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Africa/Global: Public Health, Shared Responsibilities
AfricaFocus Bulletin
November 5, 2014 (141105)
(Reposted from sources cited below)
Editor's Note
The language is moderate, as one would expect from a
prestigious mainstream institute such as Chatham House. But
the message, which echoes the clear lessons of the Ebola
epidemic, is very clear. Sustainable financing for public
health, in every country and at a global level, is not only
a moral imperative but also a pragmatic economic necessity.
The report, which comes from the Working Group on Health
Financing in the Centre on Global Health Security at
Chatham House and was released in May this year, represents
a growing consensus among policy specialists about the
enormous economic advantages of timely investment in public
health. This comes in addition to the stress in global
health institutions on the imperative to implement the
universal right to health.
Although it is obvious that political realities have and
will continue to be formidable obstacles to the
implementation of such policies in practice, the Ebola
epidemic continues to highlight the urgency of broadening
political support to take meaningful action, based on both
economic and moral imperatives.
The report stresses the need for financing at three levels,
at national levels, at the level of global public health
goods (GPHGs), and in adequate global support for national
health in countries unable at this time to fund the
minimal investment needed. Such financing, the authors note,
brings shared benefits and requires shared responsibilities.
This AfricaFocus Bulletin contains the executive summary and
a few additional excerpts from the Chatham House study. The
full study is available at http://www.chathamhouse.org /
direct URL: http://tinyurl.com/pf3arax
For previous AfricaFocus Bulletins on health issues, visit
http://www.africafocus.org/healthexp.php
Ebola Perspectives
[AfricaFocus is regularly monitoring and posting links on
Ebola on social media. A few are included here. For
additional links, see http://www.facebook.com/AfricaFocus]
New York Times, October 31, "Braving Ebola" -
http://tinyurl.com/jw4vy2y
Moving words and beautiful images of those in the front line
against #Ebola.
Thanks to https://www.facebook.com/PriorityAfricaNetwork for this
link.
Map resource, "Africa without Ebola"
http://tinyurl.com/nvjgqkj
Washington Post, October 31, "Good for you, Kaci Hickox
http://tinyurl.com/mg9usxh
Best short article on Ebola quarantines in USA
Ebola Deeply, November 4, Interview with Lawrence Gostin
Very clear statement on priorities on Ebola
http://tinyurl.com/mq2f3pt
++++++++++++++++++++++end editor's note+++++++++++++++++
Shared Responsibilities for Health: A Coherent Global
Framework for Health Financing
Final Report of the Centre on Global Health Security Working
Group on Health Financing
Chatham House: The Royal Institute of International Affairs
May 21 2014
http://www.chathamhouse.org/ / direct URL:
http://tinyurl.com/pf3arax
Executive Summary and Recommendations
Financing is at the centre of efforts to improve health
and health systems. It is only when resources are
adequately mobilized, pooled and spent that people
can enjoy robust health systems and sustained progress
towards universal health coverage - that is, all people
receiving high-quality health services that meet their
needs without exposing them to financial hardship in
paying for the services.
This report, which presents the findings and
recommendations of the Working Group on Health
Financing in the Centre on Global Health Security at
Chatham House, shows how common challenges put
such progress at risk in countries across the world, and
particularly in low- and middle-income countries. These
challenges are common not only because they happen to
be present throughout these countries, but also because
globalization means the underlying causes and transitions
know no borders. This calls for collective action on a
global scale. Specifically, the report calls for an agreed
coherent global framework for health financing capable of securing
sufficient and sustainable funding and of both mobilizing
and using these funds efficiently and equitably.
Progress towards such a framework can be made by
revising the current approach to health financing in three
areas: the domestic financing of national health systems,
the joint financing of global public goods for health, and
the external financing of national health systems where
domestic capacity is inadequate. Progress in these areas
can be achieved through a set of policy responses which can be
encapsulated in 20 recommendations.
To strengthen domestic financing of national health
systems, we conclude that:
1. Every government should meet its primary
responsibility for securing the health of its own
people. This involves a responsibility to oversee
domestic financing for health and ensure that it is
sufficient, efficient, equitable and sustainable.
2. Every government should commit to spend at least
5 per cent of gross domestic product (GDP) on
health and move progressively towards this target,
and every government should ensure government
health expenditures per capita of at least $86
whenever possible. Most middle-income countries
should be able to reach both targets without
external support.
3. Every government should ensure that catastrophic
and impoverishing OOPPs [out-of-pocket payments] are
minimized. Specifically, governments should commit to the
targets of OOPPs representing less than 20 per cent
of total health expenditures (THE) and no OOPPs
for priority services or for the poor.
4. Every government should improve revenue
generation and achieve reduction of OOPPs
through effective, equitable and sustainable ways
of increasing mandatory prepaid pooled funds for
health services. Individual contributions to the
pool(s) should primarily be based on capacity to pay
and be progressive with respect to income.
5. Every government should consider improved and
innovative taxation as a means to raise funds for
health. Promising policies include the introduction
or strengthening of excise taxes related to tobacco,
alcohol, sugar and carbon emissions, and these
should be combined with measures to increase
tax compliance, reduce illicit flows and curb tax
competition among countries. Other sources of
government revenue, particularly in countries rich
in natural resources, should also be explored.
6. Every government should ensure that mandatory
prepaid pooled funds are used with the aim of
making progress towards UHC - that is, affordable
access for everyone. Specifically, every government
should seek to ensure a universal health system with
full population coverage of comprehensive primary
health care, high-priority specialized care and
public health measures, and should not prioritize
expanding coverage of a more comprehensive set of
services for only some privileged groups in society
7. Every government, in collaboration with civil
society, should formalize systematic and transparent
processes for priority-setting and for defining a
comprehensive set of entitlements based on clear,
well-founded criteria. Potential criteria include those
related to cost-effectiveness, severity and financial
risk protection. The processes can build on the
methods of health technology assessment and multicriteria
decision analysis, which can help translate
evidence and explicit values into policy decisions.
8. Every government and other actor involved in
the financing or provision of health care must
continuously strive to improve efficiency. In
particular, this will require action on corruption and
strategic purchasing, with continuous assessment and
active management of which services are purchased
and what providers and payment mechanisms are
used.
To strengthen joint financing of global public goods for
health (GPGHs), we conclude that:
9. Every government should meet its key responsibility
for the co-financing of GPGHs and take the necessary
steps to correct the current undersupply of such
goods. Among key GPGHs are health information
and surveillance systems, and research and
development for new technologies that specifically
meet the needs of the poor. Public funding for the
latter purpose should be at least doubled compared
with the current level.
10. Every government should increase its support for
new and existing institutions charged with the
financing or provision of GPGHs. In particular,
the World Health Organization's capacity to
provide GPGHs should be enhanced and adequate
funds provided on a sustainable basis for that
purpose.
11. Every government, international organization,
corporation and other key actor should promote
a global environment that enables all countries
to pursue government-revenue policies that can
sufficiently finance their social sectors, including
health, education and welfare. This requires action
on illicit financial flows, tax havens, harmful
tax competition and overexploitation of natural
resources.
To strengthen external financing for national health
systems, we conclude that:
12. Every country with sufficient capacity should
contribute with external financing for health.
Determination of capacity should partly depend on
GDP per capita. Net contributing countries should
include all high-income countries and most uppermiddle
-income countries and not only member
countries of the OECD's Development Assistance
Committee (OECD-DAC).
13. High-income countries should commit to provide
external financing for health equivalent to at least
0.15 per cent of GDP. Most upper-middle-income
countries should commit to progress towards the
same contribution rate.
14. Every provider of external financing for health,
including contributing countries and international
organizations, should establish clear, well-founded
and publicly available criteria to guide the allocation
of resources. These should be the outcome of
broad, deliberative processes with input from key
stakeholders, including civil society in contributing
and recipient countries.
15. Every provider of external financing for health
should align its support with recipient-country
government priorities to the greatest extent
possible. This calls for strong adherence to the
Paris Declaration on Aid Effectiveness and the
Accra Agenda for Action. In particular, providers of
external financing for health should encourage and
comply with national plans and strategies, improve
transparency and monitoring of disbursements and
results, and help to build domestic governance and
institutional capacity.
16. All providers of external financing for health should
strive to strengthen coordination among themselves
and with each recipient country, in order to improve
efficiency as well as equity. In particular, they should
encourage and comply with country-led division
of labour, harmonize procedures, increase the use
of joint and shared arrangements, and improve
information sharing.
17. Every government should actively assess the existing
mechanisms for pooling of external funds for
health - including the Global Fund to Fight AIDS,
Tuberculosis and Malaria, the GAVI Alliance, and
the World Bank's health trust funds - and consider
the feasibility of broader mandates, mergers and
increased global pooling with the aim of improving
efficiency and equity.
Strong accountability mechanisms and global agreement
on responsibilities, targets and strategies will facilitate
the implementation of the needed policy responses and a
coherent global framework. We conclude that:
18. Every government and other actor involved in
domestic or external financing or in the provision
of health services should seek to strengthen
accountability at global, national and local levels.
This should be done by improving transparency
about decisions, resource use and results, by
improving monitoring and data collection and
by ensuring critical evaluation of information
with effective feedback into policy-making.
Accountability should also be strengthened through
active monitoring by civil society and by ensuring
the broad participation of stakeholders throughout
the policy process.
19. Every government and other key actor should seek
to ensure that health and universal health coverage
are central goals and yardsticks in the post-2015
development agenda. These actors should also
seek to ensure that the responsibilities, targets
and strategies of a coherent global framework
for health financing are integrated to the fullest
extent possible. Moreover, the agenda should make
clear that health is important both for its own sake
and for the sake of other goals, including poverty
eradication, economic growth, better education and
sustainability.
20. All stakeholders should enter into a process of
seeking global agreement on key responsibilities,
targets and strategies for health financing - including
on the mechanisms for monitoring and enforcement
in order to expedite the implementation of a
coherent global financing framework. In the short
term, consultation on the post-2015 development
agenda is one useful arena for building consensus,
and the agenda itself can be a valuable commitment
device. In the longer term, a more specific process
should be devised in one or more relevant forums,
such as the UN General Assembly, the World Health
Assembly, World Bank/International Monetary Fund,
or a high-level stand-alone meeting.
With successful agreements, the great potential of health
system strengthening and proven high-impact interventions
can eventually be unleashed.
The Case for Action
Unprecedented transitions, and new and persisting
challenges call for a new global approach to health
financing. These transitions include profound changes
in the global economy, changes in health and risk factors
for disease, and transformation of the institutional
landscape in the global health arena. Significant
challenges include poor health outcomes, poor access
to health services, and financial risks to patients
stemming from out-of-pocket health service payments.
They are compounded by profound inequalities in
these three dimensions both between and within
countries and by the uneven distribution of recent
improvements.
Economic growth has been accompanied by accentuation of inequalities, in terms
of both income and health, and between and within many countries. A result of
these processes is the new phenomenon that more than 75 per cent of the
world's poor now live in middle-income countries.
Health financing is central to meeting these challenges
and for improving health and health systems. We believe
that the current approach to health financing needs to be
revised with respect to the domestic financing of national
health systems, the joint financing of global public goods
for health (GPGHs) and the external financing of national
health systems where domestic capacity is inadequate.
Only through concerted efforts in these three areas can the
world move towards a global framework that is capable
of securing sufficient and sustainable funding and of both
mobilizing and using it efficiently and equitably. This is
essential for building and sustaining momentum to reduce
premature death, achieve universal health coverage (UHC)
and reach the ultimate goal of a fairer and healthier
global society.
This is also a particularly appropriate time to seek a
coherent global framework. Led by the UN, the world
is currently debating the shape of the post-2015
development agenda - i.e. the agenda to succeed the
Millennium Development Goals (MDGs) when these
expire in 2015. The role and content of health goals, and
how to reach them, are a particular focus. The broad
debate and the numerous processes informing it provide
a platform for shaping the future we want, including for
health financing.
Underlying transitions
Underlying the challenges in health financing, as well as
the broader challenges to global health, are ongoing
transitions in three areas: in the economic sphere, in
health and in global health institutions. These are
aspects of the broader processes of globalization which
have made the world increasingly complex, interconnected
and interdependent (Frenk et al. 2014). This new level of
integration has created both opportunities and
challenges.
The economic transition
There have been monumental economic changes over
the last two decades. Economic growth rates have been
impressive, not only in emerging economies (WB 2013).
Many countries have moved from low-income to middleincome
status, and 70 per cent of the world's population
now live in middle-income countries (MICs). As a result,
many countries are increasingly able to finance their own
health needs without external support, and several MICs
are also becoming significant contributors of external
financing themselves (GHSi 2012; AidData 2013; IHME
2014). However, economic growth has been accompanied
by accentuation of inequalities, in terms of both income
and health, and between and within many countries (WCSDG
2004; Ortiz and Cummins 2011; UNDP 2013a). A result of
these processes is the new phenomenon that more than 75
per cent of the world's poor now live in MICs (Sumner 2012;
Alkire et al. 2013), and MICs account for a major share of
the world's unmet health needs.
The health transition
Health outcomes have continued to improve over the last
two decades. The global under-five mortality rate nearly
halved, from 90 to 48 per 1,000 live births, between 1990
and 2012 (UNICEF 2013a), and the world average for
female healthy life expectancy at birth increased from 58.7
healthy life years in 1990 to 63.2 years in 2010 (Salomon
et al. 2012). However, there are vast inequalities between
and within countries. For example, in 2010 female healthy
life expectancy at birth ranged between 41.7 years in the
Central African Republic to 75.5 years in Japan (Salomon et
al. 2012). At the same time, many countries have
significant inequalities in health outcome measures across
gender, socioeconomic status and place of residence, and
in many countries these inequalities are increasing (CSDH
2008; UNDP 2013a; WHO 2013c).
There have also been marked changes in disease patterns.
Many countries have seen a major increase in the burden of
non-communicable diseases (NCDs) such as cardiovascular
disease, cancer, chronic respiratory disease and diabetes.
As a result, NCDs are now the major cause of premature
death and disability in the world, having increased from a
share of 43 per cent in 1990 to 54 per cent in 2010
(Murray et al. 2012).
However, the shifts in disease pattern and associated risk
factors have only been partial in many low-income countries
(LICs) and MICs. As a result, many countries are now faced
with a triple burden of disease: the unfinished agenda
of infections, undernutrition and reproductive health
problems; a rising burden of NCDs and their associated risk
factors, such as smoking and obesity; and the burdens and
risks more directly linked to globalization itself, such as
the threat of pandemics, the spread of pathogens resistant
to antimicrobials, and the health effects of climate
change and trade policies (Frenk et al. 2011; Frenk and
Moon 2013).
The institutional transition in global health
The priority accorded to global health issues has increased
substantially over the past two decades. External financing
for health almost doubled from $5.8 billion in 1990 to
$11.2 billion in 2001, and nearly tripled to $31.3 billion
(expressed in 2011 US dollar terms) by 2013 (IHME
2014). In parallel, there has been a proliferation of new
institutions in global health that now play prominent roles
(Szlezak et al. 2010; Frenk and Moon 2013). These include
philanthropic organizations, such as the Bill & Melinda
Gates Foundation, and public-private partnerships or
hybrids, such as the GAVI Alliance (GAVI) and the Global
Fund to Fight AIDS, Tuberculosis and Malaria (Global
Fund). These have supplemented and challenged the
traditional roles of national bilateral aid agencies, the
UN, including the World Health Organization (WHO),
and multilateral development banks, such as the World
Bank. In addition, civil society organizations, private
firms, professional associations, and academic institutions
have come to play a much more influential role in the
global health arena. Moreover, the impact on health of
other institutions outside the health sector, such as the
World Trade Organization (WTO), has been increasingly
recognized (Frenk and Moon 2013; Ottersen, O. et al. 2014).
At the same time, the financial crisis of 2008 and its
ongoing ramifications pose a threat to external financing
for health, and the annual increase in such financing over
the last few years fell short of that seen between 1990 and
2010 (IHME 2014).
In parallel with major changes at the global level, there
are global trends in the institutional reforms taking place
within countries, often in the context of pursuing
universal health coverage (UHC). In particular, a 'health
financing transition' is under way in numerous countries
(Fan and Savedoff 2014).
...
The call for a coherent global framework
A new, broad and coherent approach to health financing is
required. Specifically, the world needs an agreed framework
to secure sufficient, efficient, equitable and sustainable
financing to achieve health goals, including UHC.
To move towards such a framework, the challenges in the
three financing areas must be effectively addressed through
a range of policy responses, guided by the importance of
health and the ultimate objective of achieving UHC. To
promote sustained progress, agreement on clear targets
and shared responsibilities should be sought on the
basis of justice, solidarity and human rights. The policy
responses should be anchored in the post-2015 agenda by
firmly positioning health and key responsibilities, targets
and strategies of the health financing framework in that
agenda.
The shaping of a global framework for health financing
should build on the legacy of the Commission on
Macroeconomics and Health (CMH) (CMH 2001),
the (high-level) Taskforce on Innovative International
Financing for Health Systems (HLTF) (HLTF 2009b), the
World Health Report 2010 (WHO 2010) and several more
recent reports, including those of the Lancet Commission
on Investing in Health and the Lancet-University of Oslo
Commission on Global Governance for Health (Jamison
et al. 2013a; Ottersen, O. et al. 2014). However, there
is a need to go beyond this to acknowledge ongoing
changes and transitions, integrate recent experience and
insights on health and development financing, and build
a comprehensive normative framework with shared,
yet clear responsibilities and goals.
AfricaFocus Bulletin is an independent electronic
publication providing reposted commentary and analysis on
African issues, with a particular focus on U.S. and
international policies. AfricaFocus Bulletin is edited by
William Minter.
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