Submitted by: Viola Krebs (ICVolunteers)
As a medical doctor, working in the field of maternal and neonatal health, Dr. Imtiaz Jehan sees public-private partnerships and the challenges related to access to health from a Southern perspective. She shares with us how she believes progress can be made for the public and the private sectors to working together.
Q: This conference is about "global access to health". To you what are the main challenges and the most important issues when it comes to this topic?
Regarding access to health: universal and equitable access to health is a big challenge in Pakistan where I am working. There has been a realization of this challenge at all levels. At this time, the government is committed to expand the coverage of the public healthcare with the support of the international donor agencies, such USAID, DFID and many others. Efforts are put in place in order to increase access and coverage to basic health services and various models are proposed to achieve this goal.
But simply scaling up is not enough. The quality and quantity have both to be looked at. Indeed, the quality of care, the availability of equipment, and the standards of care and training of care providers are essential. Just expanding the same low quality health care is not going to solve the problem at all, and it is not available 24 hours. As a result, the population heavily relies on private facilities and services; a common scenario in the poor and under-privileged segments of the population in rural areas and slums, where in Pakistan almost 70 to 80% of the population lives. This is where public-private partnerships become pertinent.
Q: There is indeed a lot of talk about public-private partnerships (PPP's). What opportunities and challenges do you see for these kinds of collaborations?
The question is how to match the very different agendas of the public and the private sectors. Regulatory mechanisms for the private sector and accountability are the major challenges in this context. We can indeed not to ignore that for most of the private sector it is about profit. However, when we talk about accountability, we can ask if there should, for example, be a ceiling for the profit? Also, can the private sector become a true partner to the general health facilities? Can private companies help improve the standard of the government sector? And of course, it should be a two-way street: in return, what can they get from the government sector? It needs to be kept in mind that the private sector has a limited scope of service provision. For country-level overall services provision, the governments remain the main key player. It is capacity and quality of services that need to be improved and this is, I believe, where strategic PPP's can indeed help. In turn, private universities and academia, such as my institution, the Aga Khan University, can be used as resource centres, improving the services.
Q: What do you expect from a conference like this one?
First of all, I would like to commend the organizers for their initiative. On the positive but critical side of things, I would have hoped that a conference focusing on global access to health would bring even more perspectives from the developing world. This could possibly be done through roundtables. Secondly, the alternate solutions and proposals that were presented in some of the talks --for example with regards to public-private partnership and alternate healthcare financing-- the developing world perspectives were not well reflected.
September 2, 2006
Submitted by: Viola Krebs (ICVolunteers)
Mr. Salih Meky, Minister of Health of Eritrea, spoke with us about achievements and challenges in the field of health in his country and Africa more generally. In Eritrea, health care is free of charge. The country has managed to keep under control a number of infectious diseases, but faces the increasing challenge of chronic illnesses, such as diabetes, hypertension and cancer. Hospital costs are a major issue. Minister Meky also questioned whether there was a simple solution to the brain drain, but urged that it needed to be addressed not just by the South, but also by the wealthy countries in the North.
Q: The Forum closed its doors a few minutes ago. What are your impressions of the event?
The subject was really timely and very important at this moment in time. The question is one of equity in the health service of any given community. It has been said that health is a right and if it is a right, it is a human right and if that is so, it should be accessible to all. Of course, there is always a difference between a wish list and reality; equity and reality. But it is a question of getting the best care possible to all. Forums like this one, I believe, are very important for addressing these kinds of issues. One approach is to talk about things, another to actually do them. I believe both aspects are needed when addressing challenges related to health. As a Minister of Health, I see how things are done in my country, but it is helpful to see how they are done elsewhere.
Q: This Forum has been an opportunity to hear health professionals and politicians talk about challenges and achievements in their countries. Dr. Frenk, Minister of Health of Mexico, talked for example about the health reform implemented in his country to make health services more accessible to people. How would you characterize the achievements and challenges in your country?
The situation in Eritrea is quite different from the one in Mexico. Indeed, for one, health services are available to all. Insurance is not an issue for the moment but will become one soon, because the cost is not sustainable. Also, Eritrea is one of the few countries in Africa where it has been possible to eliminate polio and to keep within a manageable range infectious diseases such as tetanus, measles, malaria and HIV/AIDS.
Now to the challenges... First, Eritrea is a transition state that has to increasingly deal with illnesses among its population such as diabetes, hypertension and cancer. These illnesses are very serious, extremely costly, very difficult to cure and constitute a huge burden to the health system. The best way to address them is to prevent them. If they occur, you have to manage them. As primary health care gets established, chronic disease becomes more an issue.
Second, the financing of municipal hospitals is a challenge. Indeed, hospitals represent the largest health expenditure of all in the national health budget. People talk about the cost of specific diseases, but in our case the overwhelming part goes to hospitals. Our greatest number of workers is in hospitals. This is one of the points that is least well understood, partly because it is complex and also because it is not easily accessible to theoretical work.
Third, health professionals, doctors, nurses need to be trained. If health facilities are not well run, you train health professionals in a way you would rather not. Training is fostering the future of health personal. It has implications not only for current issues at hand, but also for the future. Overall, applied research is very important as well.
And last but not least, when talking about the question of access, you are talking about enough beds, enough doctors, medications to respond to every need. Can catastrophic events be handled? This is a pivotal element and can be used as an indicator for services. On the other hand, such events can be so overwhelming other aspects might be forgotten, but in all events primary health care is important.
Q: Organizations such as Transparency International identify corruption as a stumbling block for the development of many African nations. How do you see the issue of corruption?
You are right: corruption is a major issue in many places, but not in Eritrea. I believe that in any institution, lack of accountability is poor management. If there is no proper evaluation, if there is no transparent result from any investment, you are opening yourself to abuse. This is true in wealthy countries. For countries that have less accountability is even more important. This means governance and intervention. But I believe that to some extent the question of accountability is also in the hands of donors. Indeed, those who are managing money do not always make sure that the money goes to the right people. Also, accountability is not only internal, but there also needs to be a method to measure it in a pragmatic way, in figures. This is so political that its impact and outcome is hard to measure.
Q: Another issue mentioned over and over again during this Forum is the brain-drain of health professionals. How can we stop it?
I am not sure that you can, but if you want to change something, you must look at the cause. The US and Western countries are in need of health professionals. They can get them. What can we do? We in the South need to make living in our countries viable. Many people moved from Europe to the US, because the conditions there were more interesting. This is also happening from Africa and Asia to Europe. If living conditions were better, if people saw that there is a decent living opportunity for them, they would be happy to stay. This is why we have got to work for a common cause together, for a better and brighter future. We have an obligation and duty to our country, but there are many reasons for people to move: insecurity, marriage and many more. Hence, there is not an easy answer to the brain-drain. Developed countries ought to help us train people. Developed and developing countries need to work together. There ought to be free movement of people. The brain-drain must be solved. Africa cannot continue to lose its best citizens. There is a lot of hardship. All of us are in this.
September 3, 2006
Mary Robinson, the first woman President of Ireland (1990-1997) and more recently United Nations High Commissioner for Human Rights (1997-2002) shared with the conference team some of the main challenges at hand when it comes to access to health for all: accountability, financing, the brain drain and the responsibility of those who have the means to make a difference, such as the private sector. She pointed out that the high turnout at the Forum was an indicator of the need for it and the urgency of discussing access to health. Access for all is the concern of all.
Q: Accountability of politicians for decisions affecting human health and dignity is a key issue. If everybody agrees on the principle, the question remains of how to assess their achievements and how to enforce accountability?
I speak more and more about accountability including accountability in the social context. Human rights help greatly. We know what the legal commitments mean for countries. The UN Committee on Economic, Social and Cultural Rights has provided guidance to governments and standards against which they can be held accountable. We have more and more ways to measure their ability to fulfill the right to health. Some of the core obligations such as ensuring that no one is discriminated against in terms of access to basic treatment are to be fulfilled regardless of available resources. The increasing sophistication of civil society groups also enhances social accountability. The Treatment Action Campaign case in South Africa proved that governments can be required to implement comprehensive and coordinated programmes in order to realize the right of access to medical treatment. On 4th September, I will be in London to help Paul Hunt, the UN Special Rapporteur on the Right to Health, to defend his ideas on this matter with the UK Government. It is an important move because we need to keep accountable rich as well as poor countries.
Q: Requesting from developing countries that they finance themselves the access to health for all at a national level seems unrealistic. On the other hand it appears that financing provided by the developed countries for the South has short term effects. Is there a methodology that could be followed to obtain long-term sustainable results?
The current situation is actually shocking. Public health systems in poor countries are broken, in particular in rural areas where many problems surface. We need absolutely to change the approach. It is being recognized that the local parameters have to be far more taken into account. Many errors have been made by the IMF and the World Bank, which actually weakened the ability of countries to take local action. The new trend amongst donors to privilege general budget support since the Paris declaration on aid will put more responsibility on the countries' decision makers. Health ministers will have to be very skilled managers which is not necessarily always the case currently. In quite a number of countries corruption also remains a major issue. Everything should be done to support health ministers and their ministries in order to allow them to manage funding from the GAVI (Global Alliance for Vaccines and Immunization), NGOs, foundations and other donors and to enable them to meet, amongst other things, the Abuja declaration which targets that 15% of national budgets would go to their health systems.
Q: When one thinks of resources, a major one is the human resource. Developing countries suffer from an ongoing brain drain affecting deeply their health systems. How to stop and even reverse this trend?
It is of utmost importance to stop the brain drain. Mid-level workers need to be trained. These middle-skilled personnel are undervalued and invisible. Yet, these health personnel show more sustainability while not being tempted by migration like highly trained health professionals. A good example of this is the use of Tanzania's paramedical personnel to dispense anti-retroviral medication. On 12 September, we will have a high level meeting in New York on migration. The aim is to stimulate more bilateral agreements between countries to avoid permanent migration and to enhance shared training efforts. All countries should share responsibility in this field. In this respect, the pull factor is of importance, meaning that the rich may agree to train more. In the US, where I am currently living, 500,000 nurses and 200,000 doctors are needed by the year 2015. Nurses are being imported. The fact of acquiring them cheaply by not having to educate them is unacceptable. There are many ideas to think about.
Q: The pharmaceutical industry is often criticized. Do you think there is evolution to provide medicine at lower costs? Is there a will within those companies to become socially responsible beyond just a superficial marketing move?
We regard the private sector as an important player either providing good resources or a negative influence. We are keen to see them fully responsible and specific companies have taken this direction. Paul Hunt, the UN Special Rapporteur on Health, is developing guidelines related to the human right to health. The subject is vast and goes from intellectual property to pricing. It is evident that we need a structure and guidelines and pharmaceutical companies, as well as all other stakeholders, have to buy into this.
Q: What are your expectations from the debates during the present Forum and in what way can they influence decision makers?
The Forum comes at the right time. This is proven by the fact that the attendance overshot all expectations. I am convinced that we can initiate change in most of the fields which are on the agenda. The dynamics exist to accelerate a breakthrough in areas such as safer food and water supply, improving educational levels and other social determinants. The Millennium Development Goals have set a 0.7% of GDP level for the aid to be provided by the North to the South. The US Administration is today more willing to commit itself as well. All of this needs to be thought through. The errors of the past often found their origin in the non-coordinated approach of health issues and systems. This Forum gives the opportunity to encompass government representatives, healthcare specialists, donors and NGOs, to strengthen sustainable long-term health systems and to develop common views. With the human rights as a framework it seems that the objective of access to health for all will certainly have made some progress through the conference.
Q: A few weeks ago you attended the World Conference on AIDS in Toronto. What was your overall impression and what conclusions could be drawn from the debates?
My impression was quite similar to the one that prevailed during the previous conference two years ago in Bangkok. A lot of emphasis was put on the progress to be expected from fundamental scientific work. Subjects such as the status of development of microbicides were at the centre point of the majority of the debates, but the use of female condoms got little mention in the context of sub-Saharan Africa. The ability of women and girls to protect themselves from contracting the virus is as important as the process to prepare effective microbicides. The issue of the identification of risk groups did not seem to draw a lot of attention. It appeared as if there was a tendency not to want to address real problems. In a sense it was quite disappointing. Community groups know what they are doing and what they need, but they did not always get enough attention. The focus was more on well known guests than on rallies on women's issues and rights. A number of key issues were not addressed. The planning for the next conference in Mexico needs to put the priorities right.
For more information about Mary Robinson's current activities and work with Realizing Rights, see http://www.realizingrights.org.
September 2, 2006
Submitted by: Viola Krebs (ICVolunteers); Contributors: Jean-Pierre Joly (ICVolunteers)
Health reform is badly needed in many countries in the developing world in order to stop the burden of catastrophic healthcare costs remaining on the shoulders of individual families. We talked to Dr. Frenk, Minister of Health for Mexico, where an important healthcare system reform was launched in 2003. The reform implemented, among other things, a 7-year plan to finance "el seguro popular" or popular insurance.
Q: How do you see the development of a global health policy? What are the major issues?
Let me give you the example of Mexico to illustrate my views. It is about a real life experience regarding the deep transformation undertaken by my country in the field of developing and managing a health system. It has been a process of shared learning and innovation, inspired by other countries, including European nations. It is our aim to share our experience with others and make it available to them.
Many barriers have to be overcome when putting in place a coherent health system which provides equal access to health for all. Barriers are geographical, cultural and organizational. For example, bureaucracy will generate long queues and alter quality. In addition, a major stumbling block to enhancing health programmes is their financing. We, in Mexico, have understood that we need to demolish the financial barriers to make progress. Financing is of course not just an issue for Mexico. Indeed, nearly everywhere in the world, financing of health systems has not kept up with existing and forecasted needs. However, developing countries have to bear a double burden. Not only do they have to face health problems due to epidemic diseases but, at the same time, they have to build their infrastructure.
Hence, many low and medium income countries have been unable to adapt their health systems. But the changing environment requires them to do so. Several factors can provide pressure to trigger change. Today, we have to face new epidemic diseases such as AIDS which did not exist 25 years ago. Another factor is brought by technological evolution: there are new drugs available that can save lives. And then there is the growing pressure and awareness of populations that health is a fundamental right. Good pressures can help adjust health systems in order for them to respond better to needs.
Q: So, how did you go about bringing change to the health system in Mexico?
We decided to tackle the issue on several fronts, in particular the social, the financial and the cultural ones. What we have done is not perfect but it has produced good evidence. First, one has to understand the reality and become aware of the unacceptable paradox that the lack of financing healthcare in a country can itself create poverty. Next, you can transfer experience from elsewhere to adapt and improve the existing or non-existing system, taking into account the social, financial and cultural characteristics or limitations of the country. Once you have been able to produce good results of the interdependence between improvement of health systems and poverty reduction a new global dynamic appears.
In the Mexican case we took the decision to invest heavily in research to guarantee quality in the long run. Finally, it seems of utmost importance to me to articulate a clear ethical framework in which you can reflect the challenges of your people. Another element is the use of the ethical (universal human right) argument, to obtain the necessary political support in order to have your projects accepted.
Mexico has created a social protection scheme which is social insurance similar to what exists in several European countries and which allows poor people access to health care. This system of protection, also called popular insurance or "seguro popular" avoids that people are excluded from basic healthcare.
As I mentioned before, it is important to implement these new policies gradually in order to keep the finances of the country in balance. The Ministry of Finance only supported the changes on the basis of a sound financial plan. We adopted a 7-year horizon for the reform. A strict follow-up on the expenditure side increases credibility among parliamentarians and increases the chances of funding being continued in the future. Thanks to the support of the whole government we could create 2700 new facilities. It is true that in our case we started from a very low level and had a huge shortage, which explains why there were so many health facilities needed and created, in particular in the poorest parts of Mexico.
Our programmes also include education and training of medical staff. Another significant effort has been produced on the drug supply side. In this context, measures are taken that drugs are only obtained through prescriptions in order to have better control. And everything is done to spend the money in an efficient way.
We also are constantly assessing our policy, the state of the technology in place. A number of challenges need to be addressed. There are still existing geographical discrepancies, bureaucracy treating people without dignity, organizational and cultural barriers. 10% of the Mexican population is indigenous and more than 50 languages are spoken in the country. Health care in the patient's language is needed. Monitoring tools are being put in place and the reports are made public. The results of the present system are needed to convince members of parliament and taxpayers to continue their investment in the new social contract for health.
Q: Just some words about your candidacy to the World Health Organization (WHO) and what your plans are?
I very much value the legacy of Dr. Lee. We had the honour of working together under Dr. Bruntland. We were colleagues. Later, I followed his work being on the Mexican delegation to the World Health Assembly. Also, Mexico hosted the conference on health research for development in November of 2005, which was an opportunity to welcome Dr. Lee to Mexico. Unfortunately, his term was cut short by his sudden death. I would like to continue many of the reforms that were started under him. I was very much in line and agreed with Dr. Lee's approach, in particular his focus on Africa, AIDS treatment, partnerships and financing mechanism in those partnerships. The focus on the internal management being more accountable will also be one of my priorities. The improvements initiated by Dr. Lee must continue.