Anna Marriott is Health Policy Advisor for the Development Finance and Public Services Team at Oxfam.
The international health community had been long-awaiting last week’s launch in Berlin of the 2010 World Health Report. Its theme was how to finance health care to achieve universal coverage. Oxfam and others began with a stunt in front of the Brandenburg Gate, highlighting the devastating impact of user fees in denying health care to millions of patients; WHO Director-General Dr Margaret Chan spoke to this same issue just an hour later.
A number of health ministers gave inspiring presentations but it was disappointing not to hear from Sierra Leone. Its government stopped user fees for mothers and children in April and the results have been instant and dramatic. The WHO says that malaria treatment for children there has shot up 372% and the number of women giving birth in hospital doubled in the first month – and is still rising.
Three big problems stop countries from moving closer to universal coverage: (1) they lack resources; (2) they over-rely on direct payments, that is, patients paying out-of-pocket and (3) what resources they do have are not always used efficiently or equitably enough.
To achieve health care for all by 2015, low-income countries (LICs) will need to be spending around $60 for each man, woman and child each year by 2015. But only eight of them have any chance of generating this from domestic resources alone. Aid and new financing tools (including financial transaction taxes) must plug the hole. In fact, if rich countries fulfilled their aid pledges now, the WHO says that the financing gap to achieve the Millennium Development Goals would be eliminated overnight.
Countries waste between 20 and 40% of their health spending due to inefficiencies, according to some estimates. A big slice of this is because of unnecessarily high prices for medicines, as well as their irrational use. Inefficiencies are also caused by not spending enough on things like health worker salaries, which leave staff little choice but to spend time raising income elsewhere.
User fees are the most regressive way of paying for health care. A country can never achieve universal health coverage if it over-relies on direct payments. Solidarity is key here – countries must redistribute resources from rich to poor and from healthy to sick by pooling and reallocating them according to need. The WHO has introduced an important target for all countries to reduce direct payments to only 15-20% of total health expenditure. This is the point at which financial catastrophe and impoverishment as a result of ill health falls to a negligible level.
The WHO cautions against fragmented and voluntary health insurance schemes, which work against efficiency and equity – but it should have gone further. Even social health insurance does not have a good track record in poor countries because so many people are employed informally. Oxfam’s paper on health insurance has covered these topics. Most importantly the WHO is clear that in every country there will be a proportion of people (sometimes very large) who cannot afford to pay anything toward their health care. Countries that have made the most progress towards universal care pay for these people’s health care with taxes.
The report is optimistic that, no matter how poor, countries can make immediate and significant steps to remove direct payments and move towards health care for all. In that sense it takes us back to the core of the 1978 Alma Ata ‘Health Care for All’ Declaration. The report puts the WHO back where it belongs – at the centre stage of setting the international health agenda. We wait now for other donors lagging behind on the topic of health financing, including the World Bank, to put their full weight behind the WHO.