Health financing debates produce clear policy recommendations at the People’s Health Assembly
“Because we are poor, we can’t afford not to have primary health care based universal health coverage”. With these profound words Dr. Suwit Wilbulpolprasert from Thailand finished his rousing presentation to the 3rd People’s Health Assembly. The large audience responded with prolonged and exuberant applause. Why the excitement? Because he had demonstrated that it is perfectly feasible for a developing country to achieve the Assembly’s Goal of “Health for All Now”. For this audience, it was just like being given proof of an elusive sub-atomic particle.
What the Assembly found particularly inspiring about Thailand’s success, was the role that civil society organisations (CSOs) had played in bringing about their UHC reforms. This included collecting fifty thousand names in a petition to demand UHC at the beginning of the last decade and a strong CSO voice in Thailand’s annual National Health Assemblies.
Other People’s Health Movement activists also shared their experiences of effective political lobbying this week. For example Dr. Abhay Shukla from India, demonstrated how a targeted access to medicines campaign led to Rajasthan’s “free medicines for all” initiative, launched last October. This scheme has had an immediate impact on the coverage of health services, especially for the poor – outpatient consultations have risen 50%. But perhaps more significantly, the success of this patient-power led development, has come to the attention of the Prime Minister, who appears to be on the verge of replicating this scheme nationwide.
In the same session, Mark Heywood, from Section 27 (a human rights law centre), explained how a right to HIV medicines campaign in South Africa, mobilized communities into action which catalyzed broader and deeper health systems reforms. Clearly increasing service coverage rates so rapidly requires considerable increases in financing, so a recurrent theme throughout the Assembly has been: how should countries finance their health sectors? In particular, how can countries finance coverage for their large informal sectors?
Di McIntyre, Professor of Health Economics at Cape Town University addressed this issue during a special plenary on Africa. She said that it was now time to be honest about which financing mechanisms are likely to deliver UHC and which ones will fail. Citing evidence from high, middle and low income countries she argued persuasively that “private [voluntary] health insurance does not get you to UHC”. South African delegates didn’t need persuading about this, but this message was challenging for a number of countries experimenting with voluntary community health insurance initiatives.
To support her argument, she presented evidence that community insurance schemes were highly regressive and in many instances were ineffective at raising resources for the health sector. In fact in one large scheme in East Africa, the costs of taking premiums from members exceeded the revenues collected. In other words, the scheme was draining resources from the health sector. Subsequent sub-plenary sessions examined the performance of other voluntary insurance programmes and found similar results of low coverage rates, high administration costs and vulnerable groups excluded. Invariably schemes were only viable due to large subsidies from the government budget or from donors.
Combining these results, with the extensive literature on the adverse impact of user fees, and the more positive findings from the countries that have effectively reached UHC (e.g. Thailand), produced a clear conclusion. Countries wanting to cover their informal sectors [a condition for universal coverage] shouldn’t attempt to take significant direct contributions from this group, either in the form of fees or explicit insurance premiums. Households could contribute in different ways, for example, through tax payments, or small compulsory insurance premiums (as happens in Rwanda and China). But if they are expected to pay significant voluntary contributions, many will remain uncovered.
The policy implication for People’s Health Movement activists returning to their countries is clear. If they want “Health for All Now” they should mobilise their communities, not to finance services themselves, but to lobby for a larger share of the benefits, of increased public financing.