Dearbhla Crosse :
As the end of the health Millennium Development Goals is approaching, the sustainable development goals and their strong commitment to leaving no one behind – as well as addressing inequalities both among and within countries – provide an unprecedented opportunity to develop a more relevant global health agenda.
Action for Global Health, Global Fund to Fight AIDS, Tuberculosis and Malaria, Stop AIDS Alliance and partners held a high-level panel at this year’s European Development Days in Brussels, Belgium. They called for a paradigm shift toward equity in health care. Participants discussed ways to realize the right to health and how to strengthen health systems, focusing on sustainability and universal health coverage.
Here are five takeaways on how to turn theory into practice on delivering the right to health for all by 2030:
1. International duty bearers need to continue working with countries that transition from low- to middle-income status to ensure access to good quality health care.
In a global context of declining official development assistance levels, reduced public spending and competing international and domestic priorities, discussions focused on whether donors should continue to support countries when they transition from the low-income to middle-income country bracket.
Development partners traditionally assume that economic growth in MICs will lead to a smooth transition from international to domestic funding. But the reality in most cases is that partner governments cannot – or are unwilling to – fill the gap, which endangers the progress made over the past few decades.
Partnerships and sustainability are therefore crucial and there was an acknowledged need to look at ways to work in solidarity to support and accelerate countries toward self-sufficiency. Political will at national level plays a pivotal role here and to alleviate the problem, development partners should work with recipient governments to design strategies for domestic resource mobilization.
There was consensus too in Brussels that relying on archaic concepts, for example focusing on gross national income as a marker of development, needs to change. GNI was never designed to make development decisions and, above all, should not be used as a benchmark for development partners to cut funding. The Global Fund is one actor working on changing preconceptions by discussing the inclusion of factors such as distance to a health clinic, number of doctors per 100,000 people, and the amount of people living in poverty when analyzing funding.
The Equitable Access Initiative launched by the Global Fund and other agencies seeks to build a new policy framework to better understand the health needs and constraints countries experience as they move along the development continuum. Mark Dybul, the fund’s executive director, told the panel at #EDD15 that investing in key populations – including young women and girls – is vital.
“If we don’t sort this out then we cannot control the HIV epidemic,” he said. “Getting rid of gender-based equality goes far beyond health.”
The majority of EU aid goes to LICs, yet MICs are where you find human rights and access issues – and this is the problem with LGBT and marginalized groups. More money doesn’t necessarily mean that there is equity: Rwanda, an LIC, still gives more money to health every year than Nigeria, an MIC.
As Emmanuel Etim, pan-African coordinator at the Africa Civil Society Platform for Health highlighted: “We need a graduation from economy to equity.” Given the growing recourse to private health care by people in MICs, it is clear that governments need to adopt regulations and take private provision into account in government planning, in order to ensure equity for all.
2. New methods for financing and regulating health care systems are needed to ensure there are no financial barriers to access.
There was a consensus that financing and shared responsibility are essential to equitable health systems. Indeed, out-of-pocket payments have created huge barriers to realizing the right to health for all, preventing 1 billion people from seeking the health care they need, and pushing a further 100 million into poverty each year.
Poverty determines who should access services, and the introduction of user fees means many cannot receive the health care they need. International partnerships must work together to put strategies in place to help improve ODA and integrate health in a progressive manner.
Lydia Mutsch, Luxembourg’s minister of health and equal opportunities, argued that to ensure equitable health systems it is necessary to have adequate financing.
“We have to work together to come up with strategies that encourage the countries themselves to increase domestic funding and integrate public health in their domestic budgets,” she stressed.
Very few countries to date have achieved the Abuja declaration of 15 percent. Participants agreed that domestic financing is necessary, but should not replace ODA as countries need international support for it to work effectively.
Although ODA is a vital source of income, Gorik Ooms from the department of public health at the Institute of Tropical Medicine Antwerp predicted another promise of 0.7 percent of GNI to ODA: “It’s 42 years old now – high-income countries are giving themselves another 15 years now to perhaps live up to that promise, or perhaps not.”
3. Greater investment in health facilities is required in rural areas to increase access and to train more health workers. Last year, the World Health Organization estimated that the global health workforce shortage could reach 12.9 million in the coming decades.
Mark Dybul, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria sat down with Devex to talk about his organization’s past challenges and the road ahead. See what he had to say in this video interview.
Meanwhile, resilient and sustainable health systems require more than a billion dollars a year. A former minister of Nigeria said he wasn’t so much a minister of health but a minister of hospitals, yet a well-functioning health system must also include communities. All speakers agreed that health delivery needs to be strengthened at the local level.
Building more rural health facilities would result in the reduction of HIV incidences among adolescent girls by up to 60 percent, for example, and WHO Director for Reproductive Health and Research Marleen Temmerman emphasized the need for a global fund for public health based on rights.
4. The right to health care for all means including marginalized and vulnerable populations.
In many African countries, like Uganda, cultural barriers tend to carry more weight than financial or legal barriers – for example many clinics do not treat LGBT people with HIV and AIDS, and nonfinancial barriers to health care are often based on local customs and national laws.
Nicholas Niwagaba, one of the nominated #EDD15 future leaders, told the panel that rudimentary cultural beliefs that are perpetuated by communities create discrimination. In Uganda where homosexuality is illegal, people living with HIV and AIDS have no access to medical facilities, and in many countries health facilities are denied to marginalized groups such as drug users, prisoners and migrants, who are often in urgent need.
Mutsch agreed that vulnerable populations very often face obstacles to basic health services accompanied with financial obstacles, stigmatization and discriminatory punitive laws, finding it difficult to be integrated into the process, and insisted that collaboration between all sectors is necessary to implement change.
The principle that “no one should be left behind” was considered vital by all speakers, particularly after a government-approved health insurance scheme, introduced in Rwanda, resulted in a rapid decline in sign-up. In addition, Niwagaba noted that in Uganda, out-of-pocket payments has meant that young people can no longer avail of services.
There was also agreement that the current global approach toward UHC is too focused on addressing financial exclusion, leaving out other key aspects such as the broader social determinants of health and issues of discrimination within health systems, which could weaken the equity dimension of UHC.
The WHO draft UHC monitoring framework was discussed and Gorik Ooms, the panel’s moderator, shared civil society concerns that “all populations, independent of household income, expenditure or wealth, place of residence or sex, have at a minimum 80 percent essential health services coverage” does not capture other factors of social marginalization. In addition, civil society is calling for 100 percent coverage.
5. CSOs are integral to monitoring and implementing public health care and must be involved at all stages.
Civil society is often treated like a pariah and participation is seen as antagonistic by stakeholders and government. Etim spoke of the debate over the role civil society should play, underlining the issue that governments are reticent to bring CSOs to the table, particularly when it comes to policy decision-making.
In many countries, such as Liberia, CSOs are seeking co-decision-making. This is reflected at the international level where civil society is assuming a bigger role but it still needs to be recognized at the national level. A study undertaken by the Africa Civil Society Platform for Health shows that budget restrictions have led to a decrease in participation and monitoring. In practice, country ownership still means government ownership, but health systems can only be truly universal if they are entrenched in the community.
As Temmerman put it: “Civil society has a crucial voice calling for accountability and equity. The SDGs must ensure that civil society has the capacity, resources and enabling environment to meaningfully contribute. We need to think globally and act locally.”
Niwagaba echoed this sentiment, calling for the meaningful involvement of all stakeholders, where civil society is given the capacity to hold leaders to account.
“It is key to look at the issue of transparency,” he said. “Decisions are always left to the same core people, but we need shared responsibility, where CSOs inform governments where to invest.”
In summary, as Dybul aptly said, “As long as we see health care as ending at a clinic or a hospital, we will never have UHC. You have to have a health system that instead moves into the local community.”
(Dearbhla Crosse is communications officer at Action for Global Health, a cross-European network of health and development NGOs)
