Jean Pierre Unger
Department of public health, Institute of Tropical Medicine, Antwerp, Belgium

This document reflects an opening keynote speech of the first European Union Seminar on Global Health (Brussels, June the 27th, 2011) It is also one of the two introductions to this week’s international health policies newsletter.

Key messages:

1. People deserve a new MDG – “Universal access to individual, versatile health care”
2. If publicly financed health systems are to be strengthened, it can only happen within the perspective of generalising access to good quality individual health care


 “Strengthening health systems” and “global health” are the new buzz words.

The lack of international agreement on their meaning and practical implications reflects discrepant North – South concerns. Industrialized countries stress the containment of existing LMIC pandemics (MDG concentration on malaria, AIDS and TB), and newspapers publish headlines on new epidemics (SARS, avian-flu, H1N1, Ebola..).
When it became clear that many MDGs in health might not be attainable (for example, TB incidence in Sub-Saharan Africa was almost multiplied by 2 between 1990 and 2009iii, both industrial countries and LMIC insisted on strengthening health systems to host disease specific programs. The agenda of many LMIC governments was, however, somewhat different: they also wanted to develop health systems independent of the unpredictability and priorities of international aid. Some North and South countries and multilateral agencies thus joined efforts to coordinate fragmented international aid in one organisation – IHP+ – that vowed to strengthen health systems by coordinating aid and targeting systems deficiencies. Access to individual health care was largely absent in this strategy.

Why was the two decades old international policy a mistake and why is access to care so important?

Strengthening health systems should be articulated around a key principle: any health system should aim at securing universal access to decent individual, multifunction health care and to the related essential generic drugs (here below: ‘access’). In practice, universal access could refer to different regional adaptations of general standards. For instance, in LIC and fragile states, the minimal standards could imply access at least to decent quality bio-psychosocial care delivered in health centers and to a general hospital . Access so defined also refers to the related essential generic drugs (in the same countries, 80 – 100 molecules in health centers plus 80 – 100 others in general hospitals).

Universal access should be a new MDG. Here are the reasons for it:

1. Without universal access, the likelihood of social and political instability increases.
2. In an era of concern for human rights, poor access to care means generalized suffering (which could be treated).
3. During the last 30 years, scientific arguments have piled up to rank access as the most important social determinant of health status. And by far: up to 30 years of life expectancy gains in the last decades. Notice that in this domain, knowledge has significantly evolved since 1993.
4. Resources available for prevention and early detection of LMIC-born pandemics suggests exaggerated fears of H1N1, H5N1, SARS and Ebola. But the contemporary big killers are multi-resistant TBC (150,000 casualties yearly), Hospital Acquired Infections (100,000 casualties yearly in the US only, increasingly a global problem), acute respiratory infections, diarrhea, and, of course, AIDS. To deal with these killers, health systems need to secure early access to care, patients’ adherence, continuity of care, doctor – patient communication (e.g. to improve mutual information transfer), hospital – health centre relationships, etc. These should be key objectives / concerns of any attempt to strengthen health systems.
5. Demographic transition means ageing populations, and the burden of chronic degenerative disease is sky-rocketing. By 2020, depression will be the LMIC leading cause of morbidity. Chronic diseases are not targeted by the current MDGs.
6. To be successful, disease control programs need to be integrated within services in which all patients are welcome and thus numerous – for early detection and continuity of care in each program.

What follows are strategic proposals meant to strengthen health systems while aiming at universal access. A major reorientation in resource generation and management is needed.

1. DEBUREAUCRATISATION should be the motto of the new, proposed MDG. As early as 1986 it was shown that the cost of family medicine type care plus 5 integrated programs was equal to the cost of the same 5 vertical programs alone with their administration. Global health initiatives have generated parallel aid administrations and the associated high transaction costs. Inefficiencies are multiple in human resources management: internal brain drain, systematic under-utilization of professional skills in highly standardized programs and mechanic bureaucracies, unbalanced salary scales, etc. Verticalisation of international aid has structured most LIC (and many MIC) government services alike: in co-managing the huge disease-specific funds, 40% of international aid has been assessed as wasted – a conservative estimate.
2. DEFRAGMENTING HEALTH CARE SERVICES by tightly coordinating the health services belonging to MoH, local government, NGOs, mutual aid associations, churches, and others with a social
mission to create A NEW NOT FOR PROFIT SECTOR; applying standard analysis protocols to improve access in each hospital and health centre within this sector; homogenizing prices; and balancing care quality with knowledge transfer techniques.
3. Develop INTEGRATED HEALTH CARE NETWORKS, to coordinate health centres and hospitals, including not for profit structures. Such local health systems should functionally integrate not-for profit structures (with a social mission), ideally on a negotiated contract basis (contracting-in). Operationally, they should necessarily include a referral hospital. Administratively, there is no reason why their executive teams cannot include skilled staff of not-for-profit organisations along the side government district medical officers. Disease control programs, when integrated, should have their administration truly integrated in this individual health care management team.
4. SOLIDARITY IN FINANCING: If government funds are targeted to the poor, delivery services will be tailored to fit the poor. There are 2 problems with this: 1. services for the poor = poor services (Olof Palme). 2. the middle class, which does not benefit from government services, may refuse to finance them. Costa Rica and Spain provide a-contrario examples: no targeting, same services for everyone, solidarity rich-poor, healthy-sick, and young-old – and outstanding outputs.
5. COMBAT MYTHS: Examples of poorly evidenced health policy paradigms: “Budget support”; contracting out in healthiii; “universal coverage with health insurance as a national policy goal”. With regard to the latter, access in LMIC often goes down while insurance coverage goes up:
– In Colombia, in spite of increased insurance coverage, access to care generally decreased, with exceptions in the subsidised systemiv,v.
– A similar paradox has been observed in Peru where the population who did not consult increased from 50.5 to 56% between 2007 and 2008. At the same time, its Social Insurance coverage increased (from 26.6 to 44.7 in the population)vi.
– In Ghana, user fees increased from 9 to 11% of total health expenditure between 2007 and 2009, while insurance coverage had increased from 0% in 2003 to 60% at the end of 2009vii.
6. CO-FINANCING, CO-MANAGEMENT: Users can finance part of individual health care in first line services, not in hospitals – without jeopardizing access: if the total cost of (paid) sickness episode, including drugs, tests, etc. is lower than just free consultation. This is what many users associations have demanded. In countries not supplying non-profit services with essential, generic drugs, there is the potential for revamping and updating the Bamako Initiative, while organizing the co-management of publicly oriented services with communities.
7. The proposed MDG would justify NEW INDICATORS AND CRITERIA, e.g. population-based hospital admission rate, utilization rate of first line (professionally delivered) health care services, and quality indicators such as tuberculosis detection and case fatality rate, delivery of bio-psychosocial care, etc.
8. Technical assistance to the organization of individual health care is needed even in high income countries.
The evidence basis of these analysis and recommendations is presented in “International Health and Aid Policies. The need for alternatives”viii

To conclude, five political messages:

1. To governments of industrial countries and to the non-health business community: profit making requires stability, stability needs access to individual care, mass programs do not provide that.
2. To doctors: it is much more fun to use your entire professional knowledge than just a fraction;
3. To Europe: We have substantial experience in securing access to care. Let’s export it, adapting it to local circumstances while supporting publicly oriented (socially motivated) health facilities organised in integrated local health systems
4. To LMIC governments: catastrophic health care expenditure by families is the first cause of their falling into poverty
5. To human beings: do not do to others what you do not want them to do to you

Reference list

i MDG statistics 2011. Available at
ii An estimated 1.37 million new cases of HIV-TB occurred in 2007, representing 15% of the total global burden of TB. Lawn, Stephen Da, Churchyard and Gavin. Epidemiology of HIV-associated tuberculosis Current Opinion in HIV & AIDS: July 2009 – Volume 4 – Issue 4 – p 325-333
iii Lagarde M, Palmer N: The impact of contracting out on health outcomes and use of health services in low and middle-income countries. Cochrane Database Syst Rev; 2009;(4):CD008133
iv Zambrano A, Ramírez M, Yepes FJ, Guerra JA, Rivera D. ¿Qué muestran las Encuestas de Calidad de Vida sobre el sistema de salud en Colombia? Cad Saúde Pública 2008;24(1):122-30.
v Guarnizo-Herreno CC, Agudelo C. Equidad de género en el acceso a los servicios de salud en Colombia. Rev Salud Publica (Bogota ) 2008 Dec;10 Suppl:44-57.
vi SIS – CIES (2010) Observatorio en Salud. Seguro Integral de Salud y Consorcio de Investigación Economica y Social. (accessed 20 July 2010). Quoted from JA ChevarriaLazo. Challenges to achieve universal health insurance in Peru. MPH Thesis, Royal Tropical Institute, Amsterdam, 2010.
vii F.X. Andoh Adjei. Assessing the performance of district mutual health insurance schemes in Ghana. MPH Thesis, Royal Tropical Insttitute, Amsterdam, 2010.
viii International Health and Aid Policies. Editors: J.-P.Unger, P.De Paepe, K.Sen, W.Soors. Cambridge University Press, 2010.

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