Compared to 20 years ago in Kenya, people live for ten years less on average, more children die in infancy and a greater proportion of those who survive face stunting. Why? Soren Ambrose makes a case for holding the International Monetary Fund (IMF) responsible, arguing that the institution's obsession with low inflation rates - one of the foundations of trade liberalization - starves economies and hurts the poor.
On March 6, Kenya's Assistant Minister for Health, Enock Kibunguchy, told the press that Kenya urgently needs to hire 10,000 additional professionals in the public health sector, blurting out: “We have to put our foot down and employ. We can tell the International Monetary Fund and the World Bank to go to hell.”
These are strong words for a high-ranking government official to put on record regarding the most powerful international financial institutions (IFIs), and in particular the IMF, a body whose power extends to being able to call for the withdrawal of virtually all external assistance to a country.
Minister of Health Charity Ngilu had in fact been rumored to have made similar accusations in meetings with IMF officials and civil society representatives; since Kibunguchy's declaration she has confirmed she shares his view. Similar allegations have also been made by several civil society organizations focused on the IMF and on health rights. Indeed, in the last two years a number of organizations have identified IMF restrictions as a serious disincentive to hiring desperately-needed health professionals not only in Kenya, but in many other African and Global South countries as well.
Specific IMF policies, in particular the low ceilings it sets for inflation rates and wage expenditures in borrowing countries, are demonstrably illogical and detrimental. Together with the dubious defense the IMF mounts for maintaining such restrictions, cases like Kenya's provide a strong argument that those controlling the IMF should re-examine the restrictions it places on borrowing governments. The logic of demanding continual decreases in public wage bills is likewise suspect, as are the IMF's routine inflation targets. With increased funding from new sources, improved standards of living are within reach of even the most impoverished countries, if only the IMF would allow it.
The Health Care Crisis
Kenya's health care crisis has been 20 years in the making. Its dimensions are spelled out in the 2004 Poverty Reduction Strategy Paper (PRSP) - a government document written in consultation with the IMF and World Bank and approved by both bodies' boards. Life expectancy declined from 57 in 1986 to 47 in 2000; infant mortality increased from 62 per thousand in 1993 to 78 per thousand in 2003; and under-five mortality rose from 96 per thousand births to 114 per thousand in the same period. The percentage of children with stunted growth increased from 29% in 1993 to 31% in 2003, and the percentage of Kenya's children who are fully-vaccinated dropped from 79% in 1993 to 52% in 2003.
Why this deterioration? As in most African countries, Kenya's health care system was hit hard by the “structural adjustment” policies imposed by the IMF and World Bank as conditions on loans and as prerequisites for getting IFI approval of the country's economic policies. Those policies were introduced in the 1980s, and have left a lasting mark on Kenya's health. As usual with such programs, the emphasis was on cutting budget expenditures. As a result, local health clinics and dispensaries had fewer supplies and medicines, and user fees became more common. The public hospitals saw their standard of care deteriorate, increasing pressure on the largest public facility, Kenyatta National Hospital in Nairobi. As a consequence, that hospital, once the leading health facility in East Africa, began, like so many other African hospitals, to ask patients' families to provide outside food, medicine, and medical supplies. Most beds at Kenyatta and the regional and local hospitals accommodated two patients. Professional staff have taken jobs - some part-time, some full-time, at private healthcare facilities, or migrated to Europe or North America in search of better pay.
An October 2005 communication from an NGO coalition to the November 2005 “High Level Forum on Health MDGs (Millennium Development Goals)” notes that “between 1991 and 2003, the [Kenyan] government reduced its work force by 30%” - cuts that hit the health sector particularly hard.[3] For the period between 2000 and 2002 alone, the government was scheduled to lay off 5,300 health staff.
Those requirements were externally imposed. A World Bank Group document from November 2003, written to justify waiving a loan condition calling for a workforce reduction, notes: “This condition required retrenching 32,000 personnel from civil service over a period of two years. In practice, 23,448 civil servants were retrenched in 2000/01 before the program was interrupted by lawsuits. A specific commitment in the updated [agreement] is to reduce the size of the civil service by 5,000 per year through natural attrition.” The very same document supports Assistant Minister Kibunguchy's assessment of the sector's current needs - “the health sector currently experiences a staff shortage of about 10,000 health workers.” The document, however, draws no connection between the shortage and the insistence on cutting more workers.
The impact of the layoffs and budget slashing in the health sector over the last 15 years was cited recently by Member of Parliament Alfred Nderitu as the primary motivation for his motion of censure against the IMF and World Bank in the Kenyan Parliament. His initiative would insist that any future loans from the institutions get Parliamentary approval.
Clinics Without Nurses
Many African countries have shortages of medical staff because of lack of training capacity; in Kenya this is not the case. Thousands are unemployed or underemployed, eager to take up full time positions.
Both the Kenyan government and the IFIs regularly announce that health spending will increase substantially. With all these promises of increased resources for health care, with the World Bank's acknowledgement of a staff shortage, and with all those unemployed nurses, one might expect that the government would waste no time in hiring the thousands of nurses Kenya so desperately needs. And indeed, frequent promises are made by government officials to that effect. But the promises are almost never kept.
According to the Chief Economist in the Ministry of Health, S.N. Muchiri, the reason is that while the IFIs support increased expenditures on health, they forbid spending that money to pay staff wages. This is accomplished through insisting on a ceiling on wage expenditures; in Kenya, the targets are 8.5% of GDP in 2006 and 7.2% by 2008. The IMF doesn't specify that hiring in the health sector specifically must be limited, but when the entire wage bill must be suppressed, the chances of hiring the personnel needed are slim indeed.
So when IFI staffers call for more funding for clinics, as they do in their critique of the government's draft PRSP, they mean buildings, equipment, and medicine. Unfortunately, personnel are required to run the clinics. It is the choice by those institutions to prioritize targets for reduced spending on public salaries and on inflation, says Muchiri, that prevents Kenya from hiring health workers.
Muchiri provides valuable “inside” confirmation of charges made with increasing intensity by civil society organizations over the last two years. Advocates point out that while recent funding initiatives like the Global Fund for AIDS, Tuberculosis & Malaria and PEPFAR have made stemming the most critical health crises in Africa more possible, the IMF's power over borrowers' economic policy and its narrow focus on keeping inflation and payrolls as low as possible is actively discouraging governments from putting the available funds to use.
Numbers, Not People
On one level, it seems like commonsense for an organization like the IMF to seek out ways in which governments can reduce the amount spent on salaries, especially in countries like Kenya, which have had troubles with “ghost employees” on public payrolls in the past. But the self-defeating nature of this quest quickly becomes apparent. If the government were simply expected to identify and eliminate ghost employees, that would obviously lighten the government's burden and enable it to target its resources more wisely.
But the IMF's conditions deal with bottom-line expenditures, not with going to the root of the problem. Kenya's PRSP spells out the implications: “…achieving the 8.5 percent target by 2005/06 will require that any awards to be provided to the civil servants or any additional awards will be matched by a proportionate downsizing of the civil service.” Any hiring of nurses, for example, would require that some other public employees be eliminated - regardless of how much the nurses may be needed, or how vital the other positions may be. Indiscriminate targeting like this only demonstrates the prioritizing of abstract economic statistical standards over real-life outcomes, including those most likely to have a positive material impact on poverty and on contributing to the overall health of both Kenya's population and the economy.
So if the health budget is to rise - as both the IFIs and the government repeat often - then the PRSP must remind us that: “The fiscal strategy assumes that these health expenditures will be focused on non-wage non-transfer expenditures and will thus enable the rapid increase in basic health services.” Indeed, Muchiri reports that funds are often available for facilities or supplies, but not for staff. The result is that more people may seek out health services, but the ministry will actually be less able to provide them because of lack of personnel to administer the drugs or operate the machinery.
Inflation, Inflation, Inflation
But why does the IMF, with its power to exclude a country from the global economy by declaring it “off-track,” insist on reducing government payrolls? Adding employees to the government payroll, especially if accomplished with aid money, is considered by orthodox economists like those at the IMF to increase inflationary pressures in a developing country. And an increase in inflation is anathema to the IMF.
The IMF quite openly prioritizes inflation targeting over almost any other factor in the countries where it works. Pressed on the question, as they have been in the debate over health spending, its officials will invariably respond that inflation is a “tax” that hits the poor the hardest.
But is that true? Anis Chowdhury points out that:
“The poor have very limited financial assets; they are largely net financial debtors. Thus inflation can benefit the poor by reducing the real value of their financial debt. Meanwhile, the IMF's cure for inflation - raising interest rates - can actually harm the poor because this increases the servicing costs of their current debts. The poor fare worse when unemployment rises and persists, especially when there is no adequate safety net or social security system. At the same time, the real value of their household debt rises with falling inflation rates. Hence the poor have more reason to be averse to unemployment and less averse to inflation than the elite in society."
After this seemingly obvious point is made, it seems only too easy to point out that those who stand to lose the most from inflation are those who hold large amounts of money - financiers, investors, bankers. Yes, there are risks to the poor in high and/or persistent inflation, but increases in inflation below a certain point are far more likely to cause pain to those whose incomes depend on relatively minor fluctuations in currency values. For the impoverished, as Chowdhury explains, such increases in inflation are likely to be more beneficial than harmful.
As is so often the case, it is easiest to discern the interests of policy-makers not from their rhetoric, but from whose interests are most vigorously protected by their policies - by who “wins” as a result. The IMF's longtime prioritization of inflation over all else lends weight to those who accuse it of using its powers to protect the interests of the wealthy over those of the impoverished, regardless of their rhetoric that maintains the reverse.
IMF official Andy Berg recently admitted as much: “Higher inflation tax[es] people who hold cash or whose nominal incomes are fixed.” But Berg's next sentence restores IMF ideology, and at the same time exposes its flimsiness: “And this tax discourages private investment and tends to fall on those least able to adapt - in other words the poor.” Berg relocates the pain from the rich to the poor, but offers no logic for that move.
Drawing a Reasonable Line on Inflation
To challenge the IMF, the question must be where to draw the line - at what point, to use Berg's phrase, is “inflation out of control,” or at risk of spinning out of control? Berg says “in poor countries the danger point is somewhere between 5 and 10 percent.” The good news is that this figure is actually less conservative than the standard used in most IMF programs. In most countries with IMF loans, the conditions call for inflation to decline and stay below five percent.
Few economists outside the IMF opt for a level as low even as 10% in defining a healthy rate of inflation for a growing economy in a developing country. Terry McKinley, an economist with the United Nations Development Program (UNDP), declares: “As long as current revenue covers current expenditures, governments can usefully borrow to finance [social] investment. […] Fiscal deficits should remain sustainable as ensuing growth boosts revenue collection. The resultant growth of productive capacities will keep inflation moderate - namely, within a 15 percent rate per year.”
There is no room for neutrality in this debate. Adhering to IMF standards in order to avoid trouble will, according to McKinley, likely sabotage any hope of genuine development:
“Moderate inflation can, in fact, be compatible with growth. But low inflation can be as harmful as high inflation. When low-inflation policies keep the economy mired in stagnation or drive it into recession, the poor lose out, often for years thereafter, as their meager stocks of wealth are wiped out or their human capabilities seriously impaired. […] Without jobs and income, people cannot benefit from price stability.”
Tactfully avoiding mentioning the IMF by name, McKinley argues: “The new 'politically correct' justification for minimizing inflation is that it hurts the poor. However, this misreads the facts: very high, destabilizing inflation (above 40 per cent) definitely hurts the poor; and very low inflation (below 5 per cent) can also harm their interests when it impedes growth and employment.”
Rick Rowden points out that Latin American countries and “East Asian tigers” like South Korea grew rapidly despite inflation rates of around 20%. But that was before the IMF moved into the development world in the 1980s, and re-wrote the rules - without any definitive evidence to support their claim that doing so was advantageous to the poor.
The IMF appears to be caught in a classic case of “fighting the last battle.” When the IMF started lending to developing countries in the early 1980s, they were afflicted with astronomical, runaway inflation. It still apparently believes that hyperinflation is the most dangerous threat. But hyperinflation has been eliminated almost everywhere (apart from crisis or pariah countries like Zimbabwe); indeed most developing countries now have inflation rates well below 10%, and many below 5%. This is largely as a result of the IMF's hyper-vigilance over the last 25 years. The problem today is not hyperinflation, but IMF-induced stagnation.
More and more economists - outside the IMF - are taking a more complex view of growth and inflation. Rather than insisting that a country have a demonstrated “absorptive capacity” before increasing the flow of revenues, they look at the likely impact of increased flows. In the case of increased spending on health care, not only is employment created (if wage ceilings are set aside), but the population's overall economic capacity improves, and private-sector activity, rather than being discouraged by public funds, is spurred by the increasing availability of resources.
Muchiri, in Kenya's Health Ministry, concurs with McKinley's positions on inflation targeting, and with the view that public spending, especially on healthcare, will encourage growth. He acknowledges that his government has committed to a low inflation target - its “Letter of Intent” to the IMF states: “The monetary program for 2004/05 is designed to reduce underlying inflation to 3.5 percent.” And thus far Kenya seems to be meeting that goal.
But, says Muchiri: “3.5 percent is too low for an economy that is supposed to grow by 5 percent. A certain level of inflation is healthy - you can't grow otherwise.” This recognition moves Muchiri to criticize officials of a nearby country who have told him they must limit expenditures on health care - even refusing funds from the GFTAM - in order to prevent any risk of inflation rising. That line of thinking is clearly reflected in the recent statements by Kibunguchy and Ngilu.
But Finance Ministers who have committed to the IMF's inflation targets, and in many cases made those targets the centerpiece of their macroeconomic policy, are deeply reluctant to do anything that might raise that rate. Not only would doing so risk IMF disapproval and blacklisting, but it would also be seen as reversing a position they have publicly, and politically, committed to. Until this logjam is broken, a higher quality of life - even life itself - will continue to elude many thousands.
Muchiri counts as a significant victory the recent concession made by the IMF, after substantial negotiations, that Kenya could hire more health professionals if it could find donors willing to provide extra funds who themselves were comfortable with the impacts - economic and otherwise - that hiring additional health staff might have. It is this concession that recently allowed Kenya to announce that it will use funds from the Clinton Foundation, PEPFAR, and the GFATM to hire upwards of two thousand new nurses and other health professionals. Unlike with previous pledges, advertisements for the positions are now appearing in newspapers.
But the very existence of these policies, and the fact that he must invest so much in winning exceptions to them, cause Muchiri to reflect on his experiences of watching mothers and children die in hospitals for lack of surgeons or a lack of capacity to offer preventive care, and speculate that the IMF and World Bank could reasonably be charged with genocide. “The only difference from what happened in Rwanda is they don't use pangas [machetes]. They use policies.”
Reproduced with permission from the author from Pambazuka news 1 June 2006. http://www.pambazuka.org/en/category/features/34800
Editorial
Thirty years after the 1978 Declaration of Alma Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors need to set positive and realistic paths to implement the intentions of Alma Ata.
Sixty years ago, the World Health Organisation (WHO) stated in its constitution that health is a “a state of physical, mental and social wellbeing, not only the absence of disease or infirmity’. Thirty years later, the Alma Ata declaration on Primary Health Care (PHC) among other things declared that “health is a fundamental right” and set a thirteen point understanding to ensure this right. This understanding captured concepts of essential care, universally accessible and affordable to individuals and families in the community through their full participation, in a spirit of self determination. It located PHC as an integral part both of the country’s health system, but involving all related sectors and aspects of national and community development.
The WHO constitution’s definition of health and the Alma Ata declaration together prompt a diametrical but complementary state that need to be concurrently addressed if health is to be attained: The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.
Before the ink could dry on the Alma Ata declarations it had, however, already generated polarised antagonism. It was considered too socialist with an excessive preference of government providing state managed intervention. From a capitalist standpoint, it was a ridiculous proposition, too costly and defying economic reasoning. The conservative duo of JA Walsh and KS Warren launched the Selective PHC debate, arguing that it is probably more efficient to save children and limit population growth. The two main PHC proponents, WHO and UNICEF soon drifted apart, as UNICEF promoted a selective package of low cost interventions. With resource flows following selective PHC, Primary Health Care was translated in most countries to mean a basic package of services to be delivered at district and community levels based on a selected number of interventions with some outreach services, with a watered down district health strengthening based on this.
Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency based arguments being ridiculous propositions founded on utility based preference or embodying unattractive equity assumptions; the economic bargain in a healthy population should at least have also appealed to responsible international choice.
Alot has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its World Development Report 1993, ‘Investing in Health’. This report, which hardly acknowledged PHC, commoditised and delinked health from development and moved the world closer to the interventionist approach to health – intervening at a selective point in the epidemiology of a disease or health system.
This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone, more than all other subjects. The health Millennium Development Goals (MDGs) have further entrenched this disease specific approach to resource mobilisation. There are over eighty major global health initiatives linked to the health MDGs, providing over US$ 100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$ 3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.
PHC is hardly mentioned in these initiatives. Member States went to sleep on PHC except for anniversaries, and the occasional mention linked to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.
While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. As a result, inequalities in health have deepened to a significantly greater level than thirty years ago. There is a growing trend in urban slum development, a decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care.
Hence while a lot has been done in the past thirty years to deal with disease in individuals, the unique opportunity provided by the Alma Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in a burden of poverty and disparity related ill health that ill matches the level of knowledge or technological advance achieved globally.
As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, diagnose, treat and manage disease injury, and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, furthest from delivery on these expectations globally, the Ouagadougou declaration on Primary Health Care issued on April 30th 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.
Such declarations are encouraging. However their implementation calls for resolution of the longstanding debate of the past thirty years. These debates are not academic. They present in choices made over the policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector) and those reducing the health, social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.
And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At global level, Bretton Wood institutions and OECD initiatives for debt relief and poverty reduction have led in some African countries to short lived increases in spending on health and education, no global initiatives so far adequately address the determinants of health.
This leaves PHC as an orphan with no global home. WHO’s attempt to foster parent PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While the debates over the conceptual understanding of PHC will not end in 2008, at least 2008 could mark the turning point for a new institutional response, that builds a Global Alliance to generate the momentum and support for countries to implement PHC and that generates policy learning based on practice from the bottom up, reminiscent of another basis for the Alma Ata declaration.
A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the door step of a recognisable entity that can mobilise the needed funds and support countries with implementation.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
On 5 February 2013, in a ceremony at the WTO, the three Director Generals of WTO, WIPO and the WHO launched the trilateral publication titled:
“Promoting Access to Medical Technologies and Innovation”, the fact that a publication regarding public health was launched at the headquarters of the WTO is a reflection of the increasing importance of public health issues in the context of WTO and WIPO, an issue on which the WHO has been the leader.
The study shows progress on the part of the WTO and WIPO since they talk about these issues without “taboo”, however it does not give a complete picture of the extent to which WHO has lead this issue over the past decade. 17 resolutions by the World Health Assembly adopted between 1996 and 2012 are cited in the report in a table on page 44 concerning intellectual property and health. These resolutions are of highly prescriptive character, for the secretariat and for countries on how to protect public health from the possible negative impact of new international trade rules. Despite numerous resolutions and publications in the last 15 years by the WHO on this issue, many of which are not mentioned in the report, the disclaimer of the document says that “(…) the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WHO, WIPO and the WTO be liable for any consequences whatsoever arising from its use.”
This could give the wrong impression to the reader of this report that the WHO has no opinion on whether a compulsory license may, in special circumstances, facilitate access to drugs, or if an international exhaustion regime, that allows parallel imports from any country can reduce the cost of drugs and therefore contribute to access. The 17 WHA resolutions give a mandate to the WHO to engage, promote and defend mechanisms and policies in favour of access. Thus, it is important to ensure that the Trilateral Cooperation with WTO and WIPO do not lead the WHO to share a “neutral” vision, totally disengaged from its mandate of protection of health. This would be contrary to the exemplary leadership from the WHO on “The Revised Drug Strategy”, WHA 52.19 in 1999 or the “WHO Policy Perspectives on Medicines” published in 2001 that says: “National patent and related legislation should:
• Promote standards of patentability that take health into account. (…)
• Incorporate exceptions, trademark provisions, data exclusivity and other measures to support generic competition.
• Permit compulsory licensing, parallel importation and other measures to promote availability and ensure fair competition.
• Permit requests for extension of transitional period for TRIPS implementation, if needed and if eligible.
• Carefully consider national public health interests before instituting TRIPS-plus provisions
As expressed by the three NGOs that addressed the Executive Board in January this year, on the issue of IP and public health, the Trilateral Report is a weak and unambitious document in which the WHO does not fully reflect the work it has done on these issues in accordance with its mandate.
The question that we as member states of the WHO, international organisations with a clear vision regarding the priority of health such as UNDP or UNAIDS, or UNICEF, non-profit NGO’s working on public health, the academia and all the sectors concerned with the promotion of health and access to medicines should ask is what is the relevance and status of this report in the face of the 17 resolutions by the WHA giving a clear mandate that is not reflected in this document.
It would seem that we have overcome the debate that began in the early 2000’s about which one was first, the right to health or international trade rules, but in this trilateral publication, the mandate of the WHO to promote public health seems to have been subordinated to accommodate IP and trade interests that WIPO and WTO promote.
Therefore, the Trilateral Report is in the nature of a “Wikipedic” report that describes what others have said on the issue, without any of the three organisations saying what they think. The 251 page document contains no recommendations, not even a conclusion, or any guidance. In comparison, the 2006 WHO report on Public Health, Innovation and Intellectual Property rights (CIPIH report), led by the former president of Switzerland, Ruth Dreifuss, contained 60 recommendations.
A Japanese saying goes: “what a man does not say is the salt of a conversation”. We can say that this report…is an insipid report…
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was first featured in a 2013 mailing of the South Centre, Geneva
The way we finance health and health care makes a significant difference to the coverage and accessibility of our health care systems. It has thus been an issue capturing increasing attention from the international community, including from United Nations Children’s Fund (UNICEF), the European Union, the High Level Taskforce on International Innovative Financing for Health Systems who have all held consultations on this in the first quarter of 2009. The UNICEF meeting reviewed the evidence base on the imposition of a ‘price’ for use of health care services - user fees – and considered options and support for feasible health financing mechanisms. UNICEF itself was questioning the necessity and value of user fees in resource constrained settings, particularly given the opportunity costs, transaction costs and barriers posed to utilisation. The EU meeting sought input to its policy on health care financing for developing countries. The meeting reviewed a draft policy that was oriented towards support for general tax financing for public health care systems augmented by Social Health Insurance as a feasible next best alternative modality for long term sustainable health care financing.
There seems to be wide agreement on the question of maintaining tax revenue as the core of health financing, and on the introduction of SHI as the major source of additional domestic funds for health. The debates are more about how to implement these mechanisms in low resource settings.
The simplest mechanism is that of financing through tax revenue. There is evidence that systems that are more dependant on tax revenue have less inequality (measured through the Gini co-efficient) with regard to resource distribution and therefore a higher level of equity within the system. Recognition was made of the need to have with this a systematic resource allocation mechanism as well as a package of care that general tax revenue will purchase, to support a rationale priority setting process and to ensure fairness. It was noted that tax funded systems are more suited to achieving this. Yet increasing these tax revenues cannot simply depend on overall economic growth, as there appears to be little evidence so far that economic growth has translated into immediate gains for resourcing the health sector. There is thus need for evidence and dialogue on the options for strengthening tax revenue sources, including the role of sector wide approaches, of budget support to the health sector and of overall budget support.
Although Social Health Insurance (SHI) is often raised as an equitable option for financing universal coverage, there is limited or zero revenue generation from social security schemes in the African region. In countries such as Ghana, Tanzania and Rwanda, SHI schemes are substantially financed through taxation or support from external resources (such as the Global Fund). They therefore appear to be more hybrid tax based systems with additional transaction costs that may be generating inefficiencies in resource use and allocation. In the same countries coverage of social and private health insurance schemes is extremely limited, raising serious concerns about equity in revenue generation and in service provision and consumption. In other countries, such as South Africa, where private health insurance exists along side some social security mechanisms, the private insurance is limited in terms of coverage and yet consumes a relatively high share of total health expenditures – demonstrating again potential inefficiencies and inequality. We thus need to further analyse and evaluate equity issues in the implementation of social health insurance to inform whether and how to implement these schemes.
So there are clear areas for further work to advance progressive, equitable health financing in Africa.
It is therefore worrying that we are still locked into endless debates on user fees. These debates generate diverse opinion. In health systems in which user fees have been removed at a broad level (South Africa, Uganda, Zambia) as well as those where the user fee exemptions have been targeted at specific vulnerable groups such as child and pregnant women (in support of child, maternal and reproductive health) the evidence of increased utilisation is clear. The evidence also shows that the transaction costs of user fee administration negates any positive contribution of user fees themselves in additional revenue or value terms. The contribution of user fees to health revenues remains low. Some institutions and country representatives strongly support community financing, such as through mutual funds, as well as user fees in public sector facilities. Yet some institutions and country representatives strongly support community financing, such as through mutual funds, and user fees in public sector facilities.
This draws attention from more substantial issues, such as the fact that government commitments to improved health sector funding remains low. Countries have been slow to increase their health sector budgets, let alone reach the 15% of government budget for health set in the 2001 Abuja heads of state commitment and the Southern African Development Community commitments for the Maputo targets. Making these promised increases to the health sector budget would exceed any resources that could be raised through user fees.
One problem is that the debate on health financing is fed by a mix of evidence, values and anecdotes. Relevant evidence is not always available for health sector financing decisions, and ethical and value considerations affect the design of and preferences in health care financing. The case for user fees (alongside community financing initiatives) is often made without evidence and based on institutional interests, rather than on the basis of health system development and improvement of population health. Disappointingly at the UNICEF meeting earlier this year, no consensus was reached and further consultative processes were proposed.
Given the weight of evidence showing the negative balance in the impact of user fees on health systems and population health, I would argue that there is, however, sufficient evidence to put this issue to rest. Rather than continuing the debate on user fees, we should shift to debates on more substantive approaches to resource mobilisation, including:
* How to achieve increased health sector budgets
* How to strengthen tax revenue sources and funding for sector wide and budget support
* How to assess the equity issues in the implementation of social health insurance to inform policy decisions whether and how to introduce SHI
* How to promote accountability and transparency in the way health systems use their funds
Meanwhile as we need to move on in Africa to focus debates and build coherence on these wider financing policies, we also note the proliferation of different donor meetings on this issue. The situation is calling for a harmonised approach among donors and international agencies, if not in terms of harmonised funding, at least in terms of a common position that external funders can adopt on financing options that strengthen the health system. This would be in line with the Paris Declaration on Aid Effectiveness and Harmonisation, so perhaps the World Health Organisation should take some leadership in co-ordinating this?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on health financing issues please visit the EQUINET website- www.equinetafrica.org.
The COVID-19 pandemic and its socioeconomic consequences have affected all Eastern and Southern African (ESA) countries. The long-term impacts still remain to be seen. While COVID-19 affects everyone, it does not affect everyone equally. It has entrenched and exacerbated the extreme inequalities and injustices that existed before the pandemic.
The collective insecurity generated by the pandemic requires a decisive public health response. This response has, however, tended to apply centralised, top-down and undemocratic decision-making, often using ‘war’ narratives that prompt or reinforce fear, and that promote individual self-protection. Reactive interventions have not adequately taken local conditions and rights into account, prevented longer-term harms to health, including from gender violence, nor protected income, food security or social trust.
However, the pandemic also offers an important opportunity to demonstrate that alternative, people-centred, democratic and collective responses are possible. Indeed they are essential, not just to prevent and contain infection and mitigate the impact of the pandemic, but also to ‘build back’ using a stronger, more compassionate and equity-driven form of public health.
In October, EQUINET published 42 case studies of community action on COVID-19 that collectively demonstrate examples of this (see https://tinyurl.com/yxrekzre). The case studies come from different settings, income levels and dimensions of the response. They show innovative and solidarity-based approaches to prevent and care for COVID-19, to address social needs and hold states accountable. They provide a powerful argument for public participation and collective action in health.
One of the case studies, the Cape Town Together Community Action Network (CAN), tells the story of a self-organising network that emerged in March 2020 in South Africa as a community-led response to COVID-19.
In early March, it was clear from other countries that formal responses would struggle to keep up with the pace of the virus. As a network of autonomous, neighbourhood-level groups working together to respond to local challenges as and when they emerge, Cape Town Together felt that bottom-up community organising could spread faster than the virus and could rapidly identify and respond to its emerging health, social and economic impacts.
The Community Action Networks (CANs) actively work against a tendency to centralise planning, decision-making and management. They reject hierarchies of knowledge, resources and power. Each neighbourhood CAN operates independently and autonomously, while drawing on the collective energy and wisdom of the network as a whole. The hyper-local nature of the CANs allows for street-level organising, reminiscent of anti-apartheid activism. Generosity, trust and solidarity are important foundational principles. The CANs prioritise relationships over bureaucracy. They are enabled by inter-personal connections built during lockdown conditions largely through online co-learning, WhatsApp groups and Zoom meetings.
At the peak of the pandemic this decentralised, self-governing structure provided vital support where formal social safety nets failed, including public health guidance, mask-making clubs, community gardens, community care centres for COVID-positive people who could not safely self-isolate at home, and food and medicine deliveries to elderly people.
A few weeks after South Africa initiated its hard lockdown, 47% of households were suffering from extreme food insecurity. Across Cape Town, CANs distributed food parcels and established community kitchens. With rapid communication across the network, CANs shared experience and resources, learned from each other and worked with public health services to follow COVID-19 safety protocols in the community kitchens. Beyond the hot meals provided, the community kitchens became safe, organic spaces, enabling protective behaviours and information sharing. They responded to local social needs in a way that was inclusive, welcoming and free of stigma and shame.
The CANs generated community-level intelligence. In their inclusion of community members, researchers and local public servants, they enabled informal communication. They built trust between communities and health system actors, through dialogue and co-learning forums between CANs and health sector decision-makers. They made input into educational materials developed by the health department. With the lived local realities of those most affected by the pandemic often very different to that of health department officials, these connections proved invaluable in framing appropriate measures.
The CANs aim to support and not substitute state efforts, and this was initially possible. However, the shortcomings within state efforts became a subject of an increasingly politicised debate. For example, some CANs and local civil society organisations formed a coalition that protested the unlawful eviction of residents in informal settlements. Political actors reacted by asserting that the CANs were acting unlawfully and presented a political threat. When another CAN renovated a badly vandalised and unused public community hall, the local ward councillor accused them of unlawfully occupying the space.
Such tensions may be inevitable where community initiatives highlight deficits in state responses and provide different approaches. Bottom-up initiatives such as the CANs call for and contribute to alternative forms of governance that celebrate, enable and invest in community-led public health responses.
The case studies in the EQUINET report show that community-engaged and -led responses and relationships are more likely when they build on prior histories of social networking and organisation around social justice. The relationships, the citizen scientist and activist leadership, the connections with public, professional and civil society organisations and prior activities on different dimensions of wellbeing enabled a relatively rapid, collectively-organised range of health responses to the pandemic. Information technology was used to organise collective understanding and action. The case studies also show the importance of investing in comprehensive primary health care systems for an effective and equitable response to pandemics. If we continue to frame our health systems only in terms of efficiency-led measures to treat particular diseases and top-down responses to emergencies, we weaken the ability mobilise the relationships, capacities and creativity within communities, networks and service personnel, or the multi-sectoral responses needed to prevent and address the many health challenges we face from such crises.
We hear many negative stories about COVID-19. Yet these compassionate stories of equity, rights-driven and holistic responses also need to be documented and told. They show a solidarity-driven response to COVID-19, and that people are subjects not objects in health.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the CANs please visit the https://capetowntogether.net/ and https://www.facebook.com/groups/CapeTownTogether
Stifled by perennial under-funding, inadequate health care workers and a critical shortage of infrastructure, Uganda’s modest primary health care system has a more significant challenge to contend with – building effective demand among poor and vulnerable people. The Alma Ata declaration on Primary Health Care (PHC) declared health to be a fundamental right, but also observed that this called for full participation of communities in their health services.
Official statistics show, however, that only a third of the population uses the government-supported health system in Uganda – both public and private-not-for-profit. This means that a large share of poor and vulnerable people, including disabled people, families led by single mothers, orphans and internally displaced people, are not reached by public investments in health. They may seek services in private clinics, or buy medication from pharmacies or herbalists, but many poor people are likely to self-medicate at home, or hope for a natural healing process.
This still limited uptake of public sector health services obviously has many roots. The Coalition for Health Promotion and Social Development (HEPS-Uganda), a local health rights civil society organisation, advocates for access to affordable health care and essential medicines, especially for disadvantaged people. The evidence HEPS-Uganda has gathered from the eight of the eighty five districts of the country where it operates suggests that both service providers and users lack awareness of their rights and responsibilities in health. The Uganda Human Rights Commission confirmed this picture in 2007, observing that health rights of many Ugandans are being violated, especially the right to information, dignity and access to essential medicines. This is surely one contributor to the poor use of services, and a barrier to effective organisation of the health system around PHC.
Through its Community Outreach and Health Complaints and Counselling (C&C) programmes, HEPS-Uganda has worked with communities and health providers in eight districts of Uganda to implement initiatives aimed at increasing public and community participation in planning and implementing primary health care, including in the rational use of medicines.
The results have been telling. When expectant mothers in Kamwenge District in western Uganda, in Kawempe Division of the capital Kampala, in the districts of Pallisa and Budaka in eastern Uganda, and in the Lira District in the North of the country have increased their understanding of their health rights and the services that meet them, their uptake of antenatal services and their delivery at health centres under professional supervision has in some cases doubled over a year to eighteen months.
Through the C&C programme, HEPS-Uganda has established an independent feedback mechanism that receives complaints of health rights violations from health consumers, which it then tries to resolve through mediation with health providers and counselling. The process creates awareness of health rights and responsibilities in both sides, and has proved an effective way to identify and improve the whole system, within the community and within the local level health services.
The Uganda Human Rights Commission has observed that the violation of health rights has not been given adequate attention in Uganda. But programmes like HEPS-Uganda’s C&C programme create confidence and hope: Community members can approach health providers in an informed manner and demand the services they are entitled to. On the other side, health providers also recognize their duties and play their roles more effectively. The benefits are tangible for poor communities. In Pallisa and Budaka districts, community representation on health centre management committees is now more effective in the programme areas, and decisions are more responsive to community needs and preferences. Health centres have scrapped illegal charges that consumers have continued to incur across the country, despite government abolishing cost-sharing as far back as 2001. The end result is a more people centred, friendlier health care environment for communities as well as health workers, and the initiative is successfully demonstrating the people’s power in improving their health.
It is not that the country’s policy makers do not appreciate the value of community empowerment in the effort to achieve “Health for All”. Uganda is among the countries that adopted the Alma-Ata Declaration 30 years ago, committing itself among other things to a human rights approach to health in which “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”
At the country level, the national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”
With ill-health identified in official surveys as the leading cause of high levels of poverty, national development plans, including the Health Sector Strategic Plan and the Poverty Eradication Action Plan, contain planned activities aimed at empowering communities for health.
There are numerous examples of how communities are playing a role in efforts to create a community-based primary health care system. Community drug distributors dispense anti-malarial medicines door-to-door; village health teams mobilise communities for sanitation and HIV prevention and treatment and community members are involved in implementing the “directly-observed treatment” strategy to manage tuberculosis (TB). There have also been policies to entrust management of lower level health units to local governments and to management committees with community representatives.
However, with the exception of the TB management strategy, the performance of the rest of the initiatives still leaves alot to be desired. Other planned activities that would have empowered communities and consolidated the success of those already underway remain at the planning level, nearly a decade since the policy and other development plans were published. For example, there has not been any national programme of community capacity building “for effective participation of health problems, planning of health services, in resource mobilization and in the monitoring of health activities”.
Uganda has made the important step of guaranteeing a minimum health care package, but with minimal resources. It is trying to attain universal access to primary health care, but with US$8 per person, instead of the estimate of $34 made by the Macroeconomic Commission on Health. Without effective and collective demand from community level people will carry on ‘making do’ with poorly resourced health systems, and under-using the resources that are applied.
Effective and collective demand calls, however, for a system that involves the intended beneficiaries in planning and implementation, and for an informed and empowered community, able to demand and use the services it needs. In a resource poor setting like Uganda, the case for community empowerment for health is even stronger. It is needed in setting priorities, deciding on resource allocation, monitoring the performance of service providers and in building health care seeking behaviours. Government will have to live to its commitment to empower communities health if it is to guarantee their right to quality health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
The issue of appropriate health care financing mechanisms is once again high on the policy agenda of African governments. Not only have a number of governments (including South Africa, Uganda and Zambia) abolished some or all fees at public health facilities, which looks set to have ripple effects around the continent, but international organisations are placing considerable importance on health care financing in their engagements with African governments.
This is occurring in a context where:
• funding of health services from government tax revenue is very low, with about 60% of African countries devoting less than 10% of government expenditure to health care, despite the commitment by African Heads of State in Abuja in 2001 to commit 15% of their funds to the health sector;
• there is a heavy reliance on donor funding, with donors accounting for over a quarter of total health care financing in about 35% of African countries;
• there is very limited health insurance coverage; and
• the single largest source of health care finance is in most cases out-of-pocket payments – more than half of all health care expenditure is financed in this way in 40% of African countries.
It is critical that African governments are empowered to make their own decisions on appropriate ways of financing health services in their specific context. This is necessary to avoid the devastating consequences of financing policies imposed on Africa by international organisations over the past two decades. The most striking example is the World Bank and IMF requirement that governments reduce their funding of health services and increasingly rely on user fees as part of their Structural Adjustment Programs. This has not only contributed to the systematic devastation of public health systems but has impoverished households through the costs of illness. International organisations are already fighting for the hearts and minds of African policy makers. Some like Save the Children and the British agency DfID are pushing for rapid removal of user fees but with insufficient consideration of the need for wider action to develop the locally sustainable financing systems necessary to reconstruct national health systems. Others, specifically the World Bank, are pushing for private insurance for those working in the formal sector, with no acknowledgement of the equity problems of such financing mechanisms. The 2005 World Health Assembly adopted a resolution encouraging member states to pursue social and other forms of health insurance. WHO-AFRO is currently preparing a resolution on health care financing for review by African Ministers of Health. There is thus an urgent need for greater awareness of health care financing issues to promote locally relevant and equitable financing options.
It is particularly important that a set of equity principles are adopted at an early stage, against which alternative financing mechanisms can be evaluated within individual country contexts and which can be used to counter the arguments of international organisations and others attempting to impose inappropriate mechanisms. These include:
• The mechanism(s) should provide financial protection. No one who needs health services should be denied access due to inability to pay and payment for health care should happen before rather than at the time of use of services, such as through tax and/or health insurance.
• Contributions to health care should be based on ability-to-pay. Those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes.
• Cross-subsidies (from the healthy to the ill and from the wealthy to the poor) in the overall health system should be promoted. This implies that there should be cross-subsidies across different financing mechanisms.
• Financial resources should translate into universal access to health services. All individuals should be entitled to benefit from health services via one of the funding mechanisms in place, and the package of benefits to which they are entitled should be clear, known and accessible. There should not be substantial differences in the range and quality of health services that different groups have access to.
On the basis of these principles, and an extensive review of health care financing options (outlined in EQUINET discussion paper 27) we recommend that in Africa:
• Governments make explicit commitments to move away from out-of-pocket funding of public sector health services and pursue alternative financing approaches.
• We increase tax revenue for health through improved tax collection and more appropriate corporate and wealth taxation strategies.
• We increase the health sector’s share of government resources in line with the existing commitment of African Heads of States, made in Abuja in 2001, to a 15% share for health.
• There be unconditional cancellation of African governments’ external debt, so that debt servicing can be redirected to health care.
• We introduce or expand health insurance schemes as part of an overall financing system that allows for cross-subsidy and closely monitor their equity impacts.
• We exercise caution in relation to private insurance for formal sector workers, which has undermined system-wide cross-subsidies in countries such as South Africa and Zimbabwe.
• Ministries of Health lead and control decisions on the use of donor funds to ensure that they contribute to achieving national health priorities.
• We implement effective mechanisms for identifying and protecting the poor and other vulnerable groups, such as by ensuring that they are subsidised as members of health insurance and do access decent health services.
• We equitably allocate the funds for health to ensure universal access to services
• We carefully plan any new financing policy developments, to take into account the views of beneficiaries, gain support from the health staff responsible for their implementation and identify any other strategic action required to generate adequate political and popular support to sustain policy change. It is particularly important to recognise that health workers are often caught in the middle of these policy changes, managing patients without the resources to meet their needs and expectations.
• We monitor progress and build ‘early learning’ mechanisms to review and adapt policies as implementation proceeds.
These principles and recommendations are a signal of our recognition of a bottom line: no matter what our policy aspirations, the way we finance our health systems will fundamentally determine the way our health systems reflect our social goals and meet our social needs.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. EQUINET work on fair financing is available at the EQUINET website at www.equinetafrica.org. Discussion paper 27 on health care financing in Africa can be found at http://www.equinetafrica.org/bibl/equinetpub.php
There has been growing engagement around the inequitable benefit from the extraction of minerals, genetic and biological resources from the continent. Attention is now also growing on the exploitation of local and indigenous knowledge, and as captured in some of the articles in this newsletter, the injustice of knowledge systems that extract empirical evidence for analysis in other countries, and impose barriers to those most directly exposed to conditions being able to travel and participate in scientific programmes and forums, to bring direct knowledge on those conditions into global health forums. This international context contrasts with the experience described in this month's editorial of a sustained initiative within east, central and southern Africa to facilitate dialogue between researchers, service implementers, civil society and government policy makers in and from the region, to share and review knowledge for health and health systems within the region. How actively do we use, engage in and benefit from such platforms? What do we need to do reclaim, build and assert the knowledge systems in the region - and from the region, globally- to advance health equity? We invite you to share your experiences and perspectives as comments, opeds, or links to relevant papers and reports for our next newsletter.
A growing group of public health, social justice and human rights advocates, including a number from EQUINET, have released a Call to Action to heads of state and government at the 3-4 December UN General Assembly Special Session on COVID-19 to promote comprehensive, equity-focused and participatory public health approaches in countering the pandemic, drawing on and using diverse sources of knowledge, disciplines and capabilities.
The Call builds on a recent commentary by on Reclaiming Comprehensive Public Health in BMJ Global Health (the link is included in a later section in this newsletter) and contributions by a group of people working in public health from different regions globally, including a number from east and southern Africa. Over 250 individuals and leading organisations and networks have signed the Call so far and signatories are still invited. The full Call is at https://bit.ly/RCPHcall together with a link to sign on and other resources.
In view of the wealth existing in today's world, the prospect of Health for All must not be an illusion any longer. The world doesn’t lack the resources for health; it requires a fair use of what is available, in other words: the redistribution of wealth guided by the concept of solidarity. The world is awash in money. What is missing is the political will of those in power and – to challenge ourselves – the public pressure to make change happen.
The struggle for Health for all starts with challenging the prevailing neoliberal paradigm. It is well known that globalisation has widened health inequalities. However, more emphasis should be given to the fact that the transformation of health services into commodities, the linkage of access to health care to individual purchasing power and the dismantling of public health systems has only been possible in the context of a specific ideology - an ideology that has widely affected even those who are suffering the negative consequences of neo-liberalism, the global poor.
At the core of the neo-liberal ideology is a concept that replaces social values and institutions such as solidarity and common goods by self responsibility and individual entrepreneurship. “There is no such a thing as society”, Maggie Thatcher said in the early 80’s - paving the way for the cynical credo of neoliberal politics: If everyone takes care for him/herself, then ‘all’ are taken care of.
Although there is plenty of evidence that health is primarily a political matter determined by the social environment, neo-liberalism has succeeded in pushing the responsibility for health away from public and state institutions to private actors and individuals, including individuals perceived as business entrepreneurs in a liberalised market. Even spheres of societies that traditionally do not belong to the field of business, such as health, education and culture, have been increasingly penetrated by market values.
It was the French revolution – calling for Liberty, Equality and Fraternity – that came up with the first comprehensive list of Human Rights in 1789. ‘Fraternity’, the revolutionary agenda’s third pillar, may be equated with ‘solidarity’ in today’s discourse. It has been under permanent siege during the last decades. Millions of people have been excluded from health and social care as a consequence of neglecting the social principles that nurture the cohesion of society. Only by revitalising solidarity – both as an ethical principle and in its public institutions –can health inequalities be tackled and Health for all achieved. Indeed, there is such a thing as society.
It is a fact that there are always and everywhere people too poor to afford adequate health care out of pocket. Even in a perfect world, in which all the social determinants of health are respected, people will fall ill and will be in need of support. Therefore Health for all requires the presence of a permanent and institutionalised redistribution of wealth. Those who are in the position to pay more should also pay for those who are in need. This balancing is exactly meant with the principle of solidarity. It is perhaps the most important key to establishing an effective health care system.
In this context it doesn’t matter whether a system is tax-financed or based on the idea of social insurance schemes. Both are socially agreed funding schemes guaranteeing that even members who are not in a position to contribute a single shilling or cent financially to national budgets or social insurance will receive the same services as all the others members when they need them. While individual contributions (in terms of taxes or insurance contributions) are dependent on financial capacities, the entitlement to and claiming of services however, is only determined by needs.
It is preciously the principle of solidarity that disconnects access to health care from individual purchasing power: those who are wealthier support those who are poorer, younger, or elderly; and those who are economically active support those who are unemployed, retired and children.
Thus, the principle of solidarity goes far beyond what is usually meant when solidarity refers to empathy and charity. The principle refers rather to an institutionalised solidarity that organises a fair burden sharing. It is fundamental to the “social infrastructure” of societies. Like the hard infrastructure, like transportation, energy, administration, law enforcement, police, and so on, the social infrastructure also needs to be publically regulated and funded. The term social infrastructure stands for an ensemble of common goods, such as effective health care services, proper education systems, social protection schemes, food security, and so on. In other words, it covers social institutions that are essential for the social cohesion of societies that should therefore accessible for everybody, independent from an individual’s purchasing power.
In view of the global poverty affecting one third of the world’s population fiscal policy-making should again focus on the redistribution of wealth. At an International Conference on “Strengthen Local Campaigns for National and International Accountability for Health and Health Services” held in Johannesburg in March 2011 delegates in their statement also called for “the principles of social solidarity that are an accepted part of governance within many nations to be extended to the international level”. That sounds quite radical, but even the World Health Organisation (WHO) makes this argument. The World Health Report 2010 invites WHO member states to introduce new fiscal measures to enhance governmental revenue capacities. The report particularly points to the taxation of large and profitable companies as one of the key policy instruments to widen the fiscal space, as well as a levy on currency transactions and a financial transaction tax. The latter would only make sense if it is agreed internationally as a global resource to enable all states to adequately finance health services, including countries in the north facing persistent health sector cuts and sale of public health care services.
Health care systems based on the principle of solidarity still exist. In countries like my own, Germany, they form part of the foundations of the society. Most likely these systems can only be defended by extending them to the international level. In fighting back neo-liberal extremists who are persistently posing deadly threats to societies by dismissing solidarity institutions as a proof of “devilish socialism”, it is crucial to again struggle for solidarity. This struggle needs to be waged at national level, but it also includes an international dimension, such as in the call for an “International Fund for Health” that serves as an international equalisation payment scheme to balance existing financial gaps. For this, countries with higher incomes that can support those at lower incomes would be obliged to contribute to the health budgets of poorer countries. Taking the principle of solidarity forward internationally is not a question of money. It is rather a question of the political will to create a new international treaty regulating that richer countries with higher fiscal capacity are obliged to transfer funds to poorer countries, as long as these are lacking adequate fiscal capacity. It is this principle of solidarity that will realise Health for all and other social rights.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/healthfund