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.
Editorial
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).
We are living during a time of unprecedented threat and opportunity for the right to health. We are seeing cutbacks in the funding for prevention and treatment of HIV, retreats from commitments to ‘universal access’ to HIV and TB treatment, attacks on human rights and new threats to national and global health, including through climate change and food insecurity. At the same time there are new and better technologies available for health, new medicines and diagnostics for common diseases like tuberculosis, and an array of interventions that could improve health and reduce malnutrition. Some states, particularly South Africa and Brazil, are seriously seeking to improve health on the principle that health is a human right. But it is questionable whether they have the resources to do it. There are examples of growing global co-operation and legal agreement around social challenges, such as climate change, although not yet around the most immediate social challenges that face the poor. Activist movements exist around AIDS, health and around social justice.
The Commission on the Social Determinants of Health pointed to the demand for a response to this moment of contradiction between threat and opportunity from a leadership and governance that is driven by social justice. It stated: “In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.”
This is not a new call. It resonates with the recognition of the right to health as a human right found in the 1946 World Health Organisation Constitution, the 1966 International Covenant on Economic Social and Cultural Rights (ICESCR), the 1978 Alma Ata Declaration and the 2000 UN Committee on Economic, Social and Cultural Rights ‘General Comment 14’ on Article 12 of ICESCR. Increasingly it is also reflected in the incorporation of the right to health into the national constitutions of over seventy countries in the last decade.
Nevertheless good health and access to adequate health care services remains out of reach to billions of people. Nearly two billion people (a third of the world’s population) lack access to essential medicines and about 150 million people suffer financial catastrophe annually due to ill health, while the costs of care pushes 100 million below the poverty line.
The world is well aware of these facts. They are published by the WHO and others. When these facts are raised in international forums, it has led states to make bold promises….that they later do not keep. In Africa, 19 of the African countries who signed the 2001 Abuja Declaration to spend 15% of their government budget on health al¬locate less now than they did in 2001. Yet the WHO indicate that low-income countries could raise an additional US$ 15 billion a year for health from domestic sources by increasing health’s share of total government spending to 15%. Neither are high income countries meeting their promises. According to the ‘Africa Progress Report 2010’, published by a unique panel chaired by Kofi Annan, when the $25 billion Gleneagles commitment comes due at the end of 2011, the resources allocated by G8 countries will have fallen short by at least $9.8 billion. The panel calls this a “staggering shortfall.”
Does this mean that the right to health has no value? No. Has the right to health been sufficiently popularised or used? No. Are the state and United Nations institutions who have a duty to protect and realise the right to health fulfilling their obligations? No.
In the last decade AIDS activists have established in practice the principle that states must fund treatment as a right, with the organisation of resources globally to meet this obligation. Currently we are seeing a reversal of this basic entitlement, as the right to these resources are being challenged by arguments over cost effectiveness, a retreat from funding treatment in middle income countries, despite the fact that three quarters of the poorest people in the world live in middle income countries; and a claim that too much money is going to AIDS treatment, despite the fact that an estimated ten million people still need treatment globally. Some states in low income countries claim to have inadequate resources for health even while their political and economic elites grow visibly wealthier, and even states who have met the Abuja commitment try to fairly distribute unfairly inadequate amounts of money for health.
The Commission on the Social Determinants of Health called for conditions that would enable civil society to organize and act in a way that promotes and realises the political and social rights affecting health equity. It seems that we should go further than this, given the reversals in progress and growing inequalities in health. We need to see the level of activism by civil society as a key social determinant of health. The fight for health should be a central pillar of all movements for social justice and equality, not in the abstract, but for the specific goods, institutions, demands and resources that will realise the right to health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.This is an edited extract of a speech given at the Southern African Regional Dialogue on Realising the Right to Health in March 2011. For more information on the issues raised in this op-ed and for this and other presentations made at the conference see: www.section27.org.za.
Grace was born in a family of 9 children. She was still in school when her mother became ill, so she dropped out to care for her. She married when she was young. “God blessed us with 2 children, both girls. Then my two children and my husband died of AIDS. I too have HIV and will never marry again”, she says. When her husband died she had no support for her life as their property was taken by her late husband’s relatives. She was left with nothing and helpless. She did not want to do commercial sex work, but she couldn’t see another option, and it gave her a means to earn enough to live a poor, risky and insecure daily life in Lilongwe.
This is not an unusual story. For some even younger than Grace, the AIDS epidemic has increased the risk of sexual, physical and emotional harm and neglect. Young women and children who have been deprived of care and support are particularly susceptible to working in the commercial sex industry. They face risk environments for HIV transmission for themselves and their clients, as well as of violence and other forms of abuse.
Today the story, at least for Grace, is different. She describes the changes she has brought in her own life and in her community. She herself has a more secure and healthy life. She also talks about commercial sex workers that have now accessed loans and are moving out of bars and running small businesses. Others have gone back to school. A meeting of women involved in commercial sex work raises rights and decisions, where to get counselling, testing and treatment for HIV, how to get greater control over their sexual activities and fertility, and how to build skills for other forms of work.
Grace points to the lever for this health affirming change - theatre.
“In 2007 some of us in commercial sex work trained on legislative theatre. Theatre for a Change contributed to the transformation of my life.”
Theatre for Change in Malawi equips socially and economically marginalised communities with the communications skills, knowledge and awareness to transform their lives and the lives of others personally, socially and professionally. In Malawi, it works with groups including commercial sex workers to reduce the risk of HIV. It involves women from the core group of former commercial sex workers who work as peer facilitators among younger people getting involved in sex work. Through the theatre and by performing their stories to a variety of audiences, the women access a voice and a platform to raise concerns and open debate. The process known as Legislative Theatre. The performances involve the audiences in coming up with solutions to the issues these women face, in the process changing attitudes and catalysing change in both the women themselves, their communities and even in policy makers when they are involved. The theatre work is supported by other programmes to provide access to female and male condoms, to HIV testing and counselling, and to relevant health services, including antiretroviral treatment. These services are available, but their uptake has been blocked by barriers like stigma. This process provides a vehicle for raising the health, gender and sexual rights and responsibilities of sex workers and their clients.
As Grace comments: “Now I know my rights and no one can violate my rights. I have self esteem and I am able to make decisions about my own body.”
It is already known that it is more effective to send former commercial sex workers to mobilise and reach out to others, as much as positive peer pressure from men has influenced other men to go for testing and counselling. For the women who have been involved in commercial sex work, the theatre work has helped to reach other commercial sex workers, especially adolescents. It has led to greater openness on health problems and changed attitudes towards commercial sex workers, including amongst the health workers who used to stigmatise commercial sex workers.
Those involved learn while they teach. They are trained in psychosocial issues and counselling to support their interactions with people of different ages, gender, place and occupation. They also build a more affirmative view of themselves, from being victims of economic insecurity and social stigma to people who plan and set goals for their own and their family lives.
Grace sums it up: “Everyday of my life brings an opportunity for a new beginning…I waste not a moment mourning yesterday’s misfortunes, defeats and challenges. These have been my stepping stones."
While antiretrovirals provide a therapy for the physical effects of HIV and AIDS, it seems that theatre can also be a powerful and equally necessary therapy for its social effects.
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, a film and further information on the Theatre for a Change programme visit www.tfacafrica.com/What-we-do/TfaC-in-Malawi/Sex-worker-programme
In this issue of the newsletter one author claims that this may be a year of a ‘perfect storm’ in health, where increased knowledge, widening health priorities, new institutional coalitions, economic challenges and innovations coalesce to create new ways of doing things. Some of these new approaches could advance health equity. For example in this newsletter there are contributions that call for a shift in focus from intellectual property as a stimulus for innovation in health technology to innovative policies for equity in research and development; from aid effectiveness to development effectiveness; or from downstream medical interventions to more upstream measures addressing the population-level determinants of ill health. Debates at the recent WHO Executive Board on reform of the organisation raised issues of equity in its leadership, organisation and funding. At the recently held World Social Forum, an ‘African Consensus’ presented alternative thinking about the continent and its economic and social development to the rapid liberalization and privatization policies of the ‘Washington Consensus’. Bona Chitah's editorial suggests that translating new thinking into health equity outcomes calls for feasible technical options, but more deeply demands an ethical foundation that is clear, shared and strong enough to navigate and sustain implementation, whatever the tide.
Much attention has recently been given to raising an adequate level of resources for health, especially to achieve goals of universal coverage. But if these resources are to reach those who need them, we also need to allocate resources fairly. This is particularly important given the very different access different social groups have to health care. In spite of the recognition by many countries for needs based resource allocation, including my own country, Zambia, our experience suggests that we still face many obstacles to put this intention into practice.
Data in Zambia shows, for instance, that although the allocation formula was radically revised with policy support in 2004/5 to incorporate deprivation and population weights, the new formula has still not been fully implemented. We realize that applying a formula to redistribute resources on the basis of need is not just a technical issue, but has significant political implications. We found in our research in 2007 and 2010 that applying a formula that takes deprivation into account in Zambia implies a loss of over 30% of revenue for the wealthiest districts, if immediately implemented. This raised considerable resistance towards an immediate implementation of the revised formula from key stakeholders such as district health management teams, as well as from the political leadership in the affected districts.
Allocating a fair share of health care resources to those with greatest health need is not only an ethical issue. It also makes public health sense to reduce the burden of disease, improve the uptake of health care and reduce avoidable inequalities in health. It makes economic sense in terms of poverty reduction and improved productivity, Needs based allocation of resources combines with other elements of priority setting in health, including the setting of basic entitlements and ensuring the effectiveness of health interventions. So why have we faltered in achieving this goal?
A common explanation is that the available resources are too limited to allocate equitably. How do you distribute an unfair total amount fairly? Prior work in EQUINET has shown that it is easier to reallocate new resources equitably when budgets are increasing than to redistribute static or shrinking budgets. In 1995 to 2006 in Zambia, according to the Ministry of Health, the total health expenditure per capita ranged from $17.50 in 1999 to $58.00 in 2006, but the government share was only between 8 – 14 per cent of this. The resource allocation formula was applied only to the recurrent budget, and between 2004 and 2009, the per capita recurrent budgets to districts ranged between only US$1.50 and US$ 4.14. How much impact can be achieved on inequalities in access and coverage health when such limited resources are being reallocated? So even though fair resource allocation is a demand that arises from the scarcity of health care resources, it is itself limited by that scarcity. Breaking this vicious cycle would be important for equity.
It is thus a problem that the significant resources that come from external funders are not themselves subject to a needs based resource allocation formula. National Health Accounts data in Zambia show that 44% of health finances are spent on district health services comprising the district health management offices, district hospitals and health centres, and 20% on provincial and tertiary facilities. Of these expenditures, the share of external funding was 42%, and funding earmarked for HIV/AIDS made up almost 25% of this. These funds are disbursed as vertical funding for specific targeted programmes and purposes. The funds are distributed primarily to achieve geographical coverage, with less concern for equity, as has been the case for Prevention of Mother to Child Transmission and general ante-retroviral treatment programmes that command significant resources.
While the adequacy of funds available for reallocation and the segmentation of external funds may weaken resource allocation, there is a deeper issue: Priority setting - and thus allocation- has not been strongly grounded in ethical values or social norms. It makes a difference whether financing decisions, including those related to the allocation of resources, are based on the pursuit of equity and social justice, on utilitarian issues of efficiency, including economic efficiency, or on an egalitarian liberalism that aims for steadily improving coverage, complemented by individual actions to enhance uptake.
The lack of a shared ethical premise supporting resource allocation may be the most significant constraint to advancing the fair allocation of resources. Experiences of resource allocation in Zambia suggest that reforms aimed at enhancing fairness in resource allocation falter more easily when they are not protected, or demanded, by a strong expression of social norms and values. It could thus be the key factor leading to uncertainty, and sometimes failure to implement resource allocation in a consistent and committed way for the effective strengthening of the health system in low resource settings. So while we build the technical measures and institutional capacities to more fairly allocate the resources for health, we also need to ensure that the ethical foundation it is based on is clear, shared and strong enough to sustain implementation on the face of the other blocks we face.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed, and reports on equity in resource allocation please visit the EQUINET website at www.equinetafrica.org.
This month's editorial draws our attention to the shift the profile on universal coverage has brought in the international debate on global health. Much of this dialogue on universal coverage has been focused on financing issues. However universal policies cannot be only technical, or financial. A December 2010 World Conference on Universal Social Security Systems in Brazil put it simply - universal policies are the means to deliver on rights based guarantees that citizens are entitled to and that states have a duty to ensure, including access to health care. At national and global level there is a huge gap in how this is delivered on. Researchers from Africa, Asia and the Americas observed in a statement at the final plenary of the first Global Symposium on health systems research: “Equity is the central goal. Universal health coverage is the means of achieving equity”. As experience has taught in many places, closing this gap, nationally and globally, calls, beyond technical options, on political leadership and social power and action. What we say and do within and across all our different constituencies will be pivotal in realising universal policies in health. We wish you a safe, healthy and peaceful new year and look forward to our interaction towards equity in 2011.
Today, over 100 million people are cast into poverty each year because they have to pay for health care services “out of pocket”. The lack of adequate social protection in health and the lack of health care coverage in case of ill health, plays a decisive role in the scandalous inequity in access to proper health care - challenging all countries, not least those in Africa.
On November 22-23, 2010, on the occasion of the presentation of the World Health Report (WHO) Report for 2010 on ‘Health Systems Financing – the path to Universal Coverage’, the German Federal Government, together with the WHO, convened an International Conference in Berlin. The gathering was attended by almost thirty Ministers of Health from all over the world together with government officials, politicians, some researchers and a few non government organisations.
Everyone agreed on the aim to achieve universal coverage. Remarkably the model that was presented by WHO concerning this doesn’t speak about just going for “some coverage” or essential minimum packages for the poor, but demands from all countries to do their utmost to set up pooled funds that cover three dimensions: expanding the number of people covered, expanding the scope of services and reducing cost sharing (direct payment such as user fees).
WHO General Director Dr Margaret Chan who addressed the audience at the beginning raised the demand to get rid of user fees, because "user fees punish the poor". All countries have people who are too poor to contribute financially to health care. They need to be subsidised from pooled funds, generally tax-based health systems. Out of pocket payments have to be reduced by promoting prepayment and pooling systems (tax-based or mandatory social heath insurance). All agreed that there is no ‘silver bullet’ that serves as a solution for all countries. There is no global scheme that has to be "adopted" by all countries, but the need is to “adapt” a way to move forward in the three dimensions (population covered, the scope of services expanded and cost sharing reduced) at national level. Universal coverage cannot be achieved by connecting access to health care with individual purchasing power, but only by solidarity. This means that people who are richer also contribute to the health needs of those who are poorer. By articulating these principles, WHO has opened space for national adaptations. This provides civil society organizations with the opportunity to continuously engage and challenge their governments on their delivery on these principles, such as what they are doing to expand the scope of services.
With exception of few participants nobody mentioned private companies as relevant actors. Achieving universal coverage requires the strengthening of health systems. Ensuring affordable access to health was ultimately seen to be a public responsibility and not to be relegated to private insurance companies. Participants from Africa reiterated the 2001 Abuja Declaration to allocate at least 15% of annual government domestic spending to the improvement of the health sector.
To ultimately realize the right to health, governments have to create the needed fiscal space. In this regard, the 2010 World Health Report mentions as possible new sources of revenue: a special levy on large and profitable companies, a currency transaction levy, a financial transaction tax, and the so-called sin-taxes (alcohol, tobacco). No reference was made to ‘for profit Public-Private-Partnerships’.
In the context of global responsibilities, the report states that countries providing overseas development aid should do more to meet their international commitments, by providing a more predictable and long-term flow of aid.
We should not be surprised to find that a ministerial conference also produces nice and bubbly words. Some of the presenters mixed up risk-sharing with solidarity-actions. And when it came to actions many preferred to be vague in their statements. Nevertheless, there is an interesting shift in the international debate on global health. Thirty two years after its first use, the concept of ‘Health for all’ is back on the agenda.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the 2010 World Health Report, www.who.int/whr/2010/en/index.html , the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/
When the first Global Symposium on Health Systems Research, held under the theme "Science to Accelerate Universal Health Coverage" ended a week ago, after hearing the concluding statement (included in this newsletter), many people went back to heavily fragmented health systems with very different experiences of access and service for different social groups. The two editorials in this newsletter take the issue of universal coverage to the real time of the policies and interests being negotiated at country level in South Africa. The discussion by Di McIntyre on national health insurance in South Africa points to the importance of perspective and clarity on the long term implications of choices being made in the current debates on national health insurance; while the report by Jacky Thomas of SANGOCO points to the measures civil society are taking to move from issue specific to common platforms, to challenge unhealthy divisions in systems and in society. Together they raise the challenge of twinning perspective with knowledge, and knowledge with organisation, to build universal, integrated health systems.
There has been considerable media debate about the proposal to implement a National Health Insurance (NHI) in South Africa. This editorial attempts to unpack the options that face South Africa by painting scenarios of where we could head. These scenarios focus on two key elements of current debates: firstly whether this major health system reform will be ‘affordable’ and ‘sustainable’; and secondly, whether we are able to achieve an integrated health system or are destined to continue to have a highly fragmented health system.
It appears that we have essentially four scenarios for the South African health system:
1: the ‘no go’ option
2: the unsustainable, ‘divided forever’ option
3: the sustainable, ‘second rate’ health system with fragmentation option, and
4: the integrated, ‘healthy nation’ option.
The starting point for considering what health system changes would be helpful is to be clear about the path on which we are currently set. Our health system is heavily fragmented. A key division is between those that are medical scheme (private insurance) members (16% of South Africans) and those that are not (the remaining 84%). Health service access is very different for these two groups.
Our current health system is ‘second rate’ in many ways. For increasing numbers of families, medical scheme cover is just not affordable. In the early 1980s, medical scheme contributions for a family took about 7% of average formal sector wages and salaries. This had increased to a staggering 30% by 2007. The challenges facing the under-resourced public health sector are well known. There is no question that change is needed, and needed soon.
If this is not the direction in which we want to head, where do we want to go? Some argue that we need to pursue ‘social health insurance’ (SHI) – the ‘divided forever’ scenario. It is proposed that everyone who is formally employed and who earns more than the income tax threshold should be required to have medical scheme membership. The problem is that this scenario is a very expensive option. R1 in every R10 spent in South Africa would have to be spent on medical schemes alone, for the benefit of less than 40% of South Africans.
This scenario is called ‘divided forever’ because it will entrench a fragmented two-tier system between the haves (those that have insurance cover and access to any health service they desire) and the have nots. Proponents of this path argue that SHI is a logical step towards universal coverage. But experience in other middle-income countries, notably many Latin American countries, shows that it is very difficult to overcome the divisions created by SHI once they have been entrenched.
Many believe that, instead, an integrated system is needed. What is so prized about such a system? The global call for progress to universal health systems is based on the following two principles:
That no one should have their livelihood threatened because they have to pay for health care, i.e. that all citizens should be provided with financial protection from health care costs; and
That all citizens should be able to access the health care they need.
In order for these principles to be realised, an integrated health system is needed. It simply doesn’t work to have all the richer, healthier people contributing to and benefiting from one funding pool (or worse, a number of fragmented pools) and all the poorer, sicker people in a completely separate funding pool. You end up having a lot or most of the money for health care going to serve a relatively healthy minority and very little money available to provide health care for those who bear most of the burden of ill-health.
One way of pursuing an integrated system is to attempt to cover everyone using the current medical scheme model. However, this would result in more than R2 in every R10 that is spent in South Africa going to cover the entire population via medical schemes. For this reason, this scenario has been called a ‘no go’ – no country in the world has such a system and it is not something worth even considering for South Africa.
I believe that it is possible to achieve an affordable or sustainable and integrated system. Everyone agrees that the first step is to substantially improve services in the public health sector. There is much to be done, both in terms of improved management and resourcing. Some say: “why not just focus on improving the public sector”. The most valuable and scarce resource in the health sector is that of health professionals. We could be utilising the human resources we have far more efficiently and equitably than at present. However, this is only possible if we have a large integrated pool of public funds that can be used to purchase health services from public and private providers for the benefit of all South Africans. It is not simply a matter of focusing on improving the public sector. We need to change the way in which health services are funded if we are to effectively use the health professional resources in South Africa so that everyone can access health services on the basis of their need for care and not on the basis of their ability to pay.
Ensuring affordability in a universal health system requires other changes. Two things are particularly important. First, it is critical to have high quality primary level services and for primary care providers to determine access to specialist and hospital inpatient care. Second, we need to change the incentive structure for health care providers. At the moment, we pay private doctors and hospitals a fee for every service delivered; the incentive is to provide as many services as possible. International experience clearly demonstrates that changing the way of paying providers is necessary to secure greater value for money.
The ‘healthy nation’ scenario is what I believe public debate should focus on. Surely we can all agree that we do not want to continue on the current path (the ‘second rate system’)? Instead of saying that health system change is unaffordable, let’s focus on how we can achieve a sustainable, integrated health system that benefits all. A health system that brings our nation together rather than dividing us further.
This editorial has been modified by the author from a longer version published in the South African Independent Online media – the Mercury, the Star and the Argus. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.