Collection, editing, titling and introduction: Emmanuel Ngabire, February 4th 2013.
The UN UHC resolution: yet more havoc in low-income countries to be expected...?
The debate was launched on December 13 2012 by Alex Hakuzimana, from Rwanda, when he forwarded a UHC Forward message entitled “U.N. votes in favor of universal health coverage resolution” to the PBF CoP. Exchanges followed each other up very rapidly - by the end of the 1st day of the debate we already counted 12 interventions. Overall, the discussion was constructive, and if occasionally a more offensive style was used, other participants (or the CoP facilitator) tried to refocus the debate in a gentle but firm way. In a very measured response, for example, towards the end of the discussion, Jurien Toonen acknowledged that having this “PBF & UHC” discussion was very valuable, as this is what the CoP is all about. Yet, he also emphasized that the discussion could be even more useful if some structure was brought to it, avoiding a mix up of roles and mandates in the discussion– between international organizations, policy makers in LMIC, implementers, academics and beneficiaries. Surely something to consider in future CoP discussions. But first things first. Who really got the discussion going? Well, Robert Soeters (from SINA Health International) was the first to react to Alex’ forwarded mail – so credit goes to him for triggering the discussion. Pointedly, he noted that ambitious declarations are all very nice and wonderful but their problem is that they typically do not clarify who will bear the financial responsibilities for all these lofty aims – i.e. “who will pay the bill” - nor do they look at the cost-effectiveness and sustainability issue. He further stressed the risk that populist politicians may confound UHC with free healthcare and launch rather populist policies based on the declaration, the way it happened with Burundi’s pre-payment system, “Carte d’Assistance Maladie” (CAM). In resource-poor settings (like low and middle-income countries), a PBF mechanism can boost cost effectiveness
The issue of “who will pay” was reiterated by different CoP members who also noted that we have seen similar lofty international and national statements and declarations before (like Alma Ata (Health for All) or the Abuja Declaration). In their interventions, not all discussion participants made a clear distinction between UHC and universal health care, not unlike what happens in the general UHC debate.
Laurent Musango from WHO AFRO then intervened to bring attention to the entire health system: changes in one health system component can and do affect other components in different ways, he argued. So the discussion shouldn’t only focus on health financing, but should also take into account other health system components, and preferably so in a synergic manner. With the new declaration, the direction of health systems is clear, though: Universal Health Coverage. Along the same lines, Pascal Birindabagabo added that the UHC momentum should be supported. He also proposed that middle-income and developing countries should mobilize domestic funds to support UHC in their countries.
… or a crucial means to keep governments accountable?
The risk that the UHC declaration remains just a set of fancy words without much operational significance was also recognized by Joseph Kutzin from WHO Geneva. However, he strongly emphasized the importance of such resolutions. His experience has taught him that resolutions like these are tools that civil society organizations can use to hold countries accountable for their commitments. It’s a gentle “stick” to align country decision makers’ actions with the declaration. After highlighting the added value of such UN resolution, Joe also clarified the meaning of UHC as conceived in the World Health Report 2010. In the report, WHO did not say that UHC means “everything for everyone, free of charge”. The definition WHO uses means instead that everyone gets the services that they need, of good quality, and at cost that doesn’t impoverish them. If you operationalize this concept, Joe continued, it’s clear that UHC should be understood as a direction rather than a destination. No country - not even the richest one - is able to fully close the gap between the need for and use of services, but all countries want to reduce that gap, to improve quality and improve financial protection. Context-specific policy measures addressing the health and development priorities of a given country then become possible.
Joe acknowledged PBF has obvious appeal for him as he sees strong potential links between the PBF approach and a core message on health financing for UHC: the need for a coordinated approach to policy rather than single-instrument “magic bullets”. PBF is a means for system building through coordinated policy action. The Burundi experience of linking PBF to free care was a case in point, he argues, as it’s an example of coordinated policy.
Do such lofty resolutions really take our reality into account?
According to Longin Gashubije from the ministry of health in Burundi, UN delegations who promote these declarations in New York tend to live far from the reality on the ground in low-income countries. Since Alma Ata, UHC has been dreamed of but unfortunately not reached in countries like Burundi. This is due to various reasons including repeated wars, expectations which were set too high, weak economic growth, lack of societal and cultural progress etc. All these factors can explain the failure to reach the previous declarations on UHC. To these root causes, Mohammad Muhammad from Nigeria added another factor, corruption. He called on African leaders to open their eyes: they need to realize that UHC is not realistic in corruption-prone countries characterized by a myriad of developmental needs and scarce resources. Longin also argued that today the financial gap is far too big (more than 50% of the government budget), and as two thirds of the people live below the poverty line, government priorities can’t be too ambitious in countries like Burundi and should focus on the poor’s needs first of all. Obviously, the health financing burden is too heavy for the government, and Burundi’s partners will have to step in, he continued. But external resources can’t solve everything. Cultural progress is at least as important, he concluded.
Seize the global window of opportunity, promote good practices
Bruno Meessen from the Institute of Tropical Medicine at Antwerp then chipped in. In his opinion, the UHC resolution goes in the right direction as it opens the window of opportunity even further for the CoP members who develop better health care financing systems at country level. Bruno also advised CoP members to read again carefully the WHO Report 2010 as it clearly stresses the need to find mechanisms to be more efficient with resources. Hence, PBF can and should capitalize on the current UHC momentum, even more so now that the world is increasingly moving away from simple “blue prints”. The complexity of UHC and the need for context-specific approaches are more and more acknowledged nowadays. Furthermore, Bruno reminded people that the declaration is not just relevant to Africa but also to middle-income countries, where UHC has gained momentum recently in countries as diverse as China and Mexico. UHC is even relevant for high-income countries like the US (“Obamacare”), so it’s very much a Universal Declaration. Like many other economists, Bruno also hopes that in a not too distant future, the fiscal space for UHC will increase in many African countries. Soon, ministries of finance might invest national resources and increased revenue more in innovative schemes like PBF, he argued. Nevertheless, he agreed that in many African countries we need more than just nice words. In this respect, he also referred to the perspective of the AIDS movement, which is apparently also not very happy with the declaration, as the declaration’s section on “sustainable financing mechanisms for universal health coverage” fails to mention international health financing. Many AIDS advocates ((like Gorik Ooms) call instead for a mechanism enforcing structural transfers from rich countries to poor countries, from a right to health perspective.
Robert Soeters made a second intervention on December 14th pointing out the consequences of - what he called - the “sweeping generalized statements” of these declarations. Country realities differ in terms of resources, organization and culture, yet, lofty declarations often inspire Ministries of Health or Presidencies to ignore this reality. Robert emphasized that this may then create opportunities for populist decisions that can destroy the quality of existing health services. He gave the example of Burundi where the CAM pre-payment system was promoted and “conceptually endorsed by WHO” without defining how to finance it. The predictable result was the degradation of health facilities and reference to extremely expensive private services.
On the responsibilities of those setting the agenda at global level (and WHO in particular)
In his opinion, advocates of UHC should develop more realistic and responsible proposals adapted to the context of low- and middle-income countries. Efficiency also matters, Robert argued, and there he called on international organizations such as the WHO to also consider PBF as this approach has increased the motivation of many people in low-income countries. Alluding to 2011 skeptical articles in the WHO Bulletin and a recent Cochrane Review (which basically concluded “we need more evidence”) he stressed that criticism of PBF without coming up with good alternatives on how to finance quality health services is rather irresponsible – in fact, it can lead to situations like in Zanzibar MoH, where, despite quite some initial enthusiasm about PBF, they are now in a health policy limbo as they were told to doubt PBF given recent literature on the approach. Dr. Soeters encourages debate about social aims in the PBF CoP, but only if necessary nuance on cost, efficiency and sustainability is foreseen. In his opinion, for example, the sustainability of health systems requires that they cannot be simply financed by external aid agencies in LICs.
In a second intervention, Joseph Kutzin then explained that UN resolutions by their very nature cannot contain details like sources of funds. They are inevitably a compromise and can’t be very specific, that’s the price you pay for broad support. So it’s important to have realistic expectations about what can come from a UN resolution. The resolution is a sign of growing political support for Universal Coverage, Joe said. These declarations do not provide details but, they are nice instruments to hold governments accountable and they can be more powerful when picked up by – national and/or international - civil society groups.
Joe also rebutted some of the claims Robert Soeters made about so called “WHO positions”. Unlike what Dr Soeters implied in his intervention, WHO did not “conceptually endorse” Burundi’s CAM, as this is a voluntary health insurance arrangement. Both the WHR 2010 and Kutzin’s recent article in the Bulletin made it abundantly clear that voluntary health insurance is not a viable path to universal coverage.
According to Joe, Robert also suggested WHO is not very interested in efficiency. In response, Kutzin referred to the World Health Report 2010 where a whole section (“more health for the money”) focused on efficiency. He also referred to his recent Bulletin article in which he also argued that you can’t simply “spend your way to universal coverage”; costs have to be managed and addressing the leading causes of inefficiency need to be priority targets for reform.
A good dialogue requires a common platform but also an understanding of our respective roles
The debate continued with a contribution from Bruno Meessen connecting the positions of decision-makers and technicians. He reminded CoP members that getting the voices of practitioners and implementers heard is a major concern of (and in fact one of the rationales behind) the PBF CoP. He acknowledged the frustration caused by inappropriately designed and underfunded policies and mentioned that too often country leaders fail to listen to their technicians. He highlighted that nevertheless, political leaders willing to introduce UHC should be fully supported as they can mobilize their citizens. So PBF proponents need to surf on the current UHC wave. Also, bridges with decision makers need to be built so that technicians will be heard in time and mistakes prevented. He believes one day the CoP – intended as a platform to bring together agenda setters, policy makers and implementers – will ensure such a relationship of trust. Having said that, for the moment the emphasis of the UHC movement is too much on agenda setting, Bruno continued. It’s time to match this with an equal effort to address the stages of policy formulation and implementation: the ones in charge of formulation and implementation also need to be supported and properly resourced.
Jurien Toonen (KIT, Amsterdam) then highlighted the need to bring some structure to the discussion, and avoid a mix up of roles and mandates in the discussion on health financing and providing care and social protection, between international organizations, policy makers in LMICs, implementers, academics, advocates and beneficiaries. He elaborated on the role and mandate of each of these actors. International organizations have a role in developing a vision and strategies to bring coherence to different types of health strategies. Alma Ata, Investing in Health (World Development Report 93), the MDG for Health,… all provided impetus, even if they all had flaws. Now, perhaps one might think UHC is “the world’s new flavour of the week”, but it is because the world has learned something: UHC is more health system-wide than its predecessors, and pays more attention to the most vulnerable people. Or as Tim Evans put it in Bangkok: UHC’s starting point is “the unbearable injustice that too many have no access to health care”. Anyway, there’s no need to blame international organizations (and certainly not WHO) for providing vision, Jurien argues. As for policy makers in LMICs, they have chosen to embark on UHC, even if they live in countries not comparable to China and the US. They might struggle to make it happen, but the good news is that they are finally more able to get the Ministry of Finance interested in health care because of UHC. Unfortunately, the Ministry of Finance people often think, wrongly, that UHC is like free health care or health insurance, but things are improving. In many countries, a dialogue is starting on sound health financing – stakeholders are trying to find the right mix between different health financing instruments (tax-based and other ones). Implementers will suffer the most, Jurien argued, if design issues are not well addressed. PBF also suffers from design and implementation issues in several places, and they need to be overcome. There’s also no need to blame the academics, Jurien continued. Academics are there to provide evidence if PBF works, and if it works, why, how and where it works. The same is true for UHC by the way. Support for either PBF or UHC should thus be based on evidence, and this evidence should be challenged by implementers, strategists and other academics. Instead of lamenting a Cochrane review because it comes to the conclusion that evidence on PBF is thin, we need to take up the glove and make evidence strong, Jurien argued. Even if you know that things “work”, evidence is necessary to prove it. He reminded CoP members that research can support successful implementation like in Thailand, where implementing UHC was much underpinned by academic work. As for the advocates then, they should do what they do best: communicate, bring up discussions, even in a provocative way, make people think and react. But as advocates, they have limitations, just like the other actors do. Finally, UHC is all about the beneficiaries, “the man and woman under the baobab”, as Jurien called them, and their health status. That group, their interests, should be the starting point for the discussions.
An illustration of UHC and some clarifications on the CAM in Burundi
In other interventions, debaters clarified the concept of UHC further (Bruno Meessen, Gyuri Fritsche, referring to a field visit to Mayo-Ine Health Centre in Adamawa State in Nigeria, “This is what UHC is about: to find customized solutions to get more people accessing services, and to have metrics to prove it”, …). More clarification was also provided on the health insurance scheme in Burundi (by Olivier Basenya, Longin Gashubije, Bruno Meessen). Olivier underlined that CAM is a health assistance system rather than health insurance and he explained steps undertaken since its introduction in 1984 to improve its efficiency towards UHC.
After a wide-ranging and generally respectful discussion, it emerges that the UN resolution provides an opportunity for civil society organizations to put decision makers under pressure and hold them accountable. In addition, UHC provides an obvious opportunity for PBF proponents too, if we think strategically. Jurien Toonen summarized the window of opportunity like this, for example: “If we want to head for UHC, we will need health services that perform well, hence PBF”. Some challenges to implementing this declaration were also pointed out, however. Debaters mentioned the distance to the reality on the ground, endless wars, unrealistic expectations, cultural issues, inadequate (both domestic and international) financing, corruption etc. Nevertheless, one can hope that fiscal space for UHC in African countries will improve in a not too distant future. Finally, the discussion also emphasized the role of research in supporting implementation and providing more evidence on what works, how and why.
The debate was suspended on December 17, 2012 when the CoP was informed of the death of Guylain Kilenga who was participating in a PBF training course at Bujumbura. RIP.