PHM-Exch> [PHM NEWS] Universal health coverage stalls while financial protection goes backwards: PHM's comment to the WHA
Claudio Schuftan
cschuftan at phmovement.org
Fri May 26 18:39:12 PDT 2023
From: Miguel Garcia <miguel at phmovement.org>
From: PHM WHO Tracker <dlegge at phmovement.org>
>
> *Español incluido; francais y inclus*
> Inequities in global economy contribute to UHC shortfalls, but ignored by
> WHO
>
> View this email in your browser
> <https://mailchi.mp/phmovement/wha76_uhc?e=5f3cea0f3e>
> Universal health coverage stalls while financial protection goes backwards:
> Economic inequities contributing to UHC shortfalls ignored by WHO
>
> Under Item 13.1, at this week's World Health Assembly, the delegates will
> review the report (in A76/6
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=24e558519c&e=5f3cea0f3e>)
> on progress regarding the implementation of 'universal health coverage' and
> will also review four draft resolutions proposed by the Executive Board
> (EB152), in Jan and Feb earlier this year, including the draft resolution
> in EB152(5)
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=9e44e2edd4&e=5f3cea0f3e> which
> would provide guidance to the Secretariat and Member States preparing for
> the high level meeting on UHC at the UN General Assembly in September 2023.
>
> A76/6
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=c8dbbc5065&e=5f3cea0f3e> provides
> an assessment of the progress towards UHC at the half way point of the term
> of the SDGs (2015 to 2030) focusing specifically on target 3.8 on universal
> health coverage. The report notes that by one indicator, 3.8.1, there has
> been an increase in coverage from 45 to 67 percent in the period from 2000
> to 2019 but that this has slowed down since 2019. (This service coverage
> indicator is extremely basic and is qualified as 'indicative only'
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e3cbb147ab&e=5f3cea0f3e>
> whatever that means.) Indicator 3.8.2, which relates to financial
> protection measured by the proportion of population experiencing
> catastrophic healthcare expenditure (CHE), shows a sharp worsening. (The
> report comments that there is no indicator in place to measure care
> foregone and needs not met and that this would be required for the full
> picture of progress (or not) towards UHC.) There has been a similar lack of
> progress in most of the disease specific targets of SDG 3 as well. Further
> disaggregating the data across countries shows that much of the improvement
> has been experienced in HICs. Within countries, those who are poorer, have
> less education or are living in more under-serviced habitats did worse.
> Taken together these data present a very disappointing picture.
>
> The report affirms that the shortfalls in relation to UHC (and other SDGs)
> are in part a consequence of the COVID-19 pandemic including the lack of
> international solidarity which was manifest during and after the pandemic.
> Inequities in access to COVID-19 vaccines are stark, with 22% of the
> population fully vaccinated in lower-income economies compared to 75% in
> high-income economies, as at 19 December 2022 (para13). Likewise the impact
> of the pandemic in many countries was exacerbated by social division and
> lack of trust. A76/6 does not explore the origins and impact of the
> shortfalls in international solidarity during Covid in relation to health
> systems development, nor the fundamental political, economic, and cultural
> drivers of this failure of solidarity. Understanding these drivers would
> throw valuable light on the stalled UHC project. The report also highlights
> the barriers to UHC which arise from the intersecting crises of climate
> change and natural disaste tional and regional conflicts, economic
> recession and income inequality, spiralling inflation rates, public and
> private debt, and growing energy and cost-of-living challenges.
>
> Notwithstanding the recognition of these dynamics in the first part of
> A76/6, the later sections of the report and the commitments in the proposed
> draft resolution (EB152(5)) are largely cast within the familiar health
> policy boundaries with little of substance directed to more fundamental
> barriers to UHC. This myopia is expressed clearly in para 43 which suggests
> that, in discussing this item, the Assembly focus on how to:
>
> - strengthen their national plans and increase government financing
> towards the progressive realization of universal health coverage, supported
> by evidence-based prioritization;
> - reorient their national health systems to primary health care as a
> foundation for universal health coverage, health security and better
> health; and
> - promote equity and accountability informed by national, regional and
> global evidence, data and multistakeholder engagement to ensure that no one
> is left behind in the progressive realization of universal health coverage
> and Health for All?
>
> Clearly WHO's unique expertise resides within the technical specifics of
> health and wellness. However, WHO could be contributing more effectively to
> the intersectoral project by addressing the relationships between political
> and economic variables and health outcomes. This could include: tracing
> the trends and patterns in sovereign debt and fiscal capacity; analysing
> the impact on health care of structural adjustment packages imposed by the
> IMF; tracing the links between the flow of international assistance for
> climate change and the incidence of hunger and forced migration; or tracing
> the relations between tax avoidance and health.
>
> Even within the institutional boundaries of 'health' this report and the
> associated resolution fail to engage with the basic controversy over the
> role of subsidised insurance markets and private providers versus
> public health care delivery.
>
> The international financial institutions and big philanthropies have
> sought to limit the government role to provision of a very selective
> package of services (delivered by public and private providers) with
> beyond-the-package-services funded entirely through user pays in the
> private market, or partially underwritten through health insurance. This
> model has not worked. Primary healthcare must be organized as a global
> public good and a basic human right, rather than a marketable commodity.
> Market based approaches have not worked for primary healthcare. Primary
> health care must be universal and comprehensive, where ‘comprehensive’
> means that all essential health services are covered.
>
> The shortfalls in UHC are partly a function of limited budgets but they
> also reflect a design failure in treating 'coverage' as resource
> distribution through market forces and service delivery through private
> practitioners. This is a model which has been forced on WHO by the World
> Bank and the US, urged on by the big US philanthropies.
>
> The cause of universal access to comprehensive health care will be further
> set back if this same model is further endorsed by the UN General Assembly
> in September.
>
> In most low and middle income countries publicly funded insurance schemes
> have been introduced, mostly for hospital care, but these have failed to
> provide effective financial protection. These insurance schemes are not
> like the social insurance frameworks of Germany or Japan or Australia. In
> LMICs these subsidised insurance programs route public financing through
> private markets so as to allow private markets to grow, and in this they
> have been successful, although at great cost. However they do not provide
> significant financial protection. For primary healthcare, the push has been
> for purchasing through contracts, packaged and promoted as “strategic
> purchasing of primary healthcare”. There is no record of success in this
> approach.
>
> While there are problems with public service delivery,they remain the
> mainstay for public health goals. Public services, without user fees, deal
> with health interventions as public goods. Clearly when the funding and
> administrative capacity are inadequate there will be major gaps but to lock
> in inequitable and inefficient health care markets is not a solution. A
> further problem is the persistence of vertical global interventions, with
> very poor integration into a general health systems strengthening and
> universal primary health care. This model is being replicated where NCD
> interventions are conceptualised as discrete commodities to be
> purchased/implemented without reference to the rest of the health system.
> The alternative would be the integration of NCD programs within
> comprehensive PHC.
>
> The forthcoming high-level meeting on UHC is most welcome, but if the
> Political Declaration fails to engage with the fundamental barriers to the
> proper funding of health care and if it fails to engage with the issues of
> health system architecture it will be a lost opportunity. PHM calls on
> member states and civil society to actively engage in the shaping of the
> Political Declaration between now and September.
> PHM appreciates:
>
> - the recognition by WHO of the need to include indicators of foregone
> care and unmet needs and quality of care as important indicators of
> progress towards UHC;
> - the call for more fine grained measurement and disaggregated
> reporting of these indicators so that inequities in access are measured and
> addressed;
> - the recognition by WHO of the need to improve civil registration and
> vital statistics systems (current estimates which are often based on crude
> extrapolations from very scarce or absent country data);
> - the call for increased financial investment in the healthcare
> workforce, employed on fair terms of employment which meet labour
> standards;
> - the call for including public health actions in primary health care
> (while noting that the technical support provided in this area is
> inadequate);
> - the recognition of social determinants in the resolution, but the
> political declaration must ensure that progress on all the SDGs related to
> the social determinants of health are followed and the accountability of
> global bodies on trade, environment and human rights in these areas is made
> clear.
>
> However, PHM calls for redoubled efforts to ensure that the UN political
> declaration also include calls for:
>
> - *Closer attention (analysis and policy) to the structural roots of
> fiscal limitations.* WHO must be mandated to work with the relevant UN
> agencies to identify and ameliorate the structural barriers to domestic
> funding capacity for healthcare in LMICs;
> - *Central role for public sector service delivery. *Primary health
> care encompasses preventive, promotive care and of public health
> interventions, all of which are known areas of market failure. Accordingly,
> they require public service delivery (or publicly administered programs
> even when services are contracted from private sector providers).
> - *Caution about marketising health care*. Clinical decision making on
> care should not be shaped by personal financial incentives. Insurance
> schemes, ‘pay for performance’, and fee-for-service approaches all tend to
> shift care provision to those services and customers that are most
> profitable for the private provider and thereby undermine equitable access
> to quality healthcare.
> - *Affordable access to all essential health commodities.* Countries
> or regions must have the capacity to obtain at affordable prices all the
> essential health commodities required for all primary health care services.
> This would necessarily require greater capacity in domestic manufacture,
> price controls, and public procurement. For example, in most LMICs,
> universal access to diabetes care will not be possible until human insulin
> and insulin delivery systems become much more affordable.
> - *New technology innovation for public priorities on non-commercial
> terms.* This requires a different approach to product innovation, one
> that is less based on restrictive patent regimes and more dependent on
> public financing and cooperation between academia, industry and governments
> in the global South.
> - *Cost-effectiveness studies for choice of technology not for
> rationing access.* We see an important role for cost-effectiveness
> studies in determining what are the best technologies for addressing health
> needs and whether sophisticated new technologies are value for money. In a
> comprehensive primary healthcare approach, the principle must be that all
> basic services that are effective and cost effective must be included. Only
> exclusions need to be specified. Interventions that can be provided by
> existing categories of health workers and require health commodities are
> already on existing lists of essential medicines and diagnostics would
> cover 90% of primary care needs.
> - *Reducing the role of separated vertical programs.* As primary
> health care networks are strengthened with human resources and essential
> commodities and skills and support, separate vertical programs need to be
> integrated into coherent healthcare provision, except where needed for
> technical support, research and innovation, and action on specific social
> and commercial determinants*. *
>
> The full PHM commentary on this item
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7d70e5fbb4&e=5f3cea0f3e> provides
> more detail and references. See also Tracker links to previous
> discussions of UHC
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=be409c898b&e=5f3cea0f3e>
> .
>
> See Tracker page for this WHA76 session (here
> <https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=35c9f38cf1&e=5f3cea0f3e>).
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