On 5 February 2013, in a ceremony at the WTO, the three Director Generals of WTO, WIPO and the WHO launched the trilateral publication titled:
“Promoting Access to Medical Technologies and Innovation”, the fact that a publication regarding public health was launched at the headquarters of the WTO is a reflection of the increasing importance of public health issues in the context of WTO and WIPO, an issue on which the WHO has been the leader.
The study shows progress on the part of the WTO and WIPO since they talk about these issues without “taboo”, however it does not give a complete picture of the extent to which WHO has lead this issue over the past decade. 17 resolutions by the World Health Assembly adopted between 1996 and 2012 are cited in the report in a table on page 44 concerning intellectual property and health. These resolutions are of highly prescriptive character, for the secretariat and for countries on how to protect public health from the possible negative impact of new international trade rules. Despite numerous resolutions and publications in the last 15 years by the WHO on this issue, many of which are not mentioned in the report, the disclaimer of the document says that “(…) the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WHO, WIPO and the WTO be liable for any consequences whatsoever arising from its use.”
This could give the wrong impression to the reader of this report that the WHO has no opinion on whether a compulsory license may, in special circumstances, facilitate access to drugs, or if an international exhaustion regime, that allows parallel imports from any country can reduce the cost of drugs and therefore contribute to access. The 17 WHA resolutions give a mandate to the WHO to engage, promote and defend mechanisms and policies in favour of access. Thus, it is important to ensure that the Trilateral Cooperation with WTO and WIPO do not lead the WHO to share a “neutral” vision, totally disengaged from its mandate of protection of health. This would be contrary to the exemplary leadership from the WHO on “The Revised Drug Strategy”, WHA 52.19 in 1999 or the “WHO Policy Perspectives on Medicines” published in 2001 that says: “National patent and related legislation should:
• Promote standards of patentability that take health into account. (…)
• Incorporate exceptions, trademark provisions, data exclusivity and other measures to support generic competition.
• Permit compulsory licensing, parallel importation and other measures to promote availability and ensure fair competition.
• Permit requests for extension of transitional period for TRIPS implementation, if needed and if eligible.
• Carefully consider national public health interests before instituting TRIPS-plus provisions
As expressed by the three NGOs that addressed the Executive Board in January this year, on the issue of IP and public health, the Trilateral Report is a weak and unambitious document in which the WHO does not fully reflect the work it has done on these issues in accordance with its mandate.
The question that we as member states of the WHO, international organisations with a clear vision regarding the priority of health such as UNDP or UNAIDS, or UNICEF, non-profit NGO’s working on public health, the academia and all the sectors concerned with the promotion of health and access to medicines should ask is what is the relevance and status of this report in the face of the 17 resolutions by the WHA giving a clear mandate that is not reflected in this document.
It would seem that we have overcome the debate that began in the early 2000’s about which one was first, the right to health or international trade rules, but in this trilateral publication, the mandate of the WHO to promote public health seems to have been subordinated to accommodate IP and trade interests that WIPO and WTO promote.
Therefore, the Trilateral Report is in the nature of a “Wikipedic” report that describes what others have said on the issue, without any of the three organisations saying what they think. The 251 page document contains no recommendations, not even a conclusion, or any guidance. In comparison, the 2006 WHO report on Public Health, Innovation and Intellectual Property rights (CIPIH report), led by the former president of Switzerland, Ruth Dreifuss, contained 60 recommendations.
A Japanese saying goes: “what a man does not say is the salt of a conversation”. We can say that this report…is an insipid report…
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was first featured in a 2013 mailing of the South Centre, Geneva
Editorial
In May the World Health Assembly (WHA) will review progress on the implementation of its 2010 Resolution WHA 63.16 passing the WHO Global Code of Practice on the International Recruitment of Health. This was only the second non-binding code passed by WHO, after the 1981 Code on Breast Milk Substitutes, and its adoption was greeted with relief and optimism given the effort that went into it. Much of that pressure and momentum came from African regional bodies like the African Union, Southern African Development Community and ECSA Health Community and from their member states.
The Code contains some robust provisions for improvements of the health workforce within African countries and for responsibilities across countries, such as through bilateral agreements and leverage of international and national resources for the health workforce. The Code calls for health worker training and management systems within stronger health systems. It calls for coordination mechanisms that involve all players at national level. It sets provisions for information systems and data to monitor this. Article 7.2 of the Code provides for setting up and maintaining a database of laws and regulations on health personnel recruitment and migration. Although non-binding, it promotes accountability between countries as a means to track implementation, with a requirement for information on implementation on provisions of the Code to be reported to the WHO Secretariat every three years, and to the WHA.
So the stage was set for implementation, and the most enthusiastic implementation could have been expected from African countries. However in 2013 the activity, discourse on issues of health worker migration and sense of achievement and optimism that greeted the adoption of the Code are conspicuously absent.
In the report drafted by the Secretariat for presentation at the 2013 WHA only 13 African countries had established designated national authority, and by the end of 2012 only one African country had reported to the Secretariat on Code implementation. In total 81 countries had designated authorities and 48 had reported, but most of these were European countries. It seems thus that the situation has little changes since EQUINET last reported on this in an editorial in March 2012.
So if Africa continues to bear the brunt of the health worker crisis, if African stakeholders and countries have been so vocal and active in pushing for and negotiating for the Code up to its adoption, what is the reason for this lull in activity? Whither Africa?
The same questions asked in March 2012 are still pertinent. Why have African countries been slow to take advantage of the provisions of the Code to leverage benefit from them? Why have so few African countries established designated authorities to drive implementation of the Code or established bilateral agreements drawing on the Code to improve and retain their health workforces? Why has only one African country so far reported on the Code?
It will be important to understand these issues to inform future global health processes. The development process for the Code took nearly a decade since first mooted at WHO level, and longer taking other forums into account. In such a protracted process, the realisation of the Code may be interpreted as an end in itself. The champions for the Code may have changed, with loss of institutional memory, and those active in its negotiations may have moved on to other tasks at hand. Some have argued that the content of the Code does not reflect the original wishes of African countries for compensation or reparations, or for mutual benefits to be spelled out clearly. This may contribute to apathy for its implementation. As a voluntary, non-binding instrument it may be seen to have little effect. It may also be possible that without an active civil society lobby and with limited dissemination of information on the Code to local stakeholders there is weak pressure for its implementation.
The lull in activity since the adoption of the Code could be a lost opportunity to ride the tide of momentum and goodwill that characterised its adoption, a loss that may be difficult to reclaim. However there is still time for the concerted effort of the government and non-government players that played a role in the development of Code to apply their collective effort to ensure its implementation and to realise its benefits. At minimum the Code should be widely disseminated, discussed and follow up areas identified for national policy and diplomacy to support the training, management systems, health systems strengthening, coordination mechanisms, information systems and databases needed to ensure more equitable management across countries of health personnel recruitment and migration. There is need to set up mechanisms for institutional memory and processes that would run regardless of changes in personalities or of individual decision makers.
As a bottom line we are asking for the momentum and vigour that African health ministers, senior officials, professionals and civil society brought to the negotiation of the Code. It is not acceptable for African countries, having worked so hard and done so much to have the Code in place to let it fall at the implementation stage. As we approach the 2013 World Health Assembly we hope that the roaring fire of African voice that led to the Code has not become so hoarse during the negotiation that it is no longer audible!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The authors of this editorial are working on a research programme in EQUINET associated with the ECSA HC Strategic Initiative on Global Health Diplomacy to explore diplomacy on the Code. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
This month's editorial comes from the lens of a health worker at a rural hospital, with an appeal for policy to test itself against whether it supports and has involved those working at the frontline and reflects ground realities. In a few days time a global meeting will be held in Botswana to review the health dimension of global development goals. In the newsletter is a resolution from a meeting of local governments and communities in Guatemala that urges, as we would, for a reminder of the faces, voices, wisdom and importance of the local in that discussion. As evident from the many reports EQUINET has produced, national averages hide significant subnational and within area inequalities, many of which are growing, and social agency, community systems and frontline health services need to be given significantly greater profile in policies and goals seeking to deliver on rights to health.
There is a general perception amongst academics, government officials, non-governmental organisations (NGOs) and the South African public at large that as a country we have good policies, but that we implement these policies poorly (as reported by the South African Institute of International Affairs in 2011). In fact, one of the fundamental issues that we need to address as a country is to try to understand why, despite good policies, adequate amounts of money and more skilled workers than in most parts of Africa, South Africa performs so badly (especially in health and education) when compared to other African countries. The tendency of policy makers is to blame downstream factors, such as general lack of capacity , “lazy managers” or “obstructive clinicians”, which to some extent is reflected in the research.
But my job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life. Working in rural medicine is a bit like sitting on a rollercoaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips. The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available.
It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care. Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground. There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines).
But there are also many examples of policies and programmes that aim for an unrealistic gold standard (with its unnecessary and unhelpful complexity) and which, as a result, undermine the provision of good healthcare to as large a population as possible.
The first example of this is the new Road to Health Booklet. Although an extremely well-intentioned document, it is completely unrealistic to expect a busy primary care nurse to use this tool properly. It appears as if the designers of the document have never set foot in a packed rural (or township) immunization clinic, or tried to fill in the booklet with 60 screaming babies requiring injections in the waiting room outside. A year after it was introduced in our area, we still find that critical data such as mother’s HIV status and type of prevention-of-mother to child transmission (PMTCT) treatment provided is left out, whilst on the old, much simpler Road to Health Card, this was filled out really well.
Another example of where aiming for gold results in mud delivery is the District Health Information System (DHIS), a tool with so many parameters and different indicators that it is not actually possible to fill it out correctly unless each clinic has several dedicated data capturers with computers and technical support. As a result, much of the data is literally made up (I have seen it happen with my own eyes) and results in very poor quality data. At a recent meeting in my district, for example, several clinics had a higher than 120% coverage for measles vaccination. Yet managers and health planners scratch their heads and wonder why we get such poor quality data and complain that overloaded nurses at the coalface must just fill the data sheets out correctly. The DHIS needs to be simplified drastically, and nurses on the ground must get regular feedback on certain critical indicators that truly reflect improved care.
Many people balk at the idea of not aiming for a “gold standard” at a policy level – surely we must at least aim for the stars even if this isn’t really achievable?
Firstly, I would like to argue that we have ample evidence of how aiming for gold actually undermines the provision of care at grassroots level, and that we instead need to focus on simplicity and doing the basics really well. This would result in the biggest health impact on the greatest number of people.
Secondly, I think that we need to be cognisant of our limitations in terms of both human and financial resources in South Africa and recognise that we do not have the capacity to achieve gold right now, although it may be possible to aim for gold 20-30 years from now.
In the health sector we should be working within a framework of clear, straightforward priorities, aiming for what is achievable (silver?) and doing the basics extremely well, with simple monitoring and clear feedback to all healthcare workers.
I would like to argue that a policy cannot be labelled as “good” unless it is implementable. We need to recognise that putting policy together is the beginning of a long process. Policymakers need to be involved in drawing up implementation strategies, and government must support policy implementation through adequate finances and capacitating and empowering managers to manage the changes that will be required when policy is implemented.
Let me end with a final plea from the coalface that those of you who write policy use the following as your guiding principle: good health policies make things better and easier on the ground and result in improved patient care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was featured in a paper for the Public Health Association of Southern Africa newsletter at le Roux K. How golden policies lead to mud delivery – and how silver should become the new gold. Newsletter of the Public Health Association of South Africa. November 15, 2012. ). The views expressed are those of the author and do not necessarily represent the views of PHASA.
Hermann Biggs, a pioneering public health practitioner, said in 1894 that countries get the public health outcomes they invest in. “Within natural limitations, every community can determine its own death rate”. In this newsletter there are many facets of the choices made around this. The papers in all sections reveal a tension between the possibilities for significantly improved health, through new technologies and examples of promising practice, and of the resource and other barriers to their application. At national level, Charlotte Muheki Zikusooka questions in her editorial whether, for example, Ugandans are making adequate investment in “health for all” to get to “prosperity for all”. Other inputs focus on how the limited resources available are being allocated and spent. In 1894, when Hermann Biggs made his comment, global policies and practices had a less significant influence on health. Today their influence is growing. Various contributions in this newsletter recognise this, for example in the country call for WHO leadership in ensuring coherence in global health and for predictable innovative and mandatory international financing for health. The recently passed UN Resolution on the right to water and sanitation recognises both national and international roles in progressively realising the right to these profoundly important determinants of health. So if today we are adding to Biggs’ comment “… and we can globally determine the death rates of us all”, what rights and duties towards meeting public health costs does that imply?
As we turn the corner of 2010 and make our personal plans for 2011, it’s also appropriate to think about the plans and actions we will take to improve our lives as a nation. With election fever raging in my country, Uganda, there are more than enough promises on how to make Uganda a better country. However, some questions remain unanswered. For me, and possibly for many others, one area we need to give more attention to is the current and future health of our population. The question I pose is: are we heading towards “health for all”? Are we taking steps to achieve health care for all, more recently referred to as “universal health coverage”?
The World Health Organisation defines universal health coverage as “securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost”. In 2005, the World Health Assembly adopted a resolution urging its member states to work towards universal coverage and to ensure that their populations have access to the health interventions they need without the risk of financial calamity. This means that people should be protected from the costs of health care when they fall ill, that all people should access the services that are available to meet their health needs, and that services should meet conditions of quality and dignity, regardless of people’s ability to pay.
The goal for universal health coverage is; ‘No one should die because they cannot afford health care, and no one should be made poorer because they get sick.’ The questions we should grapple with are: how far has Uganda moved towards achieving this? And what specific plans are being laid for gradual movements towards achieving this?
It’s surprising to find that preventive and public health and health care were conspicuously missing from the principles and pillars of Uganda’s poverty reduction strategy of “Prosperity for All” (Bonna Bagagawale). For a long time, wealth creation and health have been considered to be inextricably inter-linked. People with ill-health cannot produce at their most desirable abilities, and poor people face many threats to their health. It can be a vicious cycle. Health or lack of health can be the difference between wealth and bankruptcy, especially when we consider the fact that one of the most common causes of poverty can be health care costs. In Uganda, households contribute about 49% of total health expenditure. We need to better understand the impact our health systems are having on people's health and wealth, and therefore on our economic growth as a nation.
In pursuing the goal of universal coverage for health, we should also look at how our health services are financed. In 2001, government officially abolished fee payment at public health facilities. This is one of the most commendable steps in moving towards achieving universal coverage. However, such an action would have been even more beneficial if was followed by additional actions that enhance faster movement towards “health for all”. Uganda spends about $27 per person on health per year, which is below the $40 per person recommended by the World Health Organisation for provision of a basic package. A significant proportion of the $27 spent on each person comes from external sources that are sometimes unsustainable. Sadly, even though fees have been lifted, about half of our total health funding still comes from direct cash spending by households at private health providers whose services are usually viewed to be a relatively better quality than those provided in government facilities.
This financing situation poses two problems. The first is obvious; our health sector is severely under-funded. Ministry of Health estimates current expenditure per person on essential medicines as only US$ 0.87 against an estimated requirement of US$ 10 per person. It is therefore not surprising that only 35% of the health facilities have six tracer medicines and supplies. The second is less obvious: financing a health system from people’s cash payments (out-of-pocket) is the most unfair, fragmented and least likely approach to take us towards “health for all”. Experts in health financing, in Uganda and the world over, acknowledge that universal health coverage cannot be achieved in contexts were countries have not effectively addressed the issue of equitable health financing.
So what do we need to do? Equitable financing is based on set of principles, namely: financial protection (no one in need of health services should be denied access due to inability to pay and households’ livelihoods should not be threatened by the costs of health care); progressive financing (contributions should be distributed according to ability-to-pay, and those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes); and cross-subsidies (from the healthy to the ill and from the wealthy to the poor). Uganda’s current financing systems may still be far from what we need to achieve “health for all”, but it is also possible for us to take the necessary steps to achieve it.
As Uganda turns a new corner into 2011, hopefully we can start building the road map and taking these steps to move towards “health for all”.
This editorial first appeared in New Vision Uganda on 4th Jan 2011. 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 EQUINET website at www.equinetafrica.org.
In this issue we provide in full the communique of the Second BRICS Health Ministers’ Meeting held in January 2013. How far does this emerging concerted voice provide new impetus for the social justice needed for equity in health? While the familiar commitments are included to reducing major disease burdens, there are also welcome signs in the communique of attention to dealing upstream with the "risk" environments for health, of assessing the impact on health "of all public policies at national and international levels" and of commitment to "community empowerment". Equally the communique refers to a commitment to implementing measures for technology transfer and co-operation across low and middle income countries, such as for ensuring production and access to generic medicines as part of realising the right to health. The communique was less clear on two aspects: the active role of the 43% of the world’s population living in BRICS countries in realising these commitments, and the regional solidarity and integration needed in each of their regions to ensure to benefit to the weaker economies of their regions.
The BRICS countries, represented by the Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, met in New Delhi on 11 January 2013 at the Second BRICS Health Ministers’ Meeting.
The meeting recalled the Delhi Declaration of 29 March 2012 during the BRICS leaders summit and the Joint Communiqué of the BRICS Health Ministers at Geneva of 22 May 2012 including specific areas of work under the BRICS Health Platform for each Member State, focussed on the theme “BRICS Partnership for Global Stability, Security and Prosperity” to address emerging health threats.
The Ministers recalled that BRICS is a platform for dialogue and cooperation amongst countries representing 43% of the world’s population. The Ministers reiterated their commitment to the Beijing Declaration of July 2011 for strengthened collaboration in the area of access to public health and services in BRICS States including implementation of affordable, equitable and sustainable solutions for common health challenges. The Ministers committed to strengthen intra-BRICS cooperation for promoting health of the BRICS population. The BRICS Health Ministers resolved to continue cooperation in the sphere of health through the Technical Working Group.
The Ministers drew attention to the current global threat of non-communicable diseases and noted that in 2008, around 80% of all NCD deaths occurred in low and middle income countries. The Ministers recognized the significant role of BRICS countries in the global process of prevention and control of NCDs including the Moscow Declaration of April 2011, the WHA Resolution 64.11 of May 2011 and the Political Declaration of the UN General Assembly of September 2011.The Ministers recognized the need for more research into the social and economic determinants leading to occurrence of non-communicable diseases, amongst the BRICS countries. They resolved to collaborate and cooperate to promote access to comprehensive and cost-effective prevention, treatment and care for the integrated management of non-communicable diseases, including access to medicines and diagnostics and other technologies.
The Ministers also recognized the need to combat mental disorders through a multi-pronged approach including the World Health Assembly Resolution 65.4, consideration of a Comprehensive Mental Health Action Plan through sharing of innovations in the field of Mental Health Promotion, diagnosis and management, exchange of best practices and experiences amongst BRICS countries.
The Ministers renewed their commitment to the WHO Framework Convention on Tobacco Control and stressed the importance of research and study by WHO and other stakeholders into the social and economic determinants of tobacco use and its control.
The Ministers recognized that multi-drug resistant tuberculosis is a major public health problem for the BRICS countries due to its high prevalence and incidence mostly on the marginalized and vulnerable sections of society. They resolved to collaborate and cooperate for development of capacity and infrastructure to reduce the prevalence and incidence of tuberculosis through innovation for new drugs/vaccines, diagnostics and promotion of consortia of tuberculosis researchers to collaborate on clinical trials of drugs and vaccines, strengthening access to affordable medicines and delivery of quality care. The Ministers also recognized the need to cooperate for adopting and improving systems for notification of tuberculosis patients, availability of anti-tuberculosis drugs at facilities by improving supplier performance, procurement systems and logistics and management of HIV-associated tuberculosis in the primary health care system.
The Ministers called for renewed efforts to face the continued challenge posed by HIV. They committed to focus on cooperation in combating HIV/AIDS through approaches such as innovative ways to reach out with prevention services, efficacious drugs and diagnostics, exchange of information on newer treatment regimens, determination of recent infections and HIV-TB co-infections. The Ministers agreed to share experience and expertise in the areas of surveillance, existing and new strategies to prevent the spread of HIV, and in rapid scale up of affordable treatment. They reiterated their commitment to ensure that bilateral and regional trade agreements do not undermine TRIPS flexibilities so as to assure availability of affordable generic ARV drugs to developing countries.
The Ministers committed to strengthen cooperation to combat malaria through enhanced diagnostics, research and development and committed to facilitate common access to the technologies developed or under development in the BRICS countries.
The Ministers renewed their commitment for effective control of both communicable and non-communicable diseases through cooperation in sharing of existing resource information, development of risk assessment tools, risk mitigation methods, referral systems, life course approaches, community empowerment, monitoring health impact assessments of all public policies at national and international levels.
Recognizing that an effective health surveillance, including injury surveillance, is the key strategy for controlling both communicable and non-communicable diseases, that surveillance is also the cornerstone around which the implementation of the International Health Regulations (2005) is based and further recognizing that the countries may be using different models for surveillance based on different realities and best practices, the Ministers committed to strengthen cooperation in the mechanisms for planning, monitoring and evaluating disease prevention and control activities and capacity-building for effective health surveillance systems.
The Ministers urged focus on the unique strength of BRICS countries such as capacity for R & D and manufacturing of affordable health products, and capability to conduct clinical trials. The Ministers called for strengthened cooperation in application of bio-technology for health benefits for the population of BRICS countries.
The Ministers emphasized the importance of child survival through progressive reduction in the maternal mortality, infant mortality, neo-natal mortality and under-5 mortality, with the aim of achieving the Millennium Development Goals. They confirmed their commitment to a renewed effort in this area and to enhance collaboration through exchange of best practices.
The Ministers discussed the recommendations of the Consultative Expert Working Group on Health on coordination and financing of R & D for medical products and welcomed the proposal to establish a Global Health R&D observatory as well as the move on holding regional consultations to set up R&D demonstration projects. The Ministers urged that the entire process, including priority setting, should be driven by WHO Member States and should be based on public health needs, in particular those of developing countries, with the cost of R & D delinked from the final products.
The Ministers reiterated their support to the continued discussions on the process of reform of WHO, to better respond to global challenges in programmatic, organizational and operational terms, including the future financing of WHO, and welcomed the proposal to establish a financing dialogue based on priorities collectively set by WHO Member States in a structured and transparent process.
The Ministers acknowledged the value and importance of traditional medicine and need of experience and knowledge-sharing for securing public health needs. They urged for cooperation amongst the BRICS countries through visits of experts, organization of symposia to encourage the use of traditional medicine, in all spheres of health.
The Ministers confirmed their support for the United Nations General Assembly Resolution on universal health coverage and committed to work nationally, regionally and globally to ensure that universal health coverage is achieved.
The Ministers recalled the Beijing Declaration of the 1st BRICS Health Ministers’ Meeting in 2011, emphasizing the importance and need of technology transfer as a means to empower developing countries. In this context, they underlined the important role of generic medicines in the realization of the right to health. The Ministers renewed their commitment to strengthening international cooperation in health, in particular South-South cooperation, with a view to supporting efforts in developing countries to promote health for all and resolve to establish the BRICS network of technological cooperation. The Ministers acknowledged the need of use of ICT in Health services to promote cost-effective treatment in remote areas. They encouraged strengthened cooperation amongst the BRICS countries to share their experiences in e-Health including tele-medicine. The Ministers agreed to cooperate in all international fora regarding matters relating to TRIPS flexibilities with a public health perspective.
The Ministers agreed to establish platforms for collaboration within BRICS framework and with other countries with a view to realizing the goals and objectives outlined in this Declaration.
This statement is drawn from the Government of India communique on the BRICS Health Ministers meeting at http://pib.nic.in/newsite/erelease.aspx?relid=91533. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
There is consensus that states have an obligation to ensure Universal coverage (UC), through creating and realising an entitlement for everyone to be protected against the costs of health services and to have access to the effective, quality services they need. From an equity perspective, social solidarity is essential to achieve UC, through income cross-subsidies (from the rich to the poor) so that payments are based on the ability to pay, and risk cross-subsidies (from the healthy to the ill) so that people access health services based on need and not ability to pay.
So what options do east and southern African (ESA) countries have to reach this goal? While there may be some distance before reaching UC, the choices made at this stage are critical for ensuring steady progress towards it.
The 2010 World Health Organisation’s World Health Report unequivocally states that it is not feasible to achieve UC through voluntary enrolment in health insurance schemes. A number of ESA countries are introducing community-based health insurance (CBHI) as one means of pre-payment. These schemes will not move a country towards UC, although they may temporarily assist vulnerable households until mandatory pre-payment funding increases considerably and user fees are removed. However there is a potential danger that their existence may allow governments to abrogate their responsibility to promote mandatory pre-payment funding mechanisms.
Voluntary schemes can only be complementary or supplementary to mandatory pre-payment financing mechanisms, including tax and mandatory insurance. From international experience, mandatory pre-payment funding is well over 60% (and often over 70%) of all health service expenditure in countries that have health systems that are regarded as universal.
Many African countries are now discussing or introducing mandatory health insurance (MHI) schemes. However, caution should be exercised. If MHI contributions are placed in a separate pool to benefit the contributors only (which often is the case) this creates a tiered and inequitable system that does not ensure that all have the same service benefit entitlements. If the goal is to achieve universal coverage, then it is critical to minimise fragmentation in funding pools to achieve cross-subsidies. This means that if MHI is introduced, the funds collected from it should be pooled with those from government revenue to fund benefits for the whole population.
There has also been some investigation into introducing MHI contributions by those outside the formal employment sector. This should receive more critical assessment than there has been to date, especially as such contributions are strongly regressive and generate little revenue. If there is political insistence on generating funding from those outside the formal employment sector, indirect taxes, such as VAT, are a more equitable and efficient mechanism for achieving this goal, particularly in low-income countries. However, in the context of the large income inequalities present in many east and southern African countries, efforts to improve the collection of taxes from high net-worth individuals and multinational corporations may be more appropriate. Further, some countries are generating revenue for health from royalties on natural resources such as gold, copper and oil, and not only from taxes.
There is often an almost automatic assumption that there is no ‘fiscal space’ to increase funding of health services from government revenue. It is important to critically examine this assumption.
Government revenues in ESA countries range widely from about 12% of GDP in Madagascar to 33% in the DRC, while government expenditure ranges from less than 13% of GDP in Madagascar to 33% in Mozambique. These ranges are considerably lower than the levels in advanced economies for both government revenue (36%) and expenditure (44%). Government debt levels are considerably lower in ESA countries, ranging from less than 26% of GDP in Zambia to 64% in Madagascar, than the average for advanced economies of over 100%. Given that all of these measures are expressed relative to GDP and that some lower-income countries are able to attain higher levels of revenue and expenditure, there does appear to be scope to explore increasing the fiscal space within the so-called emerging markets and low-income countries.
Health financing policy choices not only relate to how revenue is mobilised for UC. Purchasing involves determining service benefit entitlements (what services are purchased with the pooled funds and how people will be able to access these services) and how service providers will be paid. Attention should be given to more active purchasing. This requires identifying the health service needs of the population, aligning services to these needs, paying providers in a way that creates incentives for the efficient provision of quality services, monitoring the performance of providers and taking action against poor performance. Active purchasing is critical for ensuring that available funds translate into effective health services accessible to all.
Moving towards universal coverage also requires improvements in service delivery and management. In particular, emphasis should be placed on improving services at the primary health service level, which are effective in reaching the poor and which are able to address most of the health service needs of the population in ESA countries. Improving primary health services offers the greatest potential for increasing population coverage affordably. In addition, it is important to broaden the decision-space of managers at facility and district level, so that they can be more responsive to patients’ and staff needs and to the incentives created through active purchasing. Equally decentralisation of management responsibility should be accompanied by development of governance structures that allow for accountability to the local community.
East and southern African countries have some way to go in moving toward UC. The choices made at various points in the journey will be important for achieving that goal. While the detail of those choices will depend on the context in each country, international experience and regional evidence suggest that far more emphasis should be placed on government revenue funding for health services and that funds from mandatory health insurance schemes should be pooled with funds from government revenue. We also need a richer body of evidence, including from research, to support active purchasing of services and measures for addressing service delivery and management challenges, as these are essential if universal access to services of appropriate quality is to be achieved.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org and read EQUINET Discussion paper 95: McIntyre D (2012) ‘Health service financing for universal coverage in east and southern Africa’
Over the last eight years there has been an increased interest in the use of performance based funding to ‘strengthen’ African health systems. Performance based funding has been used in different ways in the past within countries. With its growing popularity at global level, we need to be clearer about how these funding models work in practice and how far the performance based agenda being advanced at global level integrates meaningful participation and partnership in building health systems in Africa. How much are African actors setting and shaping this emerging global agenda?
Performance based funding refers to the idea of transferring resources (money, material goods) for health on condition that measurable action will be taken to achieve predefined health system performance targets. These performance targets may relate to particular health outcomes, to indicators of delivery of effective interventions (such as immunization coverage), to the utilization of certain services (like HIV counseling and testing), or to meeting targets in relation to quality of care. Because performance based financing offers incentives for positive action, many global institutions promote it as a way to efficiently and effectively reform the way that health systems are planned, financed, coordinated and steered. This is particularly true of external funding in many low and middle-income African countries, where there is growing evidence to suggest that performance based funding is being championed by global and bilateral funders as a key innovation in health financing. Funding agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank claim that performance based funding promotes reform in a way that can also be locally owned and accountable. This argument is based on a claim that performance targets and indicators will be developed through the active participation of local actors from within various African states, rather than being set by global agencies from the top-down.
Despite increasing use of these arguments for performance based funding within global health policy, there is still a lack of consensus about what performance based funding actually means, and little evidence to support the assumed causal pathways through which diverse African health systems theoretically achieve the governance outcomes claimed. There is also limited evidence about the extent of local participation in the design of performance based initiatives, and particularly in how far African actors – governments, civil society, health services, individuals and the private sector – have participated in the design, implementation and delivery of performance based funding initiatives. It is thus not clear who is participating in shaping, deciding and adopting performance based funding agendas and goals and how these decision-making processes work. There are questions about how targets are set, who sets these targets, as well as about how ‘performance’ is measured, and what exactly constitutes ‘good’ performance.
These ambiguities raise concern about how performance based funding complements other key processes that aim to broaden participation within ‘global health partnerships.’ Partnership has, for example, become a key concept within the Global Fund, World Bank and WHO processes. Millennium Development Goal 8 refers to developing a partnership for development, and the Paris Declaration aims to increase the ability of national and local governments and stakeholders to engage with and shape health policy at national, regional and global levels. However, if we don’t know how far African actors do actually participate in the formulation, implementation and evaluation of initiatives such as performance base funding, it is unclear how far they meet these commitments towards more cooperative processes, where all stakeholders engage with and shape health policy. Given that participation is a key normative aim in debates about furthering more equitable health diplomacy, it is important to know whether and how far performance based funding, as it is currently being practiced, fulfills these normative aims and is (or is not) an effective strategy for reforming health system governance in a participatory and equitable manner.
These questions are being explored in collaborative research currently underway in EQUINET, through the University of Sheffield, Queen Mary University, the University of Zambia, the University of Dar es Salaam, the Ministry of Health Zambia and the University of Kwazulu-Natal, as one input to regional dialogue on global health partnership and equitable health system strengthening.
Performance based financing initiatives have potentially powerful effects on health systems. Their agendas and preferred performance targets become embedded in, and potentially shape, local and national forms of state governance, participation and authority. The current context of global actors devising and advancing such models makes it is critical for African actors to proactively and effectively access and engage in the processes that shape these emerging global health policies: from design (agenda setting) through to implementation and delivery. It is equally critical to know the possibilities and limits of the spaces and places for such participation, especially those provided for by global actors such as the WHO, World Bank and Global Fund .
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org