica.org. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
When Indonesia announced in late 2006 that it had stopped sharing H5N1 virus samples with the World Health Organisation (WHO) Global Influenza Surveillance Network (GISN) - the global alert mechanism for the emergence of influenza viruses with pandemic potential - it shone a torch on an area of global inequity. Developing countries had been freely providing samples to the GISN, but were then not able to afford the vaccines that pharmaceutical companies developed and patented using the same samples.
The sharing by countries of influenza virus samples is important for vaccine development, and for understanding how viruses are mutating. Developing countries have thus freely provided samples to the WHO. But when private pharmaceutical companies use the samples to develop and patent vaccines which the same developing countries cannot afford, this is unjust and undermines public health.
Dealing with epidemics like influenza is not simply a concern at national level. The increased movement of people across nations and continents has been accompanied by an increased risk of spread of diseases across borders, such as bird flu, swine flu, SARS and others. Dealing with these pandemics is a matter of global health security that calls for the sharing of technology, information and resources to detect and respond to epidemics, including through vaccines effective for the current virus strain. African countries, often lack the infrastructure, skilled personnel and laboratory facilities needed for detecting and managing epidemics. Africa only has 12 National Influenza Centres sampling people with influenza like illnesses. These NICs submit the virus samples to the global network, and they are used to produce to vaccines that contain the major virus strains predicted for that year. The global network provides the means for countries to share in the benefit of these viruses used for vaccines. But, as the 2006 Indonesia action exposed, the benefit is not shared.
In 2007, the World Health Assembly (WHA) requested the WHO Director-General (DG) to convene an intergovernmental meeting to review how to ensure timely sharing of influenza viruses with pandemic potential and equitable access to the benefits from this. By April 2011 the intergovernmental process had drafted a Framework for this, termed the “Standard Material Transfer Agreement” (SMTA), that has been tabled and agreed to at the just concluded WHA in May 2011. The Framework contains provisions governing the sharing of influenza viruses and the resulting benefits, and obliges the pharmaceutical industry and other entities that benefit from the WHO virus sharing scheme to share benefits. In the SMTA for entities outside the WHO network, the recipient of the virus has to commit to at least two options of benefit sharing, such as donating at least 10% percent of vaccine production to WHO, or reserving treatment courses of needed antiviral medicine for the pandemic at affordable price, or granting royalty-free licences to manufacturers in developing countries.
However the Framework does not make mandatory the commitments to share knowledge and technology with developing countries on vaccine production, and is silent on patent issues and availability of affordable vaccines in countries where there is no manufacturing capacity, as is the case in many African countries. So while the SMTA establishes the principle of equity, it doesn’t fully operationalise it.
There is some guidance in existing international instruments on this issue. The World Trade Organisation (WTO) Trade Related Aspects of Intellectual Property Rights (TRIPs) agreement makes clear, for example, that intellectual property (IP) should not compromise countries’ obligation to protect public health. IP should thus not be used to deny countries affordable and timely access to vaccines. The Convention on Biological Diversity (CBD) and its associated Nagoya protocol affirm that states have sovereign rights over their own biological resources and to the fair and equitable sharing of benefits arising from the use of their genetic resources. The Nagoya protocol goes further to provide more specific information on how this should be achieved through monetary and non monetary benefits. These are not yet provided for in the SMTA and there was some debate on mentioning the protocol in the SMTA. Although there is debate over whether the CBD, which deals with genetic resources that have functional units of heredity, applies to viruses, their intent sends a message on the principle that should guide countries in finalising the SMTA. Whether the Nagoya protocol is named or not, if WHO is a custodian of global health security, it should provide no less protection of benefit sharing than is evident in the CBD, and should further provide for the sort of innovative approaches that facilitate technology and capacity transfer between high and low income countries to operationalise benefits sharing.
When the May 2011 WHA considered the SMTA, it presented an important opportunity to redress an area of global inequity in health. The debate at the World Health Assembly (WHA) had many interventions, some of which wanted substantial changes. For example Australia and several other countries wanted to delete mention of the Nagoya protocol from the resolution, which the committee recommended. Jamaica wanted to add an obligation for WHO to facilitate access to vaccines and antivirals through stockpiling and affordable pricing. Bolivia proposed that patenting of influenza biological material is against public health interests. In general however countries did not change the text to allow the process to move forward, and Bolivia reserved its rights to seek a prohibition of the patenting of influenza biological materials outside WHO GISRS. The major preoccupation was with implementation. Many low and middle income countries (LMIC) were keen to see how the SMTA would be applied, and Kenya and Algeria urged other countries to support capacities and technology transfer for monitoring and dealing with pandemic disease.
The gathering of people from all corners of the world would seem to be a good reminder of ease with which pandemics could spread, although the environment at the WHA may be very different to that of the low income communities who may have least access to the resources to prevent or manage them. An effective response to the potential severity of a global pandemic calls for strong, and where needed, mandatory commitments, plans and actions to share knowledge, technology and know-how, to prevent IP barriers and to operationalise principles of equity in benefits sharing and access, so that the timely delivery of viral samples translates into the timely access to vaccines for those who need them.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full please visit SEATINI (www.seatini.org) or EQUINET (www.equinetafrica.org).