Before I immersed myself in some Lancet reading this morning, I read my newspaper. You gotta know your priorities. A few headlines struck my attention: “Michelle Obama is ‘fifty and fabulous’ “ (damn for all the ones among us who are forty and miserableJ). Right on the next page, the horrifying picture of a starved girl child in Syria – aid didn’t reach her. Tonight we have our annual new year reception & party at the institute. Including the opening of a restaurant. The world is a mad place.
Anyway, plenty of IHP news this week with some coverage of last week’s UNAIDS/WB meeting, the “Universal Health Coverage in Emerging Economies” conference at the Center for Strategic & International Studies (CSIS), with a key role for Jim Kim, a Review on Women and Child’s health in Geneva (for which you will have to check the tweets from Chan (or her alter ego), Horton, …). WHO’s Executive Board is coming up as well as the annual Davos party – the jury is still out which of the two global health events in Switzerland is the most important one to follow. We witnessed together with many other people yet another sorry episode in the (now pretty much global) homophobic backlash, in Nigeria this time, …
On a more cheerful note, we celebrate the arrival of Julio Frenk on Twitter! To mark the occasion, we have a rather critical guest editorial on the Mexican health care reform by Asa Cristina Laurell, an independent consultant. Do not hesitate to tweet it aroundJ.
A paper you should definitely try to read this week is a discussion paper by Akenji & Bengtsson on “Making Sustainable Consumption and Production (SCP) the Core of the Sustainable Development Goals” (and the two options to do so, either by making it a standalone goal or via mainstreaming it). Great paper. In a way, the paper also offers a way forward for the post-MDG & SDG negotiations – if developed countries showed some good will (see below to see what I mean), a lot might actually still be possible in terms of arriving at a grand bargain. But let’s first see whether Akenji & Bengtsson can sell this sort of thinking to Shinzo Abe and co. Bet it ain’t part of Abenomics.
What are some of the implicit messages of the paper? Well, the paper makes clear there is no alternative but to go for contraction in the developed countries, as ‘decoupling’ is – to a substantial extent – a sham. We might not like it, but this is the 21st century version of TINA. In the words of the paper: “After more than four decades of international policy discussions on sustainability there have been only a few examples of countries achieving relative decoupling and there is no example of absolute decoupling – the measure needed to achieve sustainability. The decoupling approach thus remains largely theoretical, based on questionable assumptions.” So to put it bluntly, the approach to ‘decouple’ economic growth from resource use and environmental degradation, as a means towards achieving SCP won’t work. Green growth is, at least to some extent, a chimera, stuff for Harry Potter movies. It’s all been said before by people like Tim Jackson and Kevin Anderson, of course, but it’s good to read it again. In short, SCP calls for a paradigm shift. It would thus be lovely if the global health community (with people like Julio Frenk, Bill Gates, Judith Rodin, Jim Kim, …) started saying this on global fora like Davos. The ‘catching up’ model of development needs to be replaced with a new vision of ‘contraction and convergence’. The Lancet Global Health 2035 agenda still mainly emphasizes the latter (convergence is possible), I have the feeling, not the former (contraction will be necessary in rich countries and some of the richer parts of emerging countries). (some BMJ articles from 2012 were an exception to this rule, although they interpret ‘contraction & convergence’ in a slightly different way; perhaps the new Lancet Commission on Emergency Actions to Protect Human Health will also change gear, we’ll see).
Also, supply chains are now global, so we need to look at consumption and the drivers of consumerism. As the paper says: “For SCP to be practically implementable as a goal would require nothing short of a critical review of the culture of consumerism that become pervasive through mass media and advertisements; has been internalized by billions of consumers around the world; and which has come to define modern macro-economic thinking and the existing economic system”.
I don’t think Julio & co will start saying this soon, not even on Twitter, it’s not exactly a popular message in the US, like elsewhere. Much easier to talk about low carbon growth. However, then we might as well drop the pretense of being in the global health business – we’re rather in the ‘Pandora box’ business then (and global health should then also open up research on geo-engineering, for example). Well, maybe Gates is already doing that, who knows. The guy’s a visionary, after all.
But let’s go back to some more conventional and/or emerging global health concerns. Registration for the Third Global Symposium on HSR is now open. Many of you will be happy to play a role in the peer review process in the coming weeks and months.
The Lancet Commission on Global Surgery has its first meeting in Boston (17-18 January). This Commission aims to prioritize surgery on the global health agenda and generate delivery of high quality and financially risk-free surgical care for all. Live streaming of the January meeting will be available here on Friday January 17, 2013 from 9am to 12:40pm EST and on Saturday January 18, 2013 from 8am to 5pm EST.
Enjoy your reading.
Kristof Decoster, Werner Soors, Peter Vermeiren, Basile Keugoung & Wim Van Damme
The Mexican health reform. A success case?
Dr Asa Cristina Laurell. Independent Consultant.
Currently the dominant notion of Universal Health Coverage (UHC) is a health insurance with a defined service package based on a payer-provider split. In the global UHC crusade, the Mexican health reform, particularly the Popular Health Insurance (PHI), is presented as a success case. However the narrative of this reform is usually quite inaccurate and closer analysis reveals a different picture.
The Mexican health system is segmented and fragmented but it is predominantly public. The drive for universal coverage rested during four decades on a social security strategy and by 1982 about 70% of the population was covered by public social security including a large part of the rural population. The Ministry of Health (MOH) attended the rest of the population. Both had their own infrastructure and salaried personal while private insurance and provision were marginal.
The 1983 fiscal adjustment, caused by the debt crisis, impoverished both the social security institutions and the MOH and deteriorated services and working conditions. This fact legitimized the introduction of structural health reform based on the Latin American adaptation of ‘Managed Competition, Structured Pluralism’, with the separation between regulation, administration of funds/service purchasing, and provision of services. This split is essential since it permits the introduction of competition and markets and consequently health system commodification.
The first stage of reform took place between 1995-1997 and its main target was the social security institute for private sector workers (IMSS) that held about 60% of the public health funds. The reform changed the financing of health insurance – it reduced the employer premium and increased the government contribution around five times. Even so the total IMSS health fund diminished. Additionally the IMF conditioned its ‘adjustment loan’ to the introduction of private fund administrators. This part of the reform failed, essentially due to a strong resistance movement and the possibility that social security health care for a majority of the population might have collapsed. The second part of the reform during this period consisted in the decentralisation of the MOH facilities to the state level and the “universal coverage” of a very small service package.
The failure to establish a payer/provider split at IMSS and to introduce private health fund administrators led to a modification of the reform strategy with the arrival of a right wing government in 2000. The new minister of health, Julio Frenk, set about to conclude the health system conversion to full-fledged Structured Pluralism. In 2003 the National System for Social Health Protection was established.
The Popular Health Insurance (PHI) is the operative program of that system. It is a voluntary insurance for people who are not covered by social security insurance and offers an explicit service package of 274 interventions including drugs and eight ‘catastrophic cost’ diseases for adults while the medical coverage for children is broader. The PHI excludes many high-cost diseases among others multiple trauma, cardio-vascular disease, stroke, most cancers, renal insufficiency that patients have to pay. The PHI package corresponds to 11% of what public social security provides for free. The PHI has no cost for the lowest income groups and the rest pay a premium of about 3-4% of their income.
It is financed by federal tax funds, state tax funds and family premiums. The organizational arrangement of PHI is the one of Structured Pluralism and sanitary security is the responsibility of decentralized agencies at federal and state level. The federal government collects, administrates and transfers funds to state fund administrators, according to the number of enrolled, and to a special fund for ‘catastrophic costs’ that purchases personal health services for PHI affiliates from public or private providers. Public health actions and collective health are financed by a special fund and are the responsibility of the decentralized state health services.
The MOH claims that universal insurance coverage has been reached in Mexico adding PHI, social security and private insurance. However this is refuted by other official data sources such as the health and nutrition and the household income/expenditure surveys of 2012 that demonstrate that 21-25% of the population lacks insurance coverage (see here, p. 35; and here). Nor is it true that the main PHI beneficiaries are the poorest part of the population: 37% of the lowest income quintile is uninsured.
Official health statistics also show that PHI is providing much less services than the public social security system to its affiliates: 1,4 consultations compared to 3; 0,07 to 0,43 for emergency room treatment and 2,7 to 4,8 per 1.000 for hospital care. These data show that insurance coverage does not mean access in the presence of a limited service package. The unequal distribution of health facilities and human resources adds barriers to access since the expansion of PHI enrollment was not accompanied by an increase in services facilities.
So far the PHI has only marginally contracted private providers which means that with or without PHI the population is attended at the same MOH facilities but with one crucial difference: the PHI population has preference, at the expense of the non-PHI population in these facilities. Comparing the access to care of the people having health problems between the uninsured, those with PHI and those with social security it was found that 15,9% of uninsured, 12,5% with PHI and 6,4% with social security failed to receive care. According to both the uninsured and PHI affiliates this failure was mainly due to economic barriers. In this context it should be noted that for each peso spent by PHI enrolled, the PHI spent 0.93 pesos while the same data for social security are one to 1,39 pesos. PHI does slightly protect against “catastrophic health costs” as compared to the uninsured. Nevertheless the overall proportions of public and private spending have changed very little.
Another PHI failure is that the financial resources to be delivered and transferred by the federal government to providers are much lower than legally stipulated and not fully applied. The PHI budget has increased by almost 300% since it was started but the health expenditure for the non-social security population is a little less than the stated objective of one percent of GDP. The MOH takes pride in the narrowing between per person expenditure for PHI and social security but disregards that per capita is stationary in social security.
This fact provides a hint on the strategy foreseen for implementing complete Structured pluralism. The present government has announced that during 2014 a ‘Universal Health System’ will be legislated and put into practice. I.e. all Mexicans will be covered by a basic insurance that will grant access to an explicit service package and will freely choose her/his public or private provider. The hidden agenda of this proposal is that the service package is the one of PHI and the free choice of provider means that private providers will be promoted and the social security institutes obliged to attend everybody despite their overcrowded facilities. Since the basic insurance only gives access to basic services a large space is created for complementary private insurance. This means that about 50% of Mexicans will lose most of their present health benefits or will have to contract such a complementary insurance. Finally, not unexpectedly, nobody has proven any positive health impact of the Mexican health reform. In this manner none of the main causes of death have changed their respective trends during the period 2000-2011 with the exception of murder (see here). Commenting on this fact the World Bank argued that health impact was not an objective of this reform! Even its creators recognize that public health activities have been increasingly neglected.
1. Public Health – special issue on WHO
As the 134th Executive Board meeting of the WHO is coming up, it’s good to engage in some thorough WHO reading, in addition to all the background material provided on the WHO website. The Journal Public Health published a set of papers dedicated to the WHO (reform, governance, history,…). It’s not open access, unfortunately although colleagues told me you can register and then access them. The papers we already read (Sridhar’s editorial, Cassells, Van De Pas, Ooms, Lee, …) convinced us of Andrew Harmer’s assessment on Twitter: “Great set of papers”. So if you can get hold of them, this should keep you busy for the whole weekend.
2. IP Watch – WHO Initiative On Poor Quality Medicines Heads To Board Next Week
For some of the latest news on SSFFC (Substandard/Spurious/Falsely-labelled/Falsified/Counterfeit Medical Products), see this article.
3. Guardian – Better funding call for vital drug approval programme
Sarah Boseley discusses a recently published article examining the prequalification of medicines program (PQP) of the WHO, launched in 2001. The program is endangered by its insecure funding, four experts say. She refers to this article in the Journal of Public Health, ‘A quiet revolution in global public health: the World Health Organization’s Prequalification of Medicines Programme’ (by Ellen ‘t Hoen et al).
4. IHP – The World Health organization: towards health-equitable globalisation
Remco van de Pas;
In the run-up to the Executive Board meeting of the WHO, Remco Van de Pas reflects on some of the recent publications related to global health governance and global governance for health. He distinguishes a gap.
In related news, the Lancet –University of Oslo Commission on Global Governance for health will present its report on 11 February.
Post-2015 & UHC
5. Devex – Fitting AIDS into the post-2015 agenda
This article reports on the WB panel meeting from last week. Nice overview of what was said there, including the need for separate sub-targets for HIV & other diseases under an UHC umbrella goal (by Helen Clark) and the need for a broader policy focus for the HIV response. See also this joint press release by UNAIDS & the World Bank (with some action points).
6. Lancet (Viewpoint) – What does universal health coverage mean ?
Thomas O’Connell et al.;
This essential article on UHC was published a while ago online in the Lancet (early online), now it’s in the print version. Must-read if you haven’t done so yet.
7. Bloomberg – World Bank’s Kim Says Health Care ‘Is a Right for Everyone’
In a meeting at the Center for Strategic and International Studies (CSIS) on UHC in Emerging Voices, in Washington, Jim Kim gave the keynote speech. And yes, the world paid attention to this sentence in particular.
8. CSIS – Global Action toward Universal Health Coverage
This report is a primer on UHC. It examines the history of UHC, the momentum the concept is gathering in countries and at international organizations, the elements needed to move toward expanded coverage, and the obstacles involved.
9. Economist – Young, fit and uninterested
Judging from the title of the article, you might think this is about Justin Bieber or Miley Cyrus. But no, for the latest on the ACA roll-out in the US, see this article in the Economist. “The fear is that if young people fail to sign up for Obamacare, insurers will raise prices, making healthy people even less likely to buy coverage in the future. Democrats say the new enrolment figures show that Obamacare is at last getting past its painful birth pangs. Republicans retort that, on the contrary, the new numbers show the whole venture is doomed. It is too early to say who is right.” NEJM also has a Perspective on the new health insurance market places.
10. Irin – Hopes and fears as Indonesia rolls out universal healthcare
Some background on the roll out of UHC in Indonesia, with all the challenges involved.
11. Economic voice – Health And Environment Prominent On Davos 2014 Agenda
If you want to know what Davos offers in terms of health & environment sessions, read this article. As you probably already read this morning, the Davos bunch are worried about the rising inequality, as it might have major social and political instability repercussions. Now that’s what I call rocket science and policy insight. They also pay quite some attention to mental health this year.
12. NEJM – Transforming Lives, Enhancing Communities — Innovations in Global Mental Health
Vikram Patel et al.;
Maybe Vikram Patel will also be around in Davos. In any case, the bigwigs of globalization would better read his Perspective in NEJM.
13. Lancet (Editorial) – Grand convergence: a future sustainable development goal?
This Lancet editorial makes the case for Grand Convergence as an SDG. Next week, Larry Summers, Bill Gates and others will probably also make this case in Davos.
14. Guardian – NTDs: treatment could lift one in six people out of poverty
The cross-cutting effects of neglected tropical diseases must make them a crucial part of the post-2015 development agenda, Mistry argues. He is managing director of the Global Network for Neglected Tropical Diseases.
15. BMJ blogs – NCD among the bottom billion
Richard Smith reacts on the recent article in the Lancet by Agnes Binagwaho et al, who made the case for a 80x40x20 target— to reduce NCD deaths under 40 by 80% by 2020. The commentary in the Lancet was developed with the NCD Synergies Group, which includes input from 10 African ministers of health. Smith is not entirely convinced.
Smith also just wrote a blog on the ‘taboo over the private sector which limits health development’ (the blog reports on a small meeting organised by the Centre for Global Development in Europe).
16. Chatham House – The Next Era of Global Health? Follow the Money
As more and more money flows through the global health domain, and emerging economies and companies take a more influential role in it, new approaches are needed to help the agenda adapt, Kickbusch argues. Creating a commission on the financial and commercial health environment, a funding mechanism for global public goods for health and a high-level independent panel on health impact would all help drive it forward.
17. Guardian – Disability issues must be part of development agenda, say aid experts
18. BMJ (news) – Agencies condemn new Nigerian law that may deny gay people access to HIV services
The winter Olympics are coming up, and no doubt Vladimir Putin still has some nasty surprises in mind for the world. As somebody said, you can boycott the Games by not watching them. In SSA, Jonathan Goodluck signed the Same Sex Marriages law this week, the content of which goes much beyond its name – it bans same-sex relationships and could impact HIV/AIDS prevention and education activities in the country. This BMJ news article reports on the reaction by UNAIDS and the GF (see their press release). John Kerry also wasn’t pleased. On the same topic, read also an article in Science Speaks.
Hard to say how the donor community should react – this warrants a thorough debate, especially now that at least some HIV activists in SSA seem to be implying that the donor rhetoric on the issue needs to be toned down; if not they risk to become the victims of popular rage if, for example, the Global Fund cuts aid for HIV (in general) in a country if it doesn’t stick to NFM requirements related to these key populations. Many other activists, however, think otherwise. But Goodluck is not Mugabe. By any means, this fight urgently needs “Mandela style” champions from many continents, with great moral standing, as for the moment it’s too much seen as a Western agenda. By way of example, Desmond Tutu just set up a gay party in South-Africa. Hope many will follow suit.
As for DFID’s reaction on the law, see here. It won’t cut aid to Nigeria, as none is going via the government. Sometimes Cameron just has all the luck.
Maternal, child health & adolescent health
19. Huffington Post – Saving Mothers, Giving Life: New Year, New Results for Maternal Health
Deborah Von Zinkernagel;
The lady with the lovely fairytale name who was the interim-boss of PEPFAR wrote this op-ed in the Huffington Post, on the first annual report of the ‘Saving Mothers, Giving life’ partnership. On the release of the report, see also a Science Speaks article and another one on the CSIS (Janet Fleischmann et al) website.
20. BMJ (news) – India targets 243 million adolescents in new health strategy
India has launched a national health programme aimed at improving the status of adolescent health in the country. Known as Rashtriya Kishor Swasthya Karyakram (RKSK), the programme is expected to benefit 243 million adolescents aged 10-19 years across the country.
21. Humanosphere – Child marriage seen as a girl’s health issue
The development community is starting to pay closer attention to the problem of child marriages. Long considered an issue of human rights, the conversation about child marriage is shifting to that of health and education, Murphy argues.
22. Guardian – WHO guidance ‘risks killing children’
Rapid fluid resuscitation of children in shock can cause death, a major trial showed in 2011, but the World Health Organisation has yet to update its advice to doctors, say scientists in a new BMJ analysis, warning thousands could be harmed. You find the WHO response here, also in BMJ.
23. KFF report – Mapping the donor landscape in global health: family planning and reproductive health
The Kaiser Family Foundation released a new report that examines the donor landscape for family planning and reproductive health in countries around the globe. It’s the final report in a series of analyses examining donor involvement in addressing different global health challenges and finds that 147 countries received FP/RH assistance from 36 different donors between 2009-2011. The analysis also found that the U.S. was the largest donor, followed by UNFPA and the UK.
Health policy & financing
24. KFF – Congress Releases FY14 Omnibus Appropriations Bill, Including Global Health Program Funding
Democrats and Republicans reached a truce, end of December, and this is the result. Although not everything has been decided yet, global health funding seems to be doing ok, especially PEPFAR & Global Fund (which are in line with what the Obama administration requested). See this KFF policy tracker for the exact figures involved.
Check out also a Science Speaks article on the Congress budget deal.
25. Mail & Guardian – Motsoaledi: Big pharma’s ‘satanic’ plot is genocide
Motsoaledi is furious, and for good reason. Read why.
26. JAIDS – The Politics & Epidemiology of Transition: PEPFAR and AIDS in South Africa
Kavanagh, Matthew M;
Earlier this week, Health GAP and its partners released a report that looks at the PEPFAR ‘transition’ in South Africa — moving from ‘directly supporting’ over one million people on ARV treatment in South Africa in early 2011 to a near complete withdrawal from support for ‘direct services.’ As South African officials have taken the lead, political transition has created unique shared-governance institutions. However, the politics are outpacing strategic health policy. Thousands of patients and the health system have experienced disruption as PEPFAR withdraws funding for direct services, in one of the largest health program transitions in history. Important lessons can be learned for South Africa, the U.S., and the future of health aid. (see also the press release, and an analysis of the report in Science Speaks ).
27. CGD (Report) – Clear Direction for a New Decade: Priorities for PEPFAR and the Next US Global AIDS Coordinator
Amanda Glassman & Jenny Ottenhoff;
PEPFAR is at a critical turning point in its decade-long existence, argue Glassman & Ottenhoff. The next US Global AIDS Coordinator is uniquely positioned to set the course for the program’s future. A change in leadership at PEPFAR creates an opportunity to ask questions about the organization and reflect in more general terms on the US response to the global AIDS epidemic. They see four priorities.
See also this CGD blog post.
28. Guardian – Experts call for new drugs and return of sanatoriums to halt TB in South Africa
Sarah Boseley reports on a study, just published in the Lancet Early online. ‘Patients with drug-resistant TB in South Africa are being systematically discharged into the community when their treatment fails, where they continue to spread the disease, doctors warn. The situation in South Africa, which does not have the advanced treatments that gives people the best chance of survival, is dire and a warning of the threat this form of tuberculosis poses to the world, say experts. Professor Keertan Dheda of the department of medicine in Cape Town, leader of a new study published in the Lancet, said that research into new drugs to treat drug-resistant TB was urgently needed and that modern versions of the old sanatoriums should be introduced, to offer voluntary seclusion and care to patients.’
29. HP&P – Policy options for pharmaceutical pricing and purchasing: issues for low- and middle-income countries
Tuan Anh Nguyen et al.;
Pharmaceutical expenditure is rising globally. Most HICs have exercised pricing or purchasing strategies to address this pressure. LMICs, however, usually have less regulated pharmaceutical markets and often lack feasible pricing or purchasing strategies, notwithstanding their wish to effectively manage medicine budgets. In HICs, most medicines payments are made by the state or health insurance institutions. In LMICs, most pharmaceutical expenditure is out-of-pocket which creates a different dynamic for policy enforcement. The paucity of rigorous studies on the effectiveness of pharmaceutical pricing and purchasing strategies makes it especially difficult for policy makers in LMICs to decide on a course of action. This article reviews published articles on pharmaceutical pricing and purchasing policies.
30. World Health Summit yearbook
On the World health summit in Berlin (in 2013) and with some more articles (including an interview with Jeanette Vega and others, a short piece on the forthcoming Lancet Commission on Global Governance for health report, …)
31. Guardian – 1.2 billion reasons to celebrate: India set to be polio-free
Pretty sure you didn’t miss this news this week. India marked three years since the last reported polio case.
32. CGD – Spatial Relationships: Does Global Health Aid Go Where It’s Needed?
Amanda Glassman et al.;
Glassman & co talk about the AidData Research Consortium (ARC), a research collaborative which aims to come up with geocoded development finance data.
33. project Syndicate – Education is a Security Issue
Don’t know whether Tony will be in Davos, but if so, he’ll probably make this case too in Switzerland – that education is now a security issue (bye bye, HIV).
34. Scidev.net – MSF pioneers opening up access to humanitarian data;
MSF is pioneering an open-access approach within the humanitarian sector in the hope that other medical aid organisations will follow suit. MSF decided to make the data its clinical and research staff collect freely available online, says a report published in PLOS Medicine last month (10 December). This is the first time a medical humanitarian organisation has fashioned a policy to openly share its data, MSF says.
35. WHO Bulletin (early online) – Compulsory patent licensing and local drug manufacturing capacity in Africa
Olasupo Ayodeji Owoeye;
There is a compelling need for African countries to collaborate to build strong pharmaceutical manufacturing capacity in the continent now, while the current flexibilities in international intellectual property law offer considerable benefits.
36. Globalization & Health – Government capacities and stakeholders: what facilitates ehealth legislation?
All international regimes — the WHO, the EU, and the OECD — promote PPPs in order to ensure the construction of a national eHealth infrastructure. This paper shows that the development of government capacities in the eHealth domain has to be given a higher priority than the establishment of PPPs, since the existence of some (initial) capacities is the sine qua non of further capacity building.
37. HP&P – Boosting health insurance coverage in developing countries: do conditional cash transfer programmes matter in Mexico?
Olga Biosca et al.;
Participation in Mexico’s Oportunidades Conditional Cash Transfer (CCT) programme is positively associated with awareness of enrolment in public health insurance, argues Olga Biosca. CCT programmes may be used to promote participation of the lowest socio-economic groups in universal public health insurance systems. This is crucial to achieving UHC in developing countries, she says.
- Owen Barder blogged on the future of development cooperation. Read also Simon Maxwell on the same issue.
- The Guardian on the World Bank’s Annual Global Economic Prospects (and possible impact on developing countries, as Western monetary policies are being reversed).
- A new UNDP report says we should much more differentiate between MICs.
- In a nice step towards accountability for the international financial institutions, IMF & World Bank directors will now have to report to the US Congress on progress on responding to the findings of the accountability mechanisms vis a vis HR violations. (see here ).
- The Guardian has an article on a new report by the European Network on Debt and Development (Eurodad). (see here ).
- A Devex article analyzes the US budget bill, and how it will affect foreign aid.
- After the election of a new government, Norway has changed its development portfolio – If you want to know how, learn Norwegian.