Public Health in the 21st Century V

The Future of Public Health

We now come to the conclusion of this introductory course on global health. Global public health has now a very large mandate in the context of sustainable development. It has grown from the foundations of public health, which itself is not relatively new. Even prior to the 20th Century, public health was deemed to be very important. Many of the important investments in public health, whether in the form of water, sanitation, or healthy nutrition, came about in the centuries preceding what we call as modernity. However in the 20th Century, marked advances in science and technology enabled us not only to understand the links between health and disease much better in terms of what causes disease and how best to protect it, but also to organize health systems around dealing with disease and promoting health. When we look at how the scientific knowledge has helped, we must also recognize that to some extent it started fragmenting our approach to public health. Epidemiology has been a remarkable science which advanced the understanding of the factors that cause disease, whether it is an infectious agent or smoking. However it is in the very nature of epidemiology that we start looking for independent associations which can be attributed to that particular risk factor over and above anything else. And therefore, necessarily we start becoming reductionist in our approach. But we also need to position that reductionist knowledge in a much more holistic context and that is where public health comes in. We have previously separated out different knowledge and practice domains like epidemiology, health economics, behavioral sciences and also to some extent management principles. But now we need to integrate all of them into the discipline of public health and to some extent we have succeeded in doing that in the 21st Century. But we now need to position it in the context of global public health, because global public health has now become a common concern for all of humanity whereas public  health previously did look at what was happening in different parts of the world but confined its actions mostly to national or regional contexts. But when we recognize that the determinants of health now act across geographical boundaries and cause common challenges that have to be faced by the world as a whole, then global public health becomes a very necessary unifying platform and here we need to integrate all of our knowledge in order to address these challenges. So while epidemiology for example provided a very necessary insight into what caused disease, public health provided a better perspective on how a complex system should be addressed, so from linear thinking to complex thinking, a complex system approach, we started having a transition. But global public health now brings in much more dynamics into the picture. It brings in the whole global economic profile of development and distribution of the products of that development. It talks about equity as an underlying value. It shows how economic inequities within countries and across countries can accelerate health inequities. It also shows how global cooperation can advance the common objective of reducing health inequities and protecting people against the spread of disease. So we now need to look at how global health has evolved from public health, how global health is now looking at the determinants of health transition across countries, the varied measure of these determinants, but how they act in concert in order to determine whether countries are going to face a huge burden of disease in one form or the other or whether they can actually telescope the transition by averting much of the disease that could have otherwise occurred. We now have a better understanding of some of the specific problems related to maternal and child health including child under nutrition. We also have a better understanding of the spread of infectious diseases as well as the methods for their control. We recognize the big threat posed by non-communicable diseases, and how these are happening in the context of health transition which again has multiple determinants and driving forces. We have seen how health systems have to be better organized in order to respond to this combination of challenges and how when we talk about health systems we are not only talking about financial protection or health workforce or access to essential drugs and technologies in isolation but we are talking about all of them and again as a combination. And where we now look at the health systems as a platform for universal health coverage, this becomes even more important to look at how universal health coverage can deliver a variety of services needed by the people while providing them adequate financial protection. This again becomes very important in the context of economic development and reducing health inequities which can be perpetuated by ill health which affects the poor people predominantly. So the interrelationship between poverty and ill health is again brought into focus not only in the area of public health at the national level, but in terms of global public health as well. So all of these complex interactions become very integral to our understanding of global health and become the basis for our action. When we really look at how we need to respond to some of these global public health challenges we further realize that we are require an all-of-society approach which brings in multi-sectoral action in order to advance global health by dealing with the multiple determinants which have impact upon health. Those within the health sector as well as those outside of the health sector, whether it’s trade, whether it is urban development, whether it’s agriculture and food systems, all of these will now have to be studied and also motivated to become better aligned to public health objectives. And this is where global public health has to now become positioned in the framework of sustainable development because we cannot really think of sustainable development without having healthy people. But we also can’t think of having sustainable development without a healthy planet and interestingly, we cannot think of healthy people without a healthy planet because environmental degradation will certainly undermine the health of the people and even imperil their very existence. So bringing together all of these elements under the framework of sustainable development is very critical not just because the United Nations wants to call them Sustainable Development Goals but because these are very important goals for humanity itself. But while all of this happens we have to contend with a huge number of social forces and decide how they can actually be driven in favor of public health. We recognize that there are different models of economic development based on ideologies, there are the free market model, there has been the state controlled model, there are people who are looking at blending some of these systems in a mixed economic system as well as in a mixed health system. While all of these debates go on, we must really recognize what works best in favor of global public health. And therefore, we need a vigorous debate on ideas but we also need to embody those debates and a set of fundamental values and global public health actually brings forth global solidarity and partnership as those values. And of course the very underlying value of public health anyway is equity. So when we are really trying to promote equity in all dimensions but use solidarity as one of the motivating forces for moving us toward that ideal of equity, then global public health becomes a very important unifying factor across the world. And therefore, irrespective of some of the ideological struggles that are inevitable, and are likely to take place even in the 21st Century, we must overcome the struggle of these competing and conflicting ideas and ensure that we have a common blending of values which will triumph over these kind of sectarian ideological battles and those values will have to reflect a commitment to global solidarity, because without that solidarity, we will not be really looking at all of humanity as one family where the concerns and problems of one section will have to be addressed by the whole family together. We must recognize that as we move towards the implementation of the Sustainable Development Goals, health is absolutely pivotal for the economic, social and environmental development and protection. And then we must also ensure that health in turn benefits from equitable development in other sectors. For all of this to happen, the Sustainable Development Solutions Network is providing a unifying platform for looking at sustainable development in all dimensions from all directions. Health and global public health are important components of the mandate of the Sustainable Development Solutions Network. We hope that after this introductory course in global health has set you in motion, you will now become important contributors to global public health and to sustainable development. Therefore, this is not the end of the course. This is the beginning of our partnership to work together for global public health and for sustainable development which are a global public good, and which are important not only for this generation, but for generations to come.

Public Health in the 21st Century IV

Health and sustainable development- II

This century began with the Millennium Development Goals but after fifteen years moved on to the Sustainable Development Goals, to build up on the gains of the Millennium Development Goals but also to pursue a much more comprehensive agenda of interlinked and inclusive development. Beginning with MDGs, and then subsequently having a strong focus on social determinants of health through the WHO commission on social determinants of health as well as a major thrust towards universal health coverage brought about by the World Health report of 2010 which focused on health financing, particularly as a foundation for universal health coverage, and then also looking at different emerging public health challenges of the 21st Century, the whole area of non-communicable diseases which in September 2011 formed the subject of a UN high level meeting resulting in a political declaration calling for concerted global action to prevent and control NCDs.

All of these in the last fifteen years have coalesced together towards the Sustainable Development Goals, but the clarion call for the SDGs came from the Rio+20 meeting in 2012 where the world pledged that they would work for sustainable development and said that collectively we will create the future we want. Basically at Rio+20 and subsequently through the actions of the United Nations for framing the Sustainable Development Goals three pillars were identified which were economic, social and environmental. Clearly, health is linked to all three of them. But along with this we also need to position another underlying element, if not as a pillar at least as the platform, and that is good governance.

The economic case for linking health to sustainability is very clear. Healthcare costs pushed 100 million people below the poverty line and this was from the World Health Report of 2010 published by the World Health Organization. Catastrophic health expenditures are commonplace not only in lower and middle income countries but also in some of the high income countries, for example in the United States we have seen a fairly large number of uninsured people suffering the problems of either inaccessible healthcare or impoverishing healthcare. Universal health coverage ensures financial protection through risk pooling and reduction of out of pocket spending. Clearly, therefore, there is a case for linking health to the economic development and ensuring that economic inequities do not affect health and also we provide greater health equity through suitable financial pathways like the universal health coverage with built in financial protection.

We also meet to ensure that households avoid spending their disposable incomes on avertable health problems so that that can be spent on other goods and services, improving the welfare of households like nutrition or even to give a fill up to the global economy by spending on other consumer goods. But if you’re spending money on avoidable angioplasties and coronary surgeries and so on, you do not have money to buy other consumer goods and that affects the pace of recovery in a sluggish global economy.

Clearly there is also a social case for linking health to sustainable development. We cannot talk of sustainable development or of health for that matter without talking about gender equality and human rights. They’re intimately linked to health. We recognize that these are important inputs into advancing health of societies and bridging gaps in health equity. So they become fundamental to any concept of sustainable development.

Other social determinants of health like education, social stability, and social networks, all of them are integral to good health. We see the co-dependency of many of these on health of societies so the social case for health is also clearly made.

When we look at the environmental case, while this was not very clear and not explicitly made in the past, we now increasingly recognize that we must place health alongside environment and the overall framework of sustainable development because there are many linked determinants and that framework will allow inter-sectoral policies that promote health as well as improved environmental sustainability simultaneously. For example agricultural sustainability. We can’t think in terms of food and agriculture systems merely as commercial activities because ultimately their purpose is to provide healthy nutrition to every citizen at every stage of life across the world. And if they’re not aligned to health, then clearly we see that agriculture and food systems are failing in their primary objective.

There are other elements as well, like resilient cities. When we talk about resilient cities, we are talking about cities that are not only resilient to climate change but also to natural disasters. We’re talking about promoting active means of transport which will reduce vehicular density, vehicular pollutions, and reduce environmental degradation at the same time protect the lungs and bodies of people and we recognize that air pollution is a major threat to health of people and we need to link that to environmental concerns. And therefore, bringing in the environment and health together into a common platform is very critical to both and that is where sustainable development provides that kind of a linkage.

We also recognize that all of this is not going to happen unless health challenges are seen as something that all of society must respond to, because they cannot be tackled in isolation. We required the engagement of multiple stakeholders, the government, the civil society, academia, the media, the private industry. It has to be an all of society effort for inter-sectoral action to take place because all of these are interlinked goals which can only be advanced by collective action. And at the same time in order to make sure that policies are not misaligned, we need health in all policies. For example, when we look at the non-communicable disease prevention and control plan of the World Health Organization, we recognize that the multi-sectorality implied in that action plan is something that warrants the active engagement of multiple ministries and multiple agencies and unless we link them together we will fail in preventing or controlling NCDs. Similarly even for a number of other areas of health, we need multiple stakeholders to come together. So health in all policies becomes absolutely critical as an important area of advancing health, but in the same time that provides a very smooth passage to sustainable development as the common agenda.

Margaret Chan, the director general of the World Health Organization has said that universal health coverage is the single most powerful concept that public health has to offer. However, there are some questions that have been raised about UHC when we talk about it as a SDG goal. Is it measurable in a comparable way across the world? What are the targets and indicators? Is it related only to financial protection or does it include other health system components? Does it balance vertical equity which is gap filling with horizontal equity which is equality of access? Does it ignore the social determinants of health by focusing only on health sector actions? These are legitimate concerns. But fortunately the global discourse on SDGs over the period when they were actually being debated actively by the global public health and development communities has brought us now closer to a consensus, that UHC needs to have a core component of financial protection but UHC cannot be delivered unless the other elements of health system are strengthened but at the same time health cannot be assured by UHC alone acting through the health sector.

But it has to now bring in actions into other sectors especially on social determinants of health to the fore by ensuring that there is synergy between the health sector actions as well as the actions in other sectors to advance the social determinants of health as well. So we now recognize as we move towards implementation of SDGs that action is required in each of these areas.

Finally there is a big question that had been asked of the SDGs while they were being developed. UHC is of course relevant and must be part of the goal but in the health goal something that we can develop which is applicable to all countries, the MDGs were not applicable to all countries, they were only applicable to the low and middle income countries, so how can we ensure that the new goal in the SDGs is something that all countries subscribe to and become accountable for? So UHC is one where it matters to everybody high or low income. We have seen that. Even countries like the United States still need to address the UHC as an important part of their agenda. Progress on MDGs is also needed but it’s still relevant to low and middle income countries. But non-communicable disease targets are relevant to all countries. They’re a bit more challenging for low and middle income countries where the epidemic is on the upswing rather than for the high income countries where the epidemic has stabilized or is on the downswing. But nevertheless, the whole world faces the challenge of NCDs so we need an income percent goal which combines all of these three elements. So we are really looking at the goal of a healthy planet with healthy people as our ultimate objective and for this it’s been proposed that firstly we must accelerate progress on the health MDGs, we must also reduce the burden of major NCDs and for these we need core enablers which are universal health coverage and access as well as action on social determinants of health. They provide the platform. So if you can combine all of these we have set the goal for health within the SDG context. So we do require what will be the ultimate way the Sustainable Development Goal is worded or interpreted, there are several actions which are needed for implementation. First is to build on addressing the gaps in achievements of the MDGs four, five and six which were the health MDGs or the health Millennium Development Goals. We also need to adopt a life course approach to health promotion, disease prevention and healthcare. We know that human beings live one single life. And therefore their health cannot be segmented and health of one stage of life impacts upon the health at other stages of life. So we need the life course approach.

We also need to increase public spending for health. Allocate at least 5% of the GDP as public financing for health. Without adequate financing health systems will remain feeble, they’ll not be able to deliver on UHC, they’ll not be able to deliver on health as an important part of the sustainable development agenda. And high income countries must do at least .1% of their gross national income as overseas development assistance for health. Of late, we have seen the declining trend in this kind of financial assistance that’s being provided except possibly to the least developed countries. Many of the low and middle income countries need that kind of a continued assistance without which their health systems cannot really be strengthened. So the high income countries must fulfill their social obligation to support other countries through an increased overseas development assistance.

All countries must provide high quality healthcare based on comprehensive primary health services. That is the foundation for good health and therefore a health system must prioritize primary health services.

We must create and support a skilled, adequately resourced workforce for health. We have a global health workforce crisis, particularly reflecting poorly on the health systems of low and middle income countries. We need to create a multi-skilled, multi-level workforce which is competent and motivated to deliver on the UHC and SDG agendas. We must ensure access to essential medicines, vaccines, commodities and technologies using pooled procurement and distribution of quality assured drugs. Whether it is HIV/AIDS or whether it is cardiovascular disease and diabetes, we need essential drugs to be available to all and pool procurement and distribution of quality generics is the way to go. Effectively implement comprehensive tobacco control programs. The Framework Convention on Tobacco Control, this is absolutely critical because tobacco is the major killer even in the 21st Century, it’s expected to kill about a billion people so we have to ensure that people do not die because of tobacco consumption whether it’s active or passive consumption and the various provisions of the FCTC or the Framework Convention on Tobacco Control is implemented in earnest can actually bring down tobacco related mortality and morbidity.

We must align agriculture and food systems to ensure nutritional security. We must align them with health, with a nutritional goal so the population at each stage of life, so our goal must be to deliver caloric adequate but also nutritionally appropriate diets to every citizen on this earth at each stage of his or her life. And that is where agriculture and food systems must deliver.

We must ensure availability of good quality water, sanitation and hygiene reduction and exposure to air, water, light and sound pollution and we must start up pro health policies in all sectors which are conventionally not regarded as part of the health sector but which nevertheless have a profound impact on the health sector.

So when we look at all of these we recognize that when we talk about economic growth, social equity and environmental protection there are a number of factors like urbanization, transportation, air pollution, food and nutrition security, labor productivity, healthcare expenditure, all of these are so interlinked and education, gender, all of these are so intertwined with health that we cannot really tease them apart and that’s why bringing them into the framework of sustainable development is very critical, even for advancing global health.

And we must learn to recognize that some of these connections are not apparent. For example when we think in terms of tobacco, we only think of the one billion deaths that may happen in the 21st Century, bad enough, but we must also recognize that tobacco is also a major cause of deforestation. Therefore it is an environmental threat because in order to cure tobacco leaf, one has to burn wood. For three hundred cigarettes smoked anywhere, someone somewhere has killed a tree. It’s also a cause of air pollution. It exacerbates poverty. It’s a cause of food insecurity. It’s absolutely unacceptable that four million hectares of arable land are now devoted world over for this killer crop than for nutrient crops. It is also a very water intensive crop and therefore, it again is an environmental threat from that point of view by exacerbating the water usage.

So when we think in terms of connection of health with other Sustainable Development Goals, especially environment, the connections really extend beyond the conventional. Similarly when we talk in terms of emerging infectious disease threats, we cannot talk in terms of zoonotic pathogens from wildlife which are now increasing threats whether it’s H1N1 or SARS or H5N1 or avian influenza without recognizing that we are actually creating conditions for this spread by extensive deforestation and by creating a conveyor belt between viruses and vectors from the forestry and the captive veterinary habitat and into the human habitat. Similarly when we are talking about drug resistant pathogens, anti-microbial resistance coming up, whether it’s anti-tubercular drugs or other forms of super bugs, we have to recognize it’s the weakness of the health systems that are really giving rise to this and also the nature of our rapid transportation and modern communication which is also resulting in their spread. So there are multiple areas in which we ought to be able to look at all of health as linked to different areas of human activity and all of those domains are built into the Sustainable Development Goals. In the 20th Century, medicine and nutrition evolved to come under the broad umbrella of public health. In the 21st Century public health must evolve, whether it’s considered as public health within countries or global health across the world must evolve under the umbrella of sustainable development if it has to survive and thrive as an important objective of human development.

Ultimately the thread of human life extends from pulse to the planet, through persons or individuals, through people or communities or populations or nations, health has to be linked ultimately to the overall goal of sustainable development

Public Health in the 21st Century III

Health and sustainable development- I

The word development means many things to many people. Mostly people think of it as economic development. Others think of it also as social development. Some would like to think of development only when it is truly inclusive development, when the fruits of development are available to everybody in society. But now we’re also moving on to the concept of sustainable development where development not only happens, but it happens in a manner that is sustainable across generations taking into account the need for planetary health as well as human health and a very balanced economic and social development across the global community.

At the beginning of this century the focus was much more on bridging the huge gaps that existed between the levels of development across the world both in terms of high income and abject poverty and also huge gaps in health equity. So the whole idea was- can we begin the century to try and promote greater equity in terms of development including some of the critical areas of health? But now we are moving on to a period where we are actually beginning to discuss sustainable development as the goal for this century and beyond. Therefore, the Brundtland Commission looked at sustainable development from the point of view of the development not only of the current generations but also the future generations. It titled its report in 1987 as Our Common Future. And sustainable development was defined as one that meets the needs of the present without compromising the ability of future generations to meet their own needs. Therefore it was very important that the inter-generational equity concept was also integrated into the idea of spreading greater equity along with progress in the present day world.

The Millennium Development Goals which were annunciated and adopted by the global community in the year 2000 under the auspices of the United Nations reflected the urge of that time to try and bridge the inequities that were very manifest in the different developmental profiles of the countries. Poverty, ill health, lack of educational opportunities, all of these were clearly reflective of those inequities. So eight goals were designed to end extreme poverty and multiple deprivations with specific targets to be achieved by the year 2015. And these eight goals reflected various areas of developmental concern.

The first one was to eradicate extreme poverty and hunger, the second was to achieve universal primary education, the third to promote gender equality and to empower women, fourth to reduce child mortality especially under the age of five years, the fifth was to improve maternal health, the sixth was to combat major infectious diseases like HIV/AIDS, malaria and other major killers, the seventh was to ensure environmental sustainability, and the eighth was to build global partnerships for development. All of these were considered absolutely essential for altering the developmental gaps that existed across the world.

Three of these Millennium Development Goals directly related to health. Goal four was to reduced child mortality and a specific target was identified for action up to 2015. The target was to reduce by two-thirds between 1990 and 2015 the under five mortality rate, taking 1990 as the base year. Goal five was to improve maternal health with two targets, one was to reduce by three-quarters between 1990 and 2015 the maternal mortality ratio. Target two was to achieve by 2015 universal access to reproductive health recognizing that there was huge gap in the access to reproductive health services in many countries and virtually all across the world. But the whole area of maternal health can not only be reduced to maternal mortality. We also have to look at maternal morbidity issues. That was implicit but not directly measured as a target. Goal six was to combat HIV/AIDS, malaria and other diseases with three specific targets. Target one was to have halted by 2015 and begun to reverse by then the spread of HIV/AIDS across the world. HIV/AIDS was the big specter that was haunting the world at 2000, as the big killer. Target two was to achieve by 2010 universal access to treatment of HIV/AIDS for all those who need it. The whole are of access to essential drugs was becoming a major concern, especially because HIV/AIDS was killing people who could potentially have life saved with access to anti-retro-viral drugs. Target three is to have halted by 2015 and begin to reverse by then the incidence of malaria and other major diseases. These other major diseases were left unspecified but it is very clear that HIV/AIDS, malaria, and tuberculosis are the main areas of focus among infectious diseases at that time.

The other goals also indirectly affected health, even though they did not specify health as their primary objective. Goal one was to eradicate extreme poverty and hunger and we know that ill health is related both to poverty as well as malnutrition. Goal two was to achieve universal primary education and we know that education actually promotes health by improving knowledge and the ability of individuals and communities to take better care of themselves. Goal three was to promote gender equality and empower women. Women have suffered health inequities more than other groups in the society and in every society we have seen unless we promote gender equality and empower women we can not achieve better health indicators not only for them but for their children and for the families of the whole.

Goal seven was to ensure environmental sustainability. For the first time we were bringing in health and environment close together along with other areas of development because we now recognize that unless the environment is also protected, health will suffer.

Goal eight was to develop a global partnership for development, obviously this included partnerships for health as well. So all of the goals in some way or the other related to health, though three of the goals were specifically directed at health related targets.

We have achieved a fair amount of progress on the MDGs by 2014 when the review was conducted it was found that as far as tuberculosis and malaria were concerned, three million malaria deaths were avoided between the year 2000 and 2012. Twenty-two million lives were saved from tuberculosis between 1995 and 2010. About 17,000 fewer children are dying per day. And between 1990 and 2010 there was a 47% reduction in maternal mortality though that has not been uniform across the world. Over 2.3 billion people have gained access to improved water between 1990 and 2012. There’s been a greater enrollment of girls in schools and greater political participation of women. Extreme poverty has been reduced by half between 1990 and 2010. About 50% of the population on less than $1.25 which was the state of affairs in 1990, to 22% of the global population at that level of extreme poverty.

So we have had much to celebrate as a result of the success of the efforts to advance the MDG goals to their targets.  However, the agenda is very much unfinished. In several cases we have fallen short of the targets. For example one in four children are still undernourished. Child mortality from preventable diseases is still a problem. About 800 women die daily from pregnancy related causes. Hunger has declined but still over 800 million people still go hungry all over the world. Nearly one billion people still resort to open defecation. So the ambitious agenda of the MDGs while having achieved several benefits still remains to be pursued in order to attain the targets if not by 2015, soon thereafter.

We have had several learnings from the Millennium Development Goals. They helped to position health very firmly in the development agenda of the world. They helped to focus attention and action on the major health problems of poverty, infectious diseases, under nutrition, as well as maternal and infant mortality because the failing health systems which particularly afflict poor people. They help to mobilize resources to achieve targets. The global community responded by committing more resources, if not in totality for all the MDGs, for selected MDGs of their choice. They helped to create platforms for multiple stakeholder partnerships and they strengthened global monitoring systems by affixing targets and by monitoring progress towards those targets. But having said all that the MDGs also fell short in very many ways.

They covered only the low and middle income countries and excluded the high income countries. So they were not universal in any way. They only focused on a set of countries, the targets, and the implied obligations were only applicable to some of the countries, not all of the countries in the world. They fragmented the health system through vertical programs by directing the programs only at maternal health or child health or TB or malaria or HIV/AIDS, they fragmented the health system and made it weaker in some respects and also created an opportunity cost by which the other programs suffered. Further, even the programs themselves which were the primary focus of the MDGs did not achieve their targets because you can not force fit a vertical program into a weak health system however well-designed the program may be. So we even fell short for example of tuberculosis control and we are seeing the specter of multi-drug resistant tuberculosis coming up.

At the same time the MDGs also segmented by age group. They looked at child mortality, then at maternal mortality, forgetting that adolescent girl in between. They did not look at the elderly, they did not look at the adults who were suffering from non-communicable diseases. They monitored only national aggregate indicators. Now that was helpful to say India or China or Zimbabwe for that matter reduced child mortality or maternal mortality but did it happen across all social groups? Were only certain social groups benefiting from this kind of mortality reduction? And the poorer sections still remained behind? Did the gaps in health equity actually widen even as the aggregate health indicators fell across the country? So that was something that was not really measured at all or not even intended to be measured.

They also measured mortality but not morbidity. It is not just enough to be alive. You are to be alive and healthy so that element of healthy life expectancy was ignored by the MDGs. While these are justifiable critiques of the MDGs, we must recognize that the MDGs have given us a platform to build upon further and that’s the knowledge that we need to transfer as we move across to the sustainable development goals after 2015. Therefore, we need to redefine some of the global health priorities for the period 2015 to 2030 which is the next period the SDG era, and there we need to accelerate the progress on MDGs because they’re not a done deal. Maternal and child health still require our attention, infectious diseases still need concerted action and under nutrition still remains a shameful challenge and we need to act upon them and provide momentum for their progress. At the same time we need to act upon the previously excluded priorities, non-communicable diseases, the number one killer in the world today.

Mental health, the number one contributor to disability in the world today. Injuries and disabilities, adolescent health, health of the elderly, all of these were out of the radar screen of the MDGs. We need to now bring them back into a composite picture of the global health agenda. In terms of the other priorities for 2015 to 2030 we need to create a strong health system platform. The health system needs to become the vehicle for all concerted actions directed at health MDGs or SDGs, because otherwise we will continue to fragment it and fail in our objectives. So we need an integrated delivery of a wide range of health services, we need an emphasis on equity, efficiency, effectiveness and economic viability because when we talk about sustainability we have to talk about also fiscal prudence of how the health system can manage to do all of this without really overrunning the budgets in a very imprudent manner. So we now have to build in all of these elements as well.

We need to implement the universal health coverage as the framework for achieving these goals through actions at national and global levels. We need to enable coordinated multi-sectoral action to influence the social determinants of health. Clearly we know that much of health depends upon actions in other sectors. And the sustainable development goals are addressing some of those other sectors as well, not as separate entities but as synergistic and complementary components of a single unified agenda of SDGs. We need to link health to other elements of sustainable development, not only achieve benefits for each of those elements but to maximize the co-benefits. Health for example benefits education. Sick children can’t gain learning. At the same time, education benefits health, so there are clear co-benefits working together across different SDG and developmental goals. So all of these domains will have to be really brought together and that is wherein the strength of SDGs will come in, including for global health between 2015 and 2030 and beyond that as well. But we do have some optimism when we look at the future.

While we regret that we’ve not been able to achieve some of the MDGs related to maternal mortality or child mortality or infectious diseases by 2015, in terms of their entirety we now know we can substantially bridge the gaps between high income countries and low income countries on those MDGs by year 2035 if we invest wisely and adequately in our health system and specific programs. And here, the Lancet Commission on Investing in Health in 2013 proposed goals that for the under five death rate per thousand live births which is the under five mortality, it can come down to 16 in the low and middle income countries as well as being very close to that in the high income countries now. Similarly, annual AIDS deaths per 100,000 population can come down to eight. Annual tuberculosis deaths per 100,000 population can be brought down to four. Which means the huge gaps that now exist between high income countries and low and middle income countries can be substantially bridged and we can have a grand convergence by year 2035 if we invest properly in the health of these countries and where the global health becomes a priority and a concern and a commitment that everyone shares under the overall umbrella of SDGs.

Public Health in the 21st Century II

The challenge of ageing populations

DR REDDY: The last hundred years have seen a huge rise in life expectancy.That should be a cause for celebration for all interested in public health. However it also brings some concern about the health of aging populations. Indeed, when we are looking at the large number of people who are reaching the age of the elderly which is about 60 years or the very elderly which is about 80 years, then we have to regard it as an important area of public health action in the 21st Century. And therefore it’s not surprising that when we are really looking at what sustainable development should really look at as a goal then it is logical to think of a life course perspective which not only looks at the health of the newborn baby or the young child, but also of the elderly person. This life course approach can be spelt out through a goal which says achieve health and well-being at all ages. We expect this to happen through universal health coverage and also pro-health policies in all of the sectors which create a healthy society. But we must ensure that in the broad sweep of our health system and social development that persons who are elderly and in great need of public health attention are not marginalized. When we look at the world, we recognize that already there are a fairly large number of people in the category of the elderly and the very elderly. But these are mostly in the high income countries or in the middle income countries where the life expectancy has risen sharply over the last century. But we are going to see a different phenomenon over the next forty years when by 2050 while the high income countries would continue to have a fairly substantial proportion of the population in that elderly age group it is the low and middle income countries which are going to see the largest rise in the numbers of the aged and the elderly. In China, for example, between 1990 and 2050 we are going to be seeing a huge change in the demographic profile from a pyramidal age structure to a very cylindrical age structure where those who are in the middle age and in the elderly age groups are going to be dominating rather than the young. We also recognize that as we move along the number of persons aged about 60 years is going to be rising progressively in all parts of the world and particularly in the developing countries this is where the maximum rise is going to be witnessed over the next four decades. In the low and middle income countries by 2050, two billion people will be aged over 60, that’s the elderly. And 80% of them will be living in low and middle income countries. By 2050, 400 million persons will be over 80 years. That’s the very elderly and 100 million of them will be in China alone. Chile, China and Iran will have a greater proportion of old people or older people than the United States of America, so that is where the major presence of the aging populations is going to be. And when we look at what are the factors affecting population aging, clearly increasing global life expectancy is the principle propellant of this change. Life expectancy has increased globally on an average from 47 years between 1950 and ’55 to 65 years between 2000 and 2005, but by 2050 we expect to reach an average global life expectancy of 75 years. At the same time we are also seeing a decline in global fertility rates from a fertility ratio of about 5 in 1955 to ’55, we are likely to see this coming down to 2 by 2050. Early in the century we had already a major decline where the fertility rate had come down to 2.6 but when it reaches 2 then we are going to see a very large number of elderly people. At the same time we are also seeing that in the developed countries restrictions on immigration are also going to affect the age structure. Previously, in pursuit of accelerated economic development, high income countries invited a large number of young and productive immigrants. But now for a variety of security reasons and because of mounting xenophobia, there are crackdowns in immigration and that is again going to result in a closed door policy which will raise the age profile of the developed countries and restrict the number of young people in those populations. We also recognize that this has an impact on the dependency ratios. When a country has a larger number of people who are in the elderly age group or are children, they are going to be dependent on the working age population. When we look at the ratios of the dependents to the working age population in the high income countries because of declining birth rates and increasing life expectancy we have seen that already changing that there is a high dependency at the moment. But in the developing countries, where the birthrates have started falling only recently but aging has now started climbing as a major factor in altering the population age profile we are going to be seeing an increasing dependency ratio in countries like China. Countries like India are still fairly young in terms of their population profile, but even they by 2050 will see a much higher dependency ratio. And this has health consequences in terms of what happens to the health of the elderly as well as the nature of the support their society provides them. The demographic and the epidemiological transitions are closely linked in populations. Older people are likely to live longer but we have also to ensure that they live healthier. It is to be expected that as people age the number of cases of chronic illness and disabilities will rise. There will be increased spending on nursing, palliative care and end of life treatments and we require also long term care for irreversible conditions. All of this is going to be an important health system priority as we move along to a larger aging population in most countries. In terms of some of the other consequences there are challenges in elderly care in terms of provision of formal care as the living arrangements for the elderly are changing globally. What has happened in general over the last fifty to sixty years is that unlike homecare which used to be the norm prior to that, people have moved to institutional care and now in some of the high income countries, they’re also moving back to assisted homecare. But countries which are now facing the problem of health systems which are under resourced, but also the challenge of catering to the needs of the elderly will now have to look at how they can provide institutional or assisted homecare. And the whole area of social security also needs to be clearly addressed. Unfortunately we are also seeing a negative side of the societal response in terms of increasing neglect and abuse of the elderly.We have seen in several societies a greater abuse of the elderly which is partly because of poverty and lack of resources for care which results in neglect and the stress of having to provide care with low resources also pressures families into abuse. There is also poor  training and education of caregivers and there is job related stress in institutional care facilities where instead of empathetic care there is very indifferent attention or actual abuse. Therefore we really must look at what happens to the elderly and particularly poignant is the state of elderly who live alone. Because of the changing population structures, one in every seven persons in the elderly age group now lives alone. That means 90 million elderly people across the world live alone and this is much more true in case of woman then in case of men and particularly an elderly woman who is a widow is often without adequate family support and lives alone in penurious circumstances with very little attention even from the healthcare system. And when we look at long term care for the elderly, we have to look at different models like institutional care, formal homecare and informal care. In high income countries like Japan which has the largest proportion of the elderly population because of the longest life expectancy we have a very large proportion of the elderly population living with adult children, though this is also showing a declining trend. In the low and middle income countries about three-fourths of their elderly population in Asia and Africa and two-thirds in Latin America stay with their families. But that has been a tradition and a part of their culture. But that is rapidly changing with urbanization, with the growth of nuclear families, with migration of the working age children and therefore the probability of the elderly getting care in the family environment is now diminishing even in these countries. When we are looking at long term care for the elderly, insurance coverage or some form of coverage under a universal health coverage scheme is absolutely important for providing healthcare to the elderly. Whether it is a wide ranging insurance which particularly caters to the needs of the elderly or a universal health coverage system which is foolproof in terms of its attention to the needs of the elderly, we need to ensure that financial barriers do not arise in providing the needed care. All high income countries presently provide public insurance coverage for hospital and physician services to the elderly. However, even the best among them provide very poor coverage for drugs and long term care. And that can be a major impediment to good health among the elderly. So we are really looking at the need for long term care financing as well. Even in high income countries, public expenditure accounts for less than 1% of spending on long term care for the elderly. The United States and New Zealand have the highest proportion of private funding. Now if you happen to be a poor person living in those countries or if you happen to be a person living in a country without adequate sources and low per capita GDP, then long term care can become a major problem indeed. Now in terms of aging and the healthcare costs, while it is natural to associate that aging itself is driving up the healthcare cost, that’s not the major factor. Health costs will continue to rise in any case in the future because of other reasons. Changes in health seeking behavior, new medical technologies, rising wages of healthcare professionals, increasing cost of drugs, health insurance premiums rising, and inefficiencies in health service delivery. While healthcare costs are spiraling up, we need to ensure that the people who will pay the maximum price for that will not be the elderly and again, universal health coverage will have to provide adequate protection for that. So when we look at the sources of payment for healthcare services and what are the major contributors to that kind of payment which is not covered by insurance or sparsely covered by the insurance, then we recognize that prescription drugs and long term care facilities are the ones that have the maximum cost attached to them. And these are seldom adequately provided for in any insurance program. So we have to make a very careful planning for ensuring that prescription drugs as well as long term care are built into the system of universal health coverage so that the elderly do not suffer deprivation. There are obviously some solutions that we need to implement on a priority. We need to develop health policies with an increased focus on sustainable financing of long term services for the elderly. And we must ensure adequacy of healthcare personnel and these are not merely people who treat in a hospital for a medical emergency or a chronic condition. We are talking about rehabilitation personnel, we are talking about physiotherapy, we are talking about mental health counselors, a variety of medical social support systems and we must incentivize the existing workforce and also provide task shifting because the health systems of many of the low and middle income countries have a great shortage of human resources and we can not leave the care of the elderly only to very specialized categories who are anyway not available in large numbers. So we ought to really ensure that some of the frontline health workers and even laypersons are provided the requisite training for providing the kind of care that elderly need and giving them the support that will make their lives healthier and more comfortable. In terms of addressing the increasing need for home-based long term care as family structures undergo changes. Again, countries have to have some definitive planning for that just as families need to do that because we can’t allow people to go abandoned by families without care if the overall health system itself is inattentive to it. We need a better legal framework in support of the elderly and we must ensure that age discrimination is not a factor for employment of fit elderly in the labor markets. Really we ought to be looking at the possibility of using this gray power to the advantage of developing societies by using their intellect and experience to greater advantage in a variety of ways. And when we also look at policy we must ensure protective mechanisms against abuse and neglect. That’s also a critical element that we must actually ensure so that people in the elderly age group do not suffer unnecessarily. So we are really looking at developing a society which is much more caring in terms of addressing the needs of the elderly but we do not always have to presuppose that the elderly will inevitably be feeble and debilitated. If we adopt a healthy life course approach and build a health society where people can actually adopt healthy living habits and have an environment which supports the choice of healthy living habits across the life course, we will see many more elderly as fit and functioning rather than frail and feeble. But when they do need care and support we must also ensure that the health system in particular but the society as a whole springs to their support.

Public Health in the 21st Century I

The threat of antibiotic resistance

REDDY -I’m in conversation with Professor Ramanan Laxminarayan, who is vice president research and policy at the Public Health Foundation of India. Ramanan is a health economist by training, but in the area of public health he has become one of the world leaders in infectious diseases, especially in the area of antibiotic resistance. While many people thought that infectious diseases were only a problem of the 20th Century, in this century antibiotic resistance is now being seen as one of the foremost threats to public health. Ramanan, why is it that antibiotic resistance is being feared so much across by health professionals, policymakers, and even economists? I understand that IMF has now declared it as one of major four threats to global economy.

RAMANAN LAXMINARAYAN: So as, as you know, we’ve had antibiotics only relatively recently, since 1942. Propensity for resistance has always been known. In fact, Alexander Fleming mentioned the possibility of resistance in his Nobel Prize winning lecture. And every antibiotic that has been introduced has been followed by resistance in a space of anywhere between five and ten years. And this is because the use of antibiotics, there are like four strains that are resistant, while killing off the strains that are sensitive. Now all of the antibiotics we have now are dependent on the same 16 or 17 basic compounds from which all antibiotics are derived. And we have not had very much new drug development over the last 25 or 30 years. The huge increase in antibiotic use globally has placed enormous selection pressure for resistance to increase and as a result of this selection pressure in many parts of the world, both developing and developed countries, bacterial infections are no longer responding to antibiotics. This is a much more serious problem today than it was even ten or fifteen years ago. Many of the infections that we used to only see in hospitals are now common even in the community. And because the use of antibiotics truly global, the spread of resistance has also become truly global.

REDDY: What are the reasons for this? I mean bacteria seem to be becoming resistant fairly quickly to antibiotics. And many killer bacteria are now emerging across the world threatening large numbers of people. What are the reasons why this has become such a huge problem now?

LAXMINARAYAN: So the single most important reason for drug resistance is selection pressure which is simply the quantity of antibiotics that we use. Now rising incomes, particularly in low and middle income countries have resulted in a huge scale-up in antibiotic use in places like India, China, the BRICs countries. In fact a paper we published earlier this year showed that total antibiotic consumption in humans has gone up about 36% between 2000 and 2010. And of that increase, three-quarters is just in the BRICs countries. Now this is a good thing because it means that many people who didn’t previously have access to antibiotics now have access to antibiotics. But what is bad is that many of the antibiotics are now being used are very powerful antibiotics that are not necessarily being used by people in rural areas to save lives, these are being used in urban settings by people who can simply afford new antibiotics and have no barriers to purchasing them and therefore go out and buy them. The other trend that is worrying is the worldwide increase in demand for animal protein. This has meant that in places again like India, China, Brazil, that there’s a demand for livestock meat, chicken, pigs, and cattle you know for consumption. And to produce the amount of livestock that is necessary to meet this demand, we have to intensify production which immediately means that antibiotics have become an essential part of that production process, also leading to resistance.

REDDY: Well we have seen that antibiotic resistance is being contributed both among human strains emerging as well as in animals because of profligacy of use of antibiotics. Is it mainly a problem of the prescribing doctors, whether they are physicians or veterinarians? Is it a problem of patients being, using antibiotics irregularly and improperly? Or is it a problem of the regulatory systems which is unable to provide the right guidelines and checks and balances? Or, a combination of all of these?

LAXMINARAYAN: It is a combination of all of these. I think you mentioned that economists have increased interest in antibiotic resistance. You know drug resistance is a lot like climate change in the sense that it involves this idea that each of us, whether we’re patients or a veterinarian or a livestock owner, we don’t take into account the impact that we’re having on overall resistance when we choose to use antibiotics, in much the same way as none of us really thinks about climate change when we decide whether to drive a car or get on an airplane or go somewhere. Now this just means that we use vastly more antibiotics than are necessary or warranted. And at the end of the day no one is really responsible for worrying about the problem as sort of a residual thing. That you know no one is, is in charge of antibiotics. And it’s sort of like this global commons that belongs to everyone like the Earth’s atmosphere or climate, but no one is really responsible for. Therein lies the problem.

REDDY: From you comment it’s very clear that it’s not merely a problem of biology, but also of sociology, of political economy. Now is there that kind of an interdisciplinary learning coming in for multi-sectoral actions to provide the right kind of response to this threat?

LAXMINARAYAN: Sadly not yet. I think we still see antibiotic resistance as primarily a medical problem, driven by prescriptions. It turns out that you know a lot of people worry about you know patients in India for instance getting access to antibiotics without a prescription, just going directly to the shop and buying an antibiotic. It turns out that physicians unfortunately are not very good guardians of antibiotics in the sense that a physician doesn’t necessarily do a better job prescribing antibiotics in the studies that we’ve seen in India for instance than what a shopkeeper might actually provide. All that the physician is doing is acting as a cost barrier to the antibiotic. And therefore we do need that sort of multidisciplinary learning to figure out what drives demand for antibiotics? Why do people behave the way that they do? And in that sense we need the sea change in, in norms with respect to antibiotics, the same kind that we’ve seen with tobacco for instance. You know today it’s no longer acceptable to, to smoke in an office or in a public place but it’s completely acceptable to go demand an antibiotic from your physician whether you’re in the United States or, or in China. And we have made it a different norm with respect to tobacco. We need to change that norm with respect to antibiotics as well, to make people aware of the fact that these are powerful drugs, they have important side effects and should not just be used whenever people have a, a sniffle or a common cold.

REDDY: You convened a major global conference about three years ago. And I know that a number of ministers from several countries also attended that. Is there a global movement building up against this, including the required political will?

LAXMINARAYAN: A number of countries led by the U.K. and Sweden have convened many meetings around the world to help the World Health Organization convene a global action plan to deal with the threat of resistance. And, but this has really increased awareness in many countries. Just early in November of 2014, South Africa convened a large meeting of multiple stakeholders from all of the various sectors to promise to do something against antibiotic resistance. A similar action is underway in many other countries. So there’s never been political awareness of the kind that exists now, but we need to push on in order to really do something to solve the problem. The U.K., the U.S., all of these countries are willing to act, but that is not sufficient because even a few countries misusing antibiotics can have global consequences. DR. REDDY: What’s the role of technology and information systems? The drug resistance index or the online resistance map for instance? How can they advance our action in this area?

LAXMINARAYAN: So one of the reasons why the problem of resistance had not received the traction that it really required was because people could not visualize it, they could not see it, they could not see where resistance was, was increasing, where it was remaining flat because of antibiotic use not going up  And tools like the drug resistance index and also the resistance map have been important for that visual connection to the problem, because people don’t get to see resistance. No one that they know dies of drug resistance in the way that they can understand it. Those tools are very important. I think there is also room for other tools which involve big data and so forth to be able to extract data on antibiotic use as well as resistance to further drive home the importance of dealing with this problem.

REDDY: Across the world there’s a huge scatter of data related to the production of antibiotics, the purchase and utilization of antibiotics and the emergence of resistant patterns and so on. How can big data actually contribute to a better and quicker understanding of this problem?

LAXMINARAYAN: So a great example is the fact that we don’t really have state on drug resistance in most countries, including India for instance, just because to set up a network to do this is, is incredibly expensive. However, many patients do send their blood samples on the advice of their doctor to a lab network. And the lab network will turn back a test result which says, yes, you have a bacterial infection and yes, you may have a resistant pathogen. What we’re trying to do is connect up multiple lab networks which collect thousands of samples every day, not to inform surveillance, they do it just to serve a patient need as a provider. But by connecting up these data we’re able to create snapshots of resistance that are only a week old to be able to inform both prescribers as well as policymakers. And this is possible only because of our ability to link data sets and to make that sort of connectivity possible. It was certainly not possible ten or fifteen years ago. But now these networks of data sets are giving us information that, that is extremely valuable.

DR. REDDY: If you were to make major recommendations to global policymakers in the context of the sustainable development solutions network where we are looking at environment and health and other areas of development together and position antibiotic resistance in that framework, what would those recommendations be?

LAXMINARAYAN: I think the recommendations would be pretty straightforward in the sense that first of all, the main way to deal with antibiotic resistance is to reduce the need for antibiotics which is improved public health, improve vaccinations, improve water and sanitation. These are common goals but particularly important because when we don’t address these, we use too much antibiotics. The second is to phase out whenever possible the use of antibiotics in animals because the benefits of these are not very large but the consequences for resistance is extremely high. The third is to invest in good surveillance. It really doesn’t take a lot of money, it really takes these kind of innovative methods to connect up large data sets, to get a better understanding of the situation to do with resistance and antibiotic use within countries. The fourth is to invest in new tools. We need ne

1022w antibiotics but we also need other tools like better diagnostics because for instance if we had a diagnostic device that would tell us within 20 minutes whether the patient had a bacterial infection, imagine the amount of antibiotics that we could not use and still make the patient better. And fifth, we need political commitment. This is a problem that is not going away. And as far as we can see, our grandchildren and their grandchildren are still going to need antibiotics. We have not found a good substitute for antibiotics yet. And knowing that the bacteria will always fight back, this is a problem that’s going to stay with us for a very long time.

REDDY: Thank you Ramanan. Bacteria will always fight back, but humans must respond intelligently. If the production and use of antibiotics for human health and welfare has been a product of human intellect, then the growing problem of antibiotic resistance is a problem of our foolishness and how we are using them. So I think antibiotic resistance, while it’s a major public health challenge of the 21st Century is something that can be met with if we take the kind of steps that Ramanan has advised us to take. Thank you.

Environment and Health II


While public health is generally expected to be dealing with the regular challenges of a health system trying to address the problems of health across the usual life course in stable societies, we also must recognize that disasters of various kinds can post a serious public health emergency. And public health needs to be ready not only to meet them, in terms of coping with them and providing appropriate relief through well geared up health services, but also to try and mitigate their impact through proper planning and preparedness. What we know about the changing environment is that temperature extremes are more likely with climate change and they will be an increased frequency and intensity of extreme climatic events. And these extreme weather events are likely to result in a variety of natural disasters. And these are likely to cause a huge amount of death and disability apart from economic loss. In the last four decades, natural disasters have caused more than three million deaths and more than two trillion dollars in economic losses. The Indonesian earthquake and tsunami of 2004 as well as the earthquake in Haiti in 2010 had the highest death toll from all natural disasters in recent times. In terms of human actions, which increase vulnerability to disasters, deforestation leading to landslides is a very good example of improper resource management by humans leading to avertable disasters. All of this is quite often seen in number of developing countries which are rapidly denuding their forests and leading to soil erosion and landslides which kill people and cause a lot of challenges to their health and wellbeing. In terms of urbanization, while it is inevitable that we will see more of urbanization, unplanned, rapid urbanization results in informal settlements being built poorly with poor access to services and unhygienic conditions. And should a disaster strike, these would be extremely vulnerable population groups. About nearly 200,000 new citizens are added to urban populations every day, globally. And urban slums are also growing proportionately with this increasing urbanization. When we look at how a disaster develops, it’s not as though it strikes suddenly and leaves devastation in its wake. There is also a huge amount of vulnerability which is built up ahead, which makes the disaster even deadlier than it should have been. There are individual factors like vulnerable age, gender and disability which enhance the vulnerability of individual persons. But at the level of the society itself, we also recognize that there are unsafe conditions, like the way buildings are constructed and way urbanization takes place in an unplanned manner with fragile slums. Also, with poor access to health services where needed in the wake of a disaster. Reduced capacity to cope which is created by inability of different planning systems. Also, lack of access to information as to what might happen in the case of a disaster, or even advance warning of a disaster. All of these enhance vulnerability of persons and people. But the trigger event is an environmental hazard which comes in the form of a natural disaster but the vulnerability that exists aggravates the damage done. When we’re really looking at a disaster, in terms of the income status of the countries, not unexpectedly, low income countries have much higher mortality in relation to the middle income countries and high income countries from disasters, because they’re low in resources and also low in preparedness. How do disasters affect human health? Quite often the images that spring in our mind are of people being washed away by flood waters, or being swallowed by the earth when earthquakes strike. But disasters can harm human health in very many other ways. For example, there can be severe damage to buildings and supply chains which can affect health. If there is damage to civil engineering structures and water sources, then you can have heavy contamination of water. You can also have personal shortages. The movement of emergency relief can be impeded if either people are unable to reach the spot or if they themselves are incapacitated and the transport systems are disrupted. The availability and access to drugs also becomes a problem as well as emergency relief equipment if the supply chains break down. Further, there is also the threat of vector control being thrown out of gear. We can have proliferation of breeding sites for example of mosquitoes and other vectors. There is increased human vector contact, created by the disaster zone. And there is a disruption of the routine disease control programs which provide the protection in usual times. Food handling also becomes a major issue and food safety is a matter of serious concern. Power outages can result in spoilage of refrigerated foods. There can be damage to food preparation facilities. And even the relief supplies that are being rushed can be contaminated or degraded by a disaster. At the same time, one of the critical challenges is the provision of clean water supply and adequate sanitation, both of which are compromised in a disaster situation. Emergency water supplies can be greatly impeded in terms of both quantity and quality. And the management of waste matter is a big problem and if that starts contaminating water supplies, then you can have a huge proliferation of water borne diseases, various infections that come with water contamination. When we come to management of disasters we really ought to be looking at vulnerability and risk assessment. And that starts with planning and also with organization of systems in order to provide a good response in a timely and efficient manner. And whenever there is a disaster, we have to quickly assess what the extent of the disaster was and what its impact has been, provide the right response and then go in for rehabilitation and reconstruction immediately after the disaster. But we also have to look at disaster mitigation, reducing the probability of a disaster or reducing the likely damage from a disaster. In terms of disaster management, we ought to be really looking at a cycle where we have the immediate response and relief followed by rehabilitation, reconstruction and then we go in for mitigation and prevention of a potential recurrence of the next disaster. But at the same time, should it happen, we should be even better prepared. So while trying to mitigate, we must also prepare for an eventuality where disasters might strike again. In terms of further steps in disaster management, we ought to be really looking at vulnerability assessment. By determining the spatial proximity of the population subgroups to potential hazards, according to personal and socioeconomic characteristics which increase the vulnerability. We also ought to take actions from mitigation by reducing the impacts of future hazard events and reduction in the susceptibility of high risk groups by proper planning. But further on, we must insure that there is adequate emergency preparedness through strengthened capacity building, to manage all types of emergency  and transition quickly and efficiently from relief through recovery to sustainable development. We need to have adequate planning at all levels from individual to community to national and international levels. And this planning has to be reflected both in terms of policy as well as in capacity building again, at all levels. In terms of the response itself, this is adequately conditioned by preparedness if the planning has been well done. And we’d require experienced, trained personnel who are absolutely vital for providing the right kind of relief and the relief phase much merge with recovery and development over time in a seamless manner. In terms of rehabilitation, reconstruction and recovery, we ought to pay attention to the physical, social, as well as psychological elements in terms of restoration of community life, appropriate environmental health infrastructure, ensuring that sanitation, water supply, shelter, all of these are provided without delay. At the same time as the rehabilitation takes place, there are important mental health effects of a community that has been shocked and shaken as a result of the damage due to disaster. So we ought to provide the necessary support also for mental health.

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Environment and Health I

Climate Change and Health

When we talk of global health in the 21st Century, one of the most important things that comes up is climate change and what its impact on global health is going to be and how can we actually respond to this major challenge, which is not merely environmental or ecological, but also threatens global health in very many ways. When we look at the temperature changes that have happened over a long period of human existence, over the last 20,000 years there have been some fluctuations in temperature, mostly because of changes in the way the earth has a planet has changed its ecology. However over the last 10,000 years we have had fairly stable temperature patterns which have helped humanity to thrive and progress. But towards the end of the 20th Century we have seen human interventions change the nature of the environment to the detriment of the climate, by raising temperatures high and at a very rapid pace so that the planet really is not prepared for this level of change. And this inevitably has an impact on health and nutrition. There is unequivocal evidence on climate change. We recognize that there are rising sea levels and global temperatures, retreating glaciers, extreme weather events. And despite some climate change deniers, there is absolute global consensus that climate change needs to be recognized as an important threat to humanity and that we need to collectively do something about it. Since the Industrial Revolution, atmospheric carbon dioxide has increased by a third. And the International Panel on Climate Change projects an increase in global temperatures by at least 1.8 degrees centigrade by 2100, by the end of this century, as the best case scenario. But there are other scenarios, if we do really nothing, of a doomsday scenario where the temperature can actually rise to up by about 5.8 degrees centigrade. And an increase in sea levels between 9 and 88 centimeters is very much possible in the next century, depending upon how much the temperature rises. Most of this change is related to human activity. That means it is anthropogenic. It is not mediated by natural changes in the earth’s environment or its geology, but it’s contributed entirely by humans. We recognize that there are very many scenarios possible with a wide range of temperature changes that are likely to occur based upon the International Panel on Climate Change modeling. But we do recognize that even in the best guess scenario we are likely to have a two-degree temperature rise or more if we do not do anything. Apart from the natural variability that occurs in the earth’s own environment, anthropogenic climate change will contribute substantially. And the kind of hazards that occur because of a variety of environmental distortions can actually accentuate global health challenges depending upon the amount of exposure that different population groups have, how vulnerable they are to these effects, and the impacts will automatically vary according to that. But there are also appropriate responses in terms of socioeconomic actions that we can undertake for mitigation as well as adaptation and how we can actually insure that there is a concerted global response to reduce some of the mediators of climate change. And they all will impact upon global health ultimately. In terms of human exposures there can be fairly acute events like heat waves or extreme weather events, also more steady rises in temperature as well as alterations in precipitation which can play out their effects over the longer period of time. Quite often the skeptics say, where is climate change because of global warming when we see sometimes extreme cold weather? That’s because global warming itself can disrupt weather patterns substantially resulting in what we can call freaky weather. Beyond global warming we are actually seeing global harming in very many ways. Based upon what the contamination pathways are, what the transmission dynamics are, and what’s the nature of changes in agro-economic systems and ecological systems and hydrology as well as the degree of socioeconomic and demographic disruption that takes place as a result of some of these exposures, you can have a variety of health effects. These will be temperature related illness and death, extreme weather related health effects, air pollution related health effects, water and food borne diseases, vector borne and rodent borne diseases. Effects of food and water shortages, particularly when agriculture and water supply are substantially affected. Mental, nutritional, infectious, and other health effects. Cumulatively, climate change can play havoc with human health over a period of time. There are direct effects of climate change, mainly from extreme weather events. Like for example, temperature extremes. In 2003, we had the major European heat wave. And most deaths were in the vulnerable populations, especially elderly with preexisting diseases. France particularly experienced this. And over 70,000 people were estimated to have died in the hottest summer that the world experienced since 1540. But there are also indirect effects of climate change which act via changing patterns of disease. Vector borne diseases, for example those due to mosquitoes or rodents. As the weather warms up, mosquitoes will start breeding at higher latitudes and at higher altitudes. And therefore you’ll see the spread of malaria to places which did not experience it before. Water, sanitation and hygiene related diseases are also going to be a major public health challenge. Reduced crop yields at lower latitudes will result in food shortages, accentuating food insecurity. At the same time, there will be migration compelled by climate change and related extreme weather events. So you’ll have climate refugees and population change will occur also as a result of that. We also recognize from the IPCC’s report that there will be negative impacts on crop yields. But while the whole world is going to be threatened, there will be some vulnerable populations within countries who are likely to suffer particularly more severe effects of climate change. The very old and the very young and the very poor and those who are socially and culturally marginalized are likely to suffer most, particularly you can imagine the plight of the homeless who have to live in very hot climates in the outdoor, exposed to extreme heat. Vulnerable cities. There are about 16 of the 23 global mega cities which are located in coastal areas. And they will have greater exposure to extreme weather events and storm surges. We’ll also see that climate change will accentuate conflict. It has been recorded that deviations from temperature and precipitation patterns correspond to significantly marked rise in conflict. And these are statistically significant rises. One degree increase in temperature, a rise in temperature increase the frequency of interpersonal conflict by 2.4% and inter-group conflict by 11.3%. So when we talk of hot weather, we must also recognize that people become hot tempered as a result. And the effect of rainfall on inter-group conflict is also interesting. As climate change reduces the amount of rainfall and accentuates water shortages, it has been noted that there is likely to be a greater possibility of inter-group conflict where they’re vying for scarce water resources. There is also a big challenge of how to adapt and how to mitigate. Mitigation is reducing the possibility of global warming through effective action. Adaptation is trying to adjust to some of the effects of climate change as it occurs and trying to improve our opportunities for survival despite some of the changes that we could not prevent. So the IPCC again suggests that the adaptive capacity is intimately linked to economic and social development. But this is unevenly distributed across countries and within countries, across population groups. Adaptation plans must be place and context specific. Like for example, heat action plans for different cities or looking at disaster response for different coastal cities. Action is needed at all levels, from individuals to governments. And the first step towards adaptation is reducing vulnerability and exposure. In terms of climate change, the mitigation strategies of course are very important to reduce the projected rise of temperature, even to limit the temperature rise to 2% or less is going to be a major challenge. And for this, we need to act in the main domains that are contributing to climate change. Food and agriculture. Our food and agriculture systems are now causing environmental disruption. And they themselves will again in turn suffer because of the effects of climate change. So this mutual degradation is something that we must stop because our food and agricultural systems are becoming water intensive, they’re also resulting in a lot of deforestation and all of this is something that we must take into account when we plan mitigation strategies. The use of household fuels, the increasing use of vehicular transport, and the way we generate power through coal plants, all of these are going to be important elements that we must look at as we design strategies to reduce the kind of forces that accelerate climate change and thereby we plan effective mitigation. When we look at some of the health co-benefits of climate change mitigation, we must recognize that the determinants are fairly common and the benefits are likely to be also complimentary. For example, when we talk about public transport and we promote cycling in cities, or more safe pedestrian pathways and reduce the dependence on vehicular transport, obviously in addition to reduced carbon emissions there is improved physical activity. There is also reduced air pollution with benefits for prevention of respiratory illnesses. And the improved physical activity itself will reduce the risk of diabetes, heart disease and other non-communicable diseases, including some cancers. Similarly, reduced meat consumption is something that we must look at, because livestock breeding is now responsible for 50% of global methane emissions, so it’s important that we address that even from the point of view of the environment. The WHO has come up with a work plan. It suggests that we must act, actively engag in advocacy to try and mitigate climate change but also promote appropriate plans for adaptation across the world, especially country level plans. It also suggests that we must promote partnerships to insure that health is well-represented in the climate change agenda. Climate change is not merely a matter for meteorologists or environmental experts or energy experts. After all, the consequences are going to be felt in terms of human health and nutrition. So the health community has to be there at the table when climate change agenda is being discussed. The WHO also says that we must coordinate reviews of links between climate change and health to develop a very strong research agenda which can inform and influence these debates on climate change from the health perspective. It also calls for strengthening of the health systems in countries and would like to assist countries in addressing their health system deficiencies and build capacity to reduce health vulnerability to climate change, the whole plan for adaptation. There are also main research areas in the climate change and health area. Firstly we need to establish baseline relationships between climate change and health. We must gather evidence for early effects of climate change. We must develop predictive modeling techniques and try and anticipate what are the likely consequences of positive or negative changes in the weather and the environment. And in terms of looking at the adaptive options and evaluating their comparative cost effectiveness in different country contexts, we must also estimate the benefits and costs of mitigation and adaptation overall. It is not far-fetched to think that if we do not control the forces that are accelerating climate change, human health would not only be degraded over the century that we live in, but in future centuries it may actually result in elimination of humanity itself. So it is from the public health perspective, from a global health platform that we must now engage in the debates on climate change and demand that climate change must not occur to the extent that humanity’s life would be threatened and also plan for mitigation and adaptation in the most effective manner possible in every country on earth.

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Health Systems VIII

Governance Mechanisms

When we talk of global health with all its complexity and challenges, the issue of governance becomes very important. The concept of governance of course arose from the feudal times when you had a ruler or a ruling class and those who are ruled or are governed. But even with the advent of democracy we had elected governments which were entrusted with the responsibility of providing a method of organizing the society and insuring the rule of law in an orderly fashion so that the society could function very well.

The notion of governance goes however beyond the formal mechanisms of government and refers to the totality of ways in which a society organizes and collectively manages its affairs. Because now we are living in a state of democracy when we recognize that it is not merely for the government to decide on how the society should be run. There are multiple actors in a society and all of them need to act concertedly after adequate consultation among themselves. So it’s a collective decision in which the responsibilities are shared, but ultimately the process of governance is contributed to by every one of the stakeholder groups.

In terms of global health governance, the concept of governance now extends across countries. It has been defined as the use of formal and informal institutions, rules and processes by states, intergovernmental institutions and non-state actors to deal with challenges to health that require cross-border collective action to address effectively. Where many of the determinants of health actually act transnationally, you’ll require international cooperation- better now known as global cooperation and global concord for collective action. And when we say state, we are talking about the collective, governmental, as well as societal image that captures a country’s interest and provides governance for that particular country.

But there are non-state actors who are acting independent of the elected state and those also need to be recognized as important contributors. In terms of the governance for global health, global governance for health refers to all governance areas that can affect health, implicitly because global health is fundamentally geared towards promoting health equity and reducing inequities. Global health can make the normative claim that health equity should be an objective for all participating sectors which goes beyond the health sector as well.

So, When we are talking about governance of global health, we are talking about governance with the health systems, when we talk about governance for Global Health we are talking about all sectors of development in human activity being aligned to the objectives of global health and being geared to promote global health equity. There are multiple global challenges that we are now seeing. For example, the threats from the past, infections, maternal and child health challenge as well as a host of emerging challenges like non-communicable diseases, zoonosis, antibiotic resistance. We’re also seeing challenges arising from globalization, increasing inequity in multiple areas whether it is access to drugs or even some of the problems of health systems compounded by migration of trained health workers from countries which need them to countries which can afford to purchase their services. We’re also seeing climate change and trade policies having an increasing influence on global health. So we recognize that no single nation or organization is currently capable of single-handedly addressing all its health challenges by itself. So we do need a global health platform in which countries can work together and multiple groups which represent different societal interests can work in concert.

At the global level we have apart from the World Health Organization and the individual national governments, we also have a number of other actors who are now coming into play. We have multilateral organizations which provide technical or even economic assistance for health. We have bilateral organizations which establish country to country collaborations. We have philanthropies which are now playing a much larger role across the world. We have academia. We have the civil society organizations. We have the private sector. We have the media. And we have hybrid partnerships which often link some of these actors. But at the level of the global health we find security becoming an important issue and health security is an important challenge for most countries now.

At the same time, we are finding other issues like migration, education, agriculture, environment, and a large number of other issues like trade and investment, all of them becoming important contributors to our debate on global health governance. So we are now reaching beyond the health sector, but we’re also bringing in a multiplicity of actors into play. But there are several challenges in this complexity. First is the sovereignty challenge. There is no government at the global level obviously. Even if the United Nations exists, it is more of a platform for consultation rather than a single authority which can dictate what should happen across the world. There is inherent tension between national sovereignty and international action. Most countries would like to collaborate with each other as long as their national interests are not affected. And therefore when we ask for shared sovereignty in the area of global health, there is always a concern that nations experience whether they’re actually surrendering their sovereignty. So we do need to find a healthy way media in which nations are comfortable with working with each other rather than feeling that they’re being compelled to act in the interests of another country.

There is also a sectoral challenge. There are multisectoral influences on health and all of these are not embedded in the health sector, therefore we require cross-disciplinary policymaking which is largely absent in global health. Many of the agencies which deal within countries or across countries with agriculture and trade for example are totally insensitive to health concerns. There is also the accountability challenge. There is a democratic deficit related to the legitimacy of international government organizations, or inter-governmental organizations. Also there is a lack of clear mechanism for accountability of non-state actors. So the question is if inter-governmental organizations as well as non-state actors have a considerable influence on the health policies of a country or a group of countries, then are they really accountable in some manner just as national governments are? If they are not, then how can they actually be held to account?

The big question is which is the organization that really represents global health? The World Health Organization was established in 1948 in the aftermath of the Second World War. It is the first multilateral global health organization and the most respected. Its imprimatur is particularly valuable in the low and middle income countries which see it as an honest broker in global health. It functions through its headquarters in Geneva and six regional offices, which are located in the Americas, in the European region, and in what’s called the Eastern Mediterranean region, the Southeast Asia region, as well as the Western Pacific region and the African region. Now each of these encompasses many countries in that region. The Pan American Health Organization for example covers north, central, southern American countries as well as the Caribbean.

Many of these regions, despite the heterogeneity that exists within themselves do try to act in concert at the regional level and are accountable to the regional committees which represent the governments of those regions. And overall, they work in concert with the headquarters in Geneva. But there are often disconnects in that relationship.

The WHO remains the only actor in the current global health system that has universal membership of all sovereignty nations. There are of course several importante international treaties and initiatives that the World Health Organization has taken in the interest of global health. One of the landmark treaties, the very first public health treaty negotiated by the WHO is the framework convention on tobacco control which was adopted in 2003 by the World Health Assembly. And now 180 countries have signed up to the framework convention on tobacco control. There are also the international health regulations to address acute public health risks. There has also been a great deal of work done by the WHO for advancement of the millennium development goals. The WHO also takes the global leadership role or it is the coordination role in mobilizing emergency response, relief work, management of outbreaks, for example recently in Ebola.

While the WHO is a globally respected organization, whose leadership still remains widely acknowledged, the role of WHO has become somewhat diminished or even contested by the emergence of multiple other actors, particularly those who fund major health programs, whether it is individual high income countries, or inter-governmental organizations, or philanthropies. And we now see that there has been a call for a reform of WHO, partly because the WHO’s original role of being a predominantly normative and technical agency which provides guidelines to countries has been supplanted to some extent by having to provide response to multiple health system challenges which it may not be able to do entirely on its own.

There is also the major problem that the WHO is grossly underfunded and as a result has become increasingly donor dependent to run its own programs. To what extent are these donors influencing individual countries, or even now, using the WHO platform to advance their own prioritized agendas for health? So this concern has again started to increase within the global health community. At the same time, there is recognition that many of the regional offices are not performing very well, or perform in a manner that is quite disconnected with the headquarters and there is no real global coordination. While ‘One WHO’ was given as a slogan by the former director general, Dr. Gro Harlem Brundtland, there is little evidence to suggest that WHO functions in smooth unison across the world, because each regional office has a regional director elected by the countries of that region and therefore there is no real accountability to the global health community beyond that region. So we have multiple challenges which the WHO faces currently.

While there has been progress in health brought about by WHO initiatives, the question that has come up is, is the WHO capable of meeting the complex challenges of an altering global health scenario? The Chatham House which is an independent organization based in the United Kingdom, put together an expert group which recently reviewed the WHO’s performance and its changing role and came up with some recommendations for WHO reform. It suggested that the core functions of WHO should be much more explicit. It also suggested reviewing and restructuring regional offices and, and indicated that they should function with far greater accountability to their regions and spend lesser money for more results. It has suggested new avenues for collaboration which must be explored by WHO. It has also called for a reviewing of the skill mix that requires to go into WHO under separation of the technical and governance departments of WHO.

Now these recommendations of course will have to be considered by the countries who are member states of WHO and to see what extent the WHO can actually re-position itself as an important lead public health agency of the world. But that the global health has become a very crowded stage with multiple actors, there are about a 175 global health initiatives, funds, agencies and donors currently existing. Can WHO act as a convening platform for all of them without being unduly influenced by any of them? That’s the big question. At the same time, can WHO engage with other agencies which are dealing with issues like environment, trade, migration which have a substantial influence on health and effectively align them to the interests of global health? That again is a role that the WHO has to define for itself.

At the same time we recognize that the United Nations itself can also play a role as a convening platform for multisectoral action. It has indeed catalyzed broad development platforms initiating action on global health, for example the millennium development goals or the MDGs which were adopted by countries in the year 2000. And now the sustainable development goals which would be adopted by the countries in 2015 are also now likely to have a strong platform for global health action. At the same time, the United Nations held two high level summits, one on HIVAIDS in 2001 which led to the formation of the global fund for AIDS, tuberculosis and malaria and brought in considerable amount of funding into that field, with concerted donor coordination. It also had another high level political meeting on non-communicable diseases in September 2011, which is again, paving the way for global action on NCDs.

It has recently constituted a task force for concerted international action on Ebola. The Ecosoc, or the Economic and Social Council of the United Nations is again another platform where the United Nations can actually coordinate action across its multiple agencies. Whether it is the World Health Organization or the food and agriculture organization, or whether it is the World Trade Organization and the World Bank, this multi-agency platform has been effective in initiating work on tobacco control after the FTCT was adopted. And now that has been transformed into the U.N. task force on non-communicable diseases. When we are looking at multiple agencies now contributing to global health, we also have to look at not only conflicts between them, but also potential synergies. For example, the report for cancer research in U.K. in 2011 suggested that partnership between public authorities as well as charities for medical research could actually bring about great benefits in the form of shared costs, pooled risks, and more stability in family. However the issue of donor engagement brings in the whole question of accountability and responsible behavior by donors. Donors cannot set agendas which are not in the interests of the recipient countries. They also have to be accountable for the manner in which they conduct themselves.

So the Paris declaration of 2005 defined the roles and responsibilities of donor organizations to promote aid effectiveness and enunciated five principles: ownership, alignment, harmonization, managing for results, and mutual accountability. Now all of these are very important, providing ownership to the countries, a greater alignment with national priorities, harmonization among donors and effective managing for results and mutual accountability. It’s not just the countries which are accountable for the aid received, but the donors too are accountable for the way they conduct their business in the countries.

However, one of the major problems has been the multiplicity of donor organizations. With all the good intentions, there have been several donor organizations stepping into countries, for example in the area of HIVAIDS, you have had Ethiopia with 27 donor organizations in that area of health alone. Kenya with 26, or Tanzania with 25, Zimbabwe with 25, Rwanda with 23. It’s a whole crowded field. This imposes a huge burden on countries because they have to coordinate and liaise with all of these donors. They have to have separate reporting system for these donors. And the under-resourced health ministries of these countries crumble under the pressure of having to deal with multiple donors. So there is a great need for harmonization among the donors.

There is also the increasing role of civil society. Civil society groups can range from those which advocate for patient rights, or those which can advocate for better accountability of different health programs and voice the concerns of the communities. They can also participate in delivery of services. So the participation of civil society from policy to actual service delivery is becoming an important component of global health and these include both national NGOs as well as international NGOs. However, with the increasing number of NGOs we also have to differentiate between the nature of NGOs in terms of their intent and their origins. It has been humorously described that there are three categories of NGOs: the PINGOS or the public interest NGOs, the BINGOS are the business interest NGOs, or the GONGOS which are the government sponsored NGOs. So we’ll really have to deal with all of these, recognizing what their main interests are.

But there is yet another challenge in terms of global health governance, even when we recognize that the WHO could be an effective convening platform for multiple agencies, including civil society and the private sector, apart from the governments. The WHO itself is a soft governance organization. It provides guidelines and recommendations that members states can adopt or adapt based on their own discretion. They’re not mandatory. The member states can take them or leave them. Whereas organizations like the World Trade Organization are hard governance organizations. Their policies canbe much more definitive and binding for the member states. And they’re not always conducive to good health.

So we have to again, try and see how this balance of power nor asymmetry of power between different global organizations representing different interests can be reset and corrected so that the WHO get greater traction when it has to deal with agencies such as WTO or even others like FAO, or the World Bank.

So the implications are that WHO remains the lead public health agency of the world, but its influence and its role are now coming in for greater debate and to some extent, are being contested. We need to move towards a better defined global health governance system in which the WHO continues to play a very important role as a convening platform, the honest broker as I said, giving an effective role to each of these major players whether they’re individual governments or philanthropies or the private sector or the civil society, but insuring that the interests of global health predominate over any sectoral interest and also insuring that the roles played by all of these groups are complimentary rather than in conflict. And that is where the WHO has to now become a very new kind of organization, setting the agenda, coordinating and at the same time, becoming the conscience keeper of global public health.

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Health Systems VII

Health for All – The Moral and Social Case for Universal Health Coverage

In this chapter we’ll be dealing with universal health coverage as one of the key requirements of providing health for all citizens across the world.

Quite often we have looked at health as a very important investment for accelerated economic development. And indeed, the need to protect and promote productivity among individuals who contribute to economic growth in a society has been emphasized often enough to make sure that governments continue to provide increasing investments to health year round. However, while increased productivity is an important ingredient for making the argument for improved investments in health and for universal health coverage, we must recognize that merely a utilitarian argument of improved economic growth would not be appropriate because we need to bring in the equity argument as well and position health as a right. Otherwise a large number of people who are not contributing to increased economic growth, either because of age or because of illness and disability may be left out of that whole equation.

The reason why universal health coverage has become a major global priority in the last 15 years is because of the huge amount of impoverishment that healthcare expenditure is causing across the world. The World Health report of 2010, published by the World Health Organization estimated that every year about 150 million people face severe financial hardship and a 100 million are pushed below the poverty line because they fall ill, use health services and pay out-of-pocket. Many have to sell assets or go into debt to meet the payments.

And it is because of this healthcare related impoverishment, especially exacerbated by catastrophic health expenditure, but also because of a continued chronic drain on personal finances that ill health imposes, that we have to look at a more caring healthcare system in which we provide financial protection along with quality health services. And that adds up to universal health coverage. In terms of private, out-of-pocket expenditure, many countries, especially in the low and middle income countries, impose a huge burden on their citizens in terms of personal, private, out-of-pocket expenditure on health. Which means that beyond what the government provides, they’re spending quite often upwards of 50% from their own personal finances.

This is not acceptable because it is indeed a huge burden which results in healthcare related impoverishment. And we see this happening in different countries of Asia. If we look at 11 countries of Asia and look at what the out-of-pocket payment is and the proportion of people who are being pushed in to poverty each year, then we recognize that those countries which have low levels of out-of-pocket expenditure have low levels of impoverishment, especially due to healthcare expenditure. On the other hand, countries like India which have had high levels of out-of-pocket expenditure, have much higher levels of impoverishment annually, of people being pushed below the poverty line.

So we do really need to move towards a system which is much better and that is universal health coverage. Universal health coverage offers a way of sustaining gains

from and protecting investments in the countries that have already invested a fair amount on attaining the millennium development goals, which are related principally to maternal mortality, child mortality, poverty reduction, relief for under-nutrition and so on. Now clearly some of these goals have been attained partially and we need accelerated progress on attaining those goals. But a health system which is relatively inefficient or inequitable cannot bring about the required momentum. Universal health coverage on the other hand can galvanize the health system to perform better and achieve the goals which are only partially met. It also accommodates the changing agenda of global health which as we know, because of health transition is bringing a host of non-communicable diseases to the fore.

So universal health coverage by definition is the practical expression of the concern for health equity and the right to health. Moreover, access to services when needed also provide financial protection and also provide the comfort and assurance that people will get the services they need.

The Rio+20 United Nations Conference on Sustainable Development recognized the importance of universal health coverage for enhancing health, social cohesion and sustainable human and economic development. The U.N. in that meeting pledged to strengthen health systems towards the provision of equitable universal coverage. The countries participating in that meeting called for the involvement of all relevant actors for coordinated, multi-sectoral action to address urgently the health needs of the world’s population.

So universal health coverage as a goal, a strong health system as the vehicle, but also supported externally by concerted multi-sectoral action which will align actions in other sectors to the health needs and to the objectives of universal health coverage. And universal health coverage does provide financial protection which is the critical aim of universal health coverage. But beyond that, it insures greater health equity within countries and across countries. It also provides the population with improved health outcomes. Longer life, better quality of life, greater healthy life expectancy, far less disability. It also enables the creation of efficient, accountable and transparent health systems.

At the same time, it reduces poverty It leads to greater productivity, a healthy population is definitely going to be better for the economy through greater productivity. Most importantly, by creating a strong health system it can actually increase employment opportunities for a large number of young people and women because if universal health coverage is going to be focusing strongly on primary health services, in a world where there are the health workforce crisis, a great shortage of doctors, nurses, allied health professionals, you need to create more jobs on the front line. Many of them won’t be doctors, but a number of technology enabled front line health workers will have to be pressed into service for energizing primary health services. So in an era where the economic situation is not promising a lot of employment for young people seeking to enter the labor market, the health sector by embracing universal health coverage can actually provide a much larger pool of employment for a lot of young people who are aspiring for gainful livelihoods.

When we come to the implementation of UHC, there are two very important interconnected components. Firstly, coverage with the needed health services, prevention, promotion, and treatment and rehabilitation as well as coverage with financial risk protection for everyone. Since we said we will not be able to do everything overnight when we are introducing UHC, unless the country is very rich, many countries the low and middle income grouping will have to prioritize primary healthcare. Many countries look at primary healthcare, most of secondary healthcare, especially comprehensive maternal and child health services, essential surgical services and the emergency services as the initial package which they must introduce for universal health coverage and then expand by addition of other elements.

But again, primary healthcare becomes the absolute mandatory, initial component of any universal health coverage initiative. But at the same time, when we come to financial risk protection, we have to look at multiple sources. Virtually no country has achieved universal health coverage without a substantial infusion of tax revenues. That means a good part of universal health coverage has to be tax funded. Depending purely on health insurance, particularly employer provided or personally purchased health insurance doesn’t usually help because we need a large risk pool for insuring that there is sufficient sustainability for the program.

When we talk about a risk pool, we are talking about a number of people contributing to an insurance program where the sick minority is being subsidized by the healthy majority at any given point in time. Of course those who are sick can be healthy tomorrow. Those who are healthy today can become sick tomorrow. But it assumes that at any given time, the majority are healthy, they continue to pay insurance, but they’re subsidizing the sick. What we recognize is that in many of the countries, people are not always in the majority in the organized employed sector. Like for example in India, 93% of the workforce is in the unorganized sector. So you can’t have payroll deductions which automatically go into an insurance program. Many of the people are poor, they can’t afford to purchase private insurance. Even if the government provides substantially subsidized social insurance, many of the poor may not be able to get enrolled.

So as the risk pool shrinks, then the principle of that kind of an insurance where the healthy subsidize the sick or the rich subsidize the poor does not operate. On the other hand, in a tax funded health insurance system for universal health coverage you have the largest risk pool possible. And there the rich do subsidize the poor by paying higher taxes as a part of their social obligation. And the healthy majority does subsidize the sick. Therefore tax funding becomes an inescapable component of any financing for universal health coverage virtually in most parts of the world. And even in those countries, which have been really talking about insurance based systems, there is a substantial amount of government funding, even in the United States. So we need to look at a mixture of different funding sources with tax funding as the base and possibly other forms of insurance like employer provided insurance or government subsidized social insurance as additional components. One of the best known health economists, Bill Hsiao, or William Hsiao from Harvard writes that empirical evidence indicates that a free market for insurance cannot achieve social equity and that serious market failures allow insurers to practice risk selection.

That means they leave out the most vulnerable and make them uninsured. So if you are cherry picking and taking only relatively healthy people, for whom you do not have to pay much in terms of healthcare reimbursements, the people who really need healthcare are left uninsured. Dr. Hsiao also says that adverse selection among insurance buyers impairs the functions of the insurance market and deters pooling of health risks widely. Moreover the insurance markets high transaction costs yield highly inefficient results. However, there are some advantages. Dr. Hsiao indicates that evidence suggests that reliance on market competition for the provision of healthcare may hold potential for more efficient and higher quality care. What we are really looking at is the weaknesses of multiple competing insurance systems which adopt an adverse selection process. On the other hand, we still would like to bring in quality and efficiency into the healthcare system and even if we are going for a tax funded system, that is a requirement, to look for efficiency and higher quality of care.

Many countries have grappled with this problem and have adopted different models of universal health coverage, basically looking at their own country context and resource scenario. Indonesia has a social security providers law which replaced the previous community health insurance. And under this, 95% is paid by the government with the holder contributing 2% and the employer paying the remaining 3%. This has been particularly effective in Jakarta and is likely to be expanded across the country later.

Now in Canada, Medicare includes coverage based on health on need rather than the ability to pay. Provincial and territorial governments are responsible for the management, organization and delivery of health services for their residents. In Mexico, there have been a combination of different health insurance programs, substantially tax funded or government subsidized. Even though they are called insurance in the broad sense, they’re bringing a lot of government funded and government provided health services. And here particularly the introduction of Seguro Popular in 2003 brought financial risk protection to a further 50 million persons in the population. So that was a huge leap in terms of the number of people provided some assurance of healthcare with financial protection.

In Thailand, the universal health coverage scheme started off with what was called the 30 Bhat Scheme where people paid less than one dollar and that plan added about 14 million previously uninsured people to the Thai system. And this scheme has now been transformed with even greater coverage and a greater degree of financial protection at even lesser contribution at the personal level. In China, where there was previously an urban employer provided insurance scheme and the rural and migrant populations were left uncovered, since 2003, two more schemes have been introduced. One for the rural population and one for the migrant population. And between these three schemes now the coverage by some form of health insurance for provision of healthcare with some financial protection has extended to 96%. That means 96% of the Chinese people have some form of coverage.

But since the depth of services is still a bit limited, they’re still seeing the effects of out-of-pocket expenditure and catastrophic expenditure. As public financing increases, this is likely to decrease, even in China. In Brazil, the unified health system which is the nationalized program, provides primary healthcare while a network of public and contracted hospitals deliver specialist care. Primary care provision has substantially increased since its inception. And this also includes a national immunization program. And Brazil has adopted universal health coverage as an objective because the constitution has a right to health incorporated and therefore UHC is an important value.

In the United Kingdom, where the National Health Service started off as a model for many other countries which are now aspiring for universal health coverage, the government is responsible for funding access to healthcare and for supplying health services. And this is now a very important area where we find tax funded services reaching all sections of the people with assurance.

The whole world is now moving towards universal health coverage it appears, because in 2005, the World Health Assembly adopted a resolution asking all countries to adopt universal health coverage as a goal. In 2010, the World Health report focused on health financing for universal health coverage and then introduced the concept of the cube and how the cube can be progressively filled. We recognize that in most countries you can’t fill cube all at once. But you have to start visualizing the cube, recognizing that universal health coverage will be incomplete unless we try and fill most of the cube, but start moving progressively by prioritizing on each dimension as to where you begin and how you move forward, moving from the essential to the optimal.

In 2012 the U.N. had the Rio+20 conference, which again adopted this as an important goal. And then surprise, in 2012, the United Nations had a session on health and foreign policy in which they brought universal health coverage as an important component, recognizing that universal health coverage is important for global development and therefore for global stability and therefore for global security and therefore must form an important component of foreign policy initiatives as well. So whether it is the World Bank or the WHO or the United Nations or even diplomats or public health experts or economists, now universal health coverage has become the common currency of development discourse.

One of the important things that we must remember is that as we move towards universal health coverage, we are also moving towards a higher civilizational state because universal health coverage cannot exist without social solidarity. Unless society feels that they’re responsible for each other’s health, that they’re willing to support healthcare for another citizen who is in need, by contributing to the risk pool of ensuring that the health of every individual in that society is adequately cared for, you will not have universal health coverage as a successful model. Therefore the moment we adopt universal health coverage, not merely as a political slogan, not merely as a public health system goal, but as a societal commitment, then we are moving towards social solidarity. Without that we will not have UHC. But we have to make it effective through a functioning health system and through adequate financial investments to provide financial protection.

So in the context of the sustainable development goals, we now are likely to see universal health coverage positioned as a part of the health goal in the post-2015 agenda. but it is important that all countries start understanding first what universal health coverage entails and then start preparing not only their health systems, but their financing mechanisms as well as multisectoral coordination processes in order to pave the way for successful introduction and implementation of universal health coverage to promote health equity within countries and across countries.

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Health Systems VI

Access to Medicines-II

When it comes to reliability of supply systems we need a good distribution system that ensures the availability of all essential medicines at all levels of the health system- primary, secondary and tertiary. And we can have several strategies for this. Firstly we need to integrate medicines in the health sector development. We cannot look at this as a separate problem of a pharmaceutical department which is often not even in the health ministry. And if pharmaceutical production is seen more as a commercial or an industrial activity, divorced from the needs of the health sector there can’t be anything worse than that for universal health coverage. So we need to integrate the whole availability and production and supply of medicines into the health sector development program. We also need to ensure that there is a fairly efficient and well-functioning public-private NGO mix in terms of the approaches to supply delivery. So the supply chain, while it may be driven substantially by the public sector, ought to be able to accommodate the private as well as NGO sectors also because they’re also often very major contributors to supply. We need to assure the quality of medicines through regulatory control. This is absolutely important particularly where we are now seeing a huge need for medicines across the world which are being met by generics, but these generics will have to be quality assured. And this requires appropriate drug testing and regulatory control. We need to explore a variety of purchasing schemes and pool procurement often reduces the overall pricing of medicines. Because if you actually have procurement cooperatives, or pool procurement, you’ll be able to eliminate the middle man and then remove multiple intermediate stages where there is price markup and ultimately get almost directly from the manufacturer a bulk procurement which can be substantially low priced and very close to cost of production, rather than the traditional market price which has multiple layers of markup. So we have to look at pool procurement and procurement cooperatives. At the same time we need to look at also procurement of traditional medicines. We’re not only talking about allopathic medicines here, many countries, especially in low and middle income countries have traditional systems of medicine which form a part of the health system and which are frequently accessed by the people and are often affordable. So we ought to be able to look at the supply of traditional medicines as well in healthcare provision.

Coming to the whole area of stock-outs, you can see this happening not only across countries, but even in health systems within countries. For example, in India where there are multiple states with different health system capabilities. The health system in Tamil Nadu, which is very well-functioning, has a very little problem of stock-out. On the other hand, Bihar has much lower availability and a much higher level of stock-out at any given point in time, though recent improvements are beginning to change that situation. So we need to address this whole problem as an issue of health system capacity for effective functioning.

And that the global level, we actually meet other challenges. We see the whole area of trade coming sometimes as an opportunity but quite often as a barrier to access. Trade in pharmaceutical products has been heavily influenced by international trade agreements, intellectual property rights, and globalization. And pharmaceutical companies have been researching on development of new products which are mostly based on the market expectations of utilization in the rich countries and not by the needs in the developing world which constitutes the majority of the global population. They are looking at who is likely to buy and particularly at a high cost rather than who actually needs them in terms of life-saving medication. And therefore, we find that many of the neglected tropical diseases do not have medicines and some of the medicines available for even common diseases are not often available at affordable cost. Many of these companies are also exploiting patent laws for their own profit. For example, stretching of patents, even when the patents are supposed to be expiring and the drugs are supposed to be coming into common domain for production by other companies, some of the companies are actually resorting to what’s called evergreening, which is a method to retain the patent protection and royalties from products, either by extending patents or buying out competitors, particularly by minor changes in formulation. Or in the manner of delivery in terms of the time of release of the actual drug by minor changes in pharmacokinetics. They’re actually declaring a drug to be a new product and are trying to extend the patent and stretch the patent out. And these are some of the things that actually are becoming barriers in terms of pharmaceutical company practice and challenge to countries which want to really take drugs off patent and then put them in the health system in the form of generics. But trade agreements are not entirely dispensable. Sometimes they may actually provide support to the less developed countries in other domains, like for example, traditional knowledge and genetic resources. So some of these actually by patent protection may help some other low income countries and the middle income countries generate more resources for their own health system. So the challenge of global trade is to ensure- yes, there should be some degree of intellectual property rights being protected, but at the same time, we need to ensure that this does not become a major barrier for access to medicines. And we have to look at the availability of medicines as a social contract between the industry and the wider population in the world in which the need for live-saving essential medicines outweighs commercial considerations. And the whole area of affordable pricing has become a subject matter of TRIPS- the trade related aspects of intellectual property rights. This agreement was first signed in 1995 at the Uruguay Round Agreement of the World Trade Organization. This mandated minimum standards for patent protection for pharmaceuticals. Clearly the pharmaceutical industry, particularly concentrated in high income countries, had an interest in ensuring that their products were patent protected so that they could make profits out of them from their exclusivity of production. But between signing of the TRIPS and the WTO Doha Ministerial Accord, the world witnesses a major crisis in terms of access to the drugs for HIV/AIDS. And especially in Africa and this became a major global issue. When some of the generic antiretroviral drugs were being supplied to South Africa by an Indian generic manufacturer, there was a major challenge from the multinational company which was producing the drugs. Indeed, the Mandela government was sued by this pharmaceutical company, much to the consternation and shock of the rest of the world. But fortunately the public outcry and the revulsion as well as civil society action across the world, including communities in the high income countries compelled not only the pharmaceutical industry to withdraw and permit the utilization of generics, but it also led to the global community to look at how trade agreements ought to be modified in order to protect the interests of patients who most need life-saving drugs. And that is why the WTO Doha agreement then came about. In 2001, in Doha, there was a declaration on the TRIPS agreement and public health. While reiterating our commitment to the TRIPS agreement, that’s what the countries said, we affirm that the agreement can and should be interpreted and implemented in a manner supportive of the WTO members right to protect public health. And in particular, to promote access to medicines for all. So public health could now start trumping to some extent the right to intellectual property which became restrictive on occasions. Especially for public health emergencies. So this was a very important victory for looking at how public health could be still advanced despite some of the drugs being on patent. And in 2003, in Cancun, adjustments and provisions were made in the TRIPS agreement to allow improved access to essential medicines. So we have to really look at the whole area of trade and evolving developments in the trade agreements and trade related treaty discussions from the point of view of global public health. And when we come to chronic therapy, long-term therapies for cardiovascular diseases, cancers and diabetes, these countries are going to be bankrupted if the drugs are high-priced and people are going to be dying prematurely if they do not have access to life-saving medication.

So access to effective non-communicable disease related drugs remains a high priority for the rest of the world, especially those in the low and middle income countries who do have access at the moment to drugs produced by pharmaceutical industry in the high income countries, mostly for those markets. Even when we look at generic drugs, there is a disparity across the world in terms of international generic drug pricing. There is really no consensus on how generic drugs should be priced. There is a fair amount of opportunistic pricing which is being employed by different manufacturers. If we look at the potential for lowering of the pricing of generic drugs by domestic manufacture as opposed to internationally available generic drugs, we see a huge disparity. Like for example in South Africa or Kenya or other countries or Brazil, the domestically manufactured generic drugs are far lower than the internationally branded products or the internationally sold generic products.

We therefore need to ensure that in as many countries as possible, at least in the middle income countries, we ought to be able to increase the capacity for domestic production of quality assured, low priced generic drugs. When we look at improving access, we can look at seven major strategies. First is enhancing capacity for generic substitution and the specific solution there is to expand the scope of the WHO prequalification project and build capacity of local regulatory, drug regulatory authorities to fast-track registration of generics. Secondly is to expedite generic availability by overcoming legal barriers related to patents and licensing. This we can do by increasing the use of compulsory licensing under Article 31 of TRIPS. Compulsory licenses are where countries in extraordinary situations, where public health needs are to be prioritized, can actually issue license to other companies, even for a drug which is still under patent protection. Optimizing local procurement practices in the public sector is absolutely important and this is done by recruiting local support for better supply chain management and using mobile and information technology to map stock-outs. We have the capacity now to use information technology to forecast the needs, to track the availability, to spot where the stocks are diminishing and readily replenish them and we ought to use that technology much more effectively than is presently being done.

We also need to broaden global procurement where third party price negotiations. As we said, pool procurement at the national level can be very effective in reducing costs, especially for the public sector, or for networks of private sector hospitals. But even at the global level pool procurement is possible because agencies – whether they are WHO or other international agencies, or a community of countries can actually negotiate jointly to try and obtain drugs directly from the manufacturer at a much lower cost by assuring a very large market size, When it comes to engaging the private sector to differentially price medicines in low and middle income countries, there is a movement in that direction. Many of the large companies are now looking at the market size in the developing countries and saying, okay, we will differentially price medicines for high income countries and for low income countries. And we will ensure that people who need it in low and middle income countries can get it at a different tiered pricing arrangement.

We can regulate retail markups in the supply chain by use of government controls to restrict markups. Price control is an important mechanism that countries must utilize judiciously in order to reduce unnecessary markups. Finally, we must eliminate tariffs on medicines. We must adhere to international treaties to eliminate import tariffs and preferably eliminate national sales taxes. These are not luxury goods. These are goods required for saving people from death and disease. And therefore, to have import tariffs and sales taxes is absolutely improper because we are playing with people’s lives. So by adopting a variety of strategies to provide access to drugs of assured quality, preferably generic drugs, preferably obtained through pool procurement with affordable prices, and ensuring regular, predictable distribution through a supply chain that eliminates stock-outs, we can ensure access to drugs. But this cannot be done only for high income countries, or even for middle income countries, it has to become a globally assured supply of drugs which are needed. And this can only be done if universal health coverage becomes not only a national aspiration, but a shared global value.

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Health Systems V

Access to Medicines-I

In this chapter we’ll be looking at access to essential medicines. Very clearly the introduction of life-saving drugs has made a great deal of contribution to improving life expectancy as well as reducing disability. And when we are looking at global health, the access to medicines becomes a very important element of universal health coverage[1]. Essential medicines are those that satisfy the priority healthcare needs of the population. Obviously there are several medicines, some of which are taken for relief of very temporary conditions, some are often taken as supplements to diet, some are taken for example to relieve cough or something like that. But essential medicines are those that are really required for protecting the health by reversing disease and reducing disability They’re selected with due regard to public health relevance, evidence on efficacy and safety and comparative cost effectiveness. Clearly there can be a wide range of medicines for treating the same condition but you need to be very sure that they’re effective, safe, at the same time, cost effective. Essential medicines are also intended to be available to the health system so that we are not uncertain about their regular availability for being provided in various healthcare facilities as needed. They should be available at all times in adequate amounts and in appropriate dosage forms with assured quality. Now quality is going to be an absolutely important criterion because without that, you cannot be sure either of effectiveness or of safety. And there should also be adequate information available about each of these drugs, not only for the physicians but also for the patients who are receiving it. And they should be available at a price that the individual and the community can afford and certainly the health system also should be able to afford it as a part of the public financing. Access to medicines has become a worldwide challenge and the World Health Organization estimates that about 1.3 to 2.1 billion, depending upon the criteria that are employed, do not have access to medicines. Unfortunately many of these are in the countries where there’s the greatest need in terms of unmet health challenges that is Africa and India. Access to essential medicines is closely related with the other aspects of the health system performance. That is, we find wherever there is a high level of disability- adjusted life years lost because of major health disorders, there, access to medicines which ought to be assured is unfortunately deficient. In terms of inequities in production and utilization, we ought to be able to really look at where the population lies and where the actual money is being spent in terms of purchase and prescription of medicines. Whereas the largest populations lie in the low and middle income countries and the low income countries and a much lower proportion of the population, about 16% is in the high income countries, the actual expenditure on medicines at the global level is the highest in the high income countries that is about 78.5%. Whereas in the low income countries, the expenditure is only 1%. This is a huge inequity in terms of availability and affordability of medicines across the world, reflected in the utilization patterns. When we are really looking at access, there are four critical elements which promote access. The World Health Organization says firstly there should be rational selection based on first quantification of the medicines that are there in the overall pharmacopoeia and then trying to select among them according to the criteria of essential medicines and forecasting the need according to the disease burdens and the various health system priorities within that country. And rational selection of course goes as I said, on the basis of effectiveness or efficacy, safety, and cost effectiveness. That brings us to affordable prices because we need to really look at how affordable these medicines are, both for public procurement by the health system and also for personal purchase by an individual patient. So that becomes the second element of how we actually ensure that the prices are within easy reach. And then we actually look at the procurement process which then brings the medicines into the health system. And we definitely require reliable supply systems. Unfortunately many public procurement systems and distributions systems do not pay attention to regularity of supply and there are frequent stock-outs that means non-availability of medicines within the facilities. And that means that many of the people who actually go to these facilities do not have the opportunity to get them on a regular basis as needed. And similarly if they’re also not available on a predictable manner in the open market for purchase at affordable prices, that again deprives people of access. So having reliable supply systems is absolutely critical. Rational selection refers to choosing safe and effective medicines which are appropriate to the country’s health situation. Accordingly, essential list of medicines will have to be prepared by each country. The World Health Organization, since 1977, has been providing a reference list of essential medicines, which actually serves as a guideline for individual countries which will adapt it for their own use based on their own national requirements. So each country has to have its own national list of essential medicines. And sometimes within large countries, provinces or states also modify the national list to suit some of their regional priorities. The number of countries which have essential list of medicines is of course is fairly large. But the number of medicines that enter the lists varies based on the national income. Low income countries for example have much lower number of essential medicines on their lists as compared to middle income. But the high income countries have a far higher number. The low income countries have had on an average, 355 drugs. The middle income countries have 441. Whereas the high income countries have a total of 1700 drugs as a part of their armamentarium in their essential list. Sustainable financing is the next step that we need to really look at, and here we need to increase the public funding for health system in general, but especially for essential medicines. Unless public financing of health through universal health coverage programs increases to a level where essential medicines can be procured and distributed at no cost or low cost we will find that there will be a continuing barrier to essential medicines for most of the people in that country. So we need to raise public financing and use a substantial fraction of that for procurement of medicines. We also will get an added benefit in that because much of the out-of-pocket spending in many of the countries is related to private expenditure on purchase of medicines. Of course by expanding various forms of health insurance, particularly social insurance or government subsidized insurance, we will be able to provide greater coverage and we need to bring in medicines also into the ambit of insurance programs which frequently do not cover outpatient care or provision of medicines. And of course there are other financing mechanisms that we ought to be looking at, including debt relief as well as international supply by various donor agencies. Sustainable financing of course requires a fair amount of public expenditure, which is predictable. As a paradoxical situation, high income countries seem to be having a greater degree of public financing as compared to private financing. And this situation has remained unchanged or even worsened over the years, when you compare 1996 to for example, 2006. In the other categories of countries, which are in the middle income or the low income bracket, we find that the private expenditure on medicines is increasing, which is again, quite indicative of the fact that public financing is at low levels as a response to the needs of the people and certainly fall short of the objectives of universal health coverage. When we look at the overall global situation in relation to sustainable financing, out of the high income countries, categorized by the WHO, the share of pharmaceutical expenditure in high income countries is about 18.2%. Whereas in low and middle income countries, it’s about 26.6%. And the low income countries, it’s 29.5%. Which means that these countries, despite the fact that they’re unable to invest adequate amounts of public financing into the universal health coverage program, or even into the health system as it exists today, are still having to spend a fair amount of their health budget on medicines. Unless the overall health financing goes up as public financing for the health sector, we will be unable to raise within the limitations of the currently available funding the expenditure on medicines to meet the huge gap in access to medicines.

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Health Systems – IV

The Politics of Health Systems and Universal Health Coverage

In this final lecture on health systems I want address a topic that’s often neglected in these discussions and that concerns the politics of health systems and universal health coverage. Universal health coverage and health systems reforms are fundamentally political. One could see this all over the world, not least in the United States, which is having great debates how it moves towards universal health coverage.741

But this is true in every country across the world. Now why is it that this issue of health coverage and universal health coverage is so political? It really is for a variety of reasons. Firstly, everybody wants good quality health services with financial protection. Universally it comes out in polls that this is the expectations of people across the world. So it matters a lot to people that they get this financial protection and they get the health services they need. Secondly, it’s actually a very easy concept to understand. And politicians find it therefore very easy to sell to electorates that this is something they’re going to bring to them. And in fact people demonstrate specifically for universal health coverage and an expectation that the states will deal with the healthcare financing. Now as I’ve mentioned in the previous lecture, universal health coverage requires public financing and a lot of it as well. It also must be done progressively with the healthy wealthy cross-subsidizing the sick and the poor. Now delivering this is inherently political. Finally, universal health coverage and health systems reforms can actually bring nationwide results very quickly. This is quite unusual for a government policy to have an impact right across the country, benefiting virtually all households so quickly. It doesn’t happen with infrastructure reforms and other economic reforms. Therefore it can bring very quick political benefits to people and that’s really why politicians are so interested in it. Now because it is so important to so many people, and it is so political, it’s absolutely essential that health reforms like this are led by the head of state. If it’s just done by the ministry of health, often this doesn’t work. There are so many political benefits to be gained, but also costs to be taken care of that this really is a head of state’s issue. Also, successful universal health coverage reforms really need the full cooperation across all of government. It’s way beyond just the remits of the ministry of health to deliver on this, but across cabinets and local governments as well. Often what you find though is ministries of health are actually often rather weak ministries within the cabinets. And ministries of finance often actually don’t want to suddenly increase public financing, maybe doubling the health budget. And really the only way they’ll be persuaded to do so is when they’re instructed to do so by the head of state. We’ve mentioned that big UHC reforms require significant increases in public financing. And the decision on, on doing that is therefore one that must be taken right across government. And in particular, the head of state, needing to take control of the situation, mobilizing supporters behind this political strategy, making sure that the public financing is, is raised properly, but also tackling the opponents which there will undoubtedly be for these reforms. What’s also interesting to note is that universal health coverage reforms are particularly popular in post-conflict states, or in new democracies.

742And this is really for the reason around the quick wins that these policies can deliver. And new heads of state are often looking to demonstrate to the population that they brought around change that’s benefiting everyone. So universal health coverage could be quite a good way to legitimize the state and particularly a new state, because it provides tangible benefits to the population very quickly. And here’s some examples of countries that have done this, include the, the United Kingdom in the immediate aftermath of the Second World War, in introducing the National Health Service. Also right across Latin America, in the, in the last 20 or 30 years where there have been transitions, particularly from military dictatorships to democratic governments, often one of the first things the governments have done is introduce massive universal health coverage reforms. And other examples include Nepal in 2008. The new ANC governments in South Africa in 1994, one of their first policies was universal free healthcare for pregnant women and children. In Liberia, Sierra Leone, Burundi and Rwanda, these are all countries that have come out of periods of conflict and one of the first major policies they’ve introduced is universal health coverage reforms. Now looking at the transition that countries make from a system of privately financed system where there isn’t universal coverage to one where there is, what are the economic and political determinants of that process? Well firstly it’s undoubtedly the case that it’s economic growth and more resources that drives up health spending. Not surprisingly, as countries get richer, they spend more money on health. But what’s interesting to note is that as a proportion of GDP that rises as well. As countries get richer, people want more money to be spent on health. But another thing happens as well, which is very interesting is that as countries develop, the proportion of the financing of the health sector, that is public financing usually increases as well. You get this switch from a private voluntary financing system to one that is more governed by the state. Now that process is inherently political. And we’ve seen this process happening in countries all across the world, particularly in making the transition from being low income to middle income countries. But this process isn’t a slow and gradual linear process, what you tend to find happens is that suddenly there’s a step when countries make this transition to covering the entire informal sector, which as I mentioned before, invariably requires a big increase in public financing. Typically in the order of about 1% of GDP, which is a lot of money.

743Now what prompts that is usually political windows of opportunity. A new government coming to power, a contested election. When a politician announces that they’re going to run on this platform and you see this sudden transformation. And therefore these processes are very associated with particular individuals and very strong charismatic leaders. And it’s very striking that across the world one can name almost the year and the politician that prompted these reforms. So for example, Nye Bevin in 1948 in the U.K. President Park in Korea in 1977. So if this is a good idea to move towards universal health coverage through a publicly financed system, why is it so difficult? Why do you find these processes are so contested? And really it’s because in making that move towards universal health coverage, there are undoubtedly winners in terms of people who are now covered, but also financially there are losers, people who now have to pay more into the public pool. The costs and the, the…associated with that transition tend to be concentrated in organized groups who possess a lot of political resources. Powerful groups like the medical profession like pharmaceutical industry and insurance companies and the urban elite who will have to, to pay more for their health services. Whereas the beneficiaries, the people who really like these transformations tend to be more in unorganized groups, lacking political resources, particularly the rural poor population. Now I’d like to describe one or two countries that are making this transition to illustrate these, these points. One country where there’s been a fascinating transformation or ongoing transformation of the health sector is Indonesia which recently elected a new president, President Joko. Now he previously was the governor of Jakarta and in becoming governor of Jakarta only in 2012, one of the first measures he introduced was universal health coverage in the city of Jakarta. And it was largely on the basis of the popularity of that scheme that he became so popular nationwide and in the election campaign announced that he was going to extend the benefits of this to the, the whole Indonesian population. And he was elected president only in July and has already started implementing this universal health coverage program. Now interestingly he’s financing this through increased tax revenues that he’s secured by reducing fuel subsidies. Indonesia had very high fuel subsidies. In fact they were spending three times as much on subsidizing fuel as they were on their health system. And now by removing these fuel subsidies he has the resources to be able to pay for universal health coverage. Now this is quite an interesting political tactic which seems to be followed by other countries as well and makes a lot of sense in terms of the broader sustainable development goals. Because many governments have found themselves historically now subsidizing fuel which they recognize isn’t a good idea economically and it’s also not a good idea for the environment as well. But unfortunately, these fuel subsidies are very popular and the population have got used to them. So therefore, in removing these subsidies, one needs to give something back to the population in return and give them benefits that they see relatively quickly. Governments therefore looking for quick win policies that can benefit all households and people being able to make the tradeoff between having subsidized fuel and other services. Now universal health coverage reforms fit this bill perfectly because all households require health services on a pretty regular basis. And governments are very cleverly looking now at linking increasing access to health services, in particular, access to medicines with removing fuel subsidies. So this is happening in Indonesia, but it’s also happening in Iran which has recently introduced universal health coverage reforms and likewise is linking these reforms to reducing fuel subsidies. So maybe this might be a trend for us to encourage thinking about the sustainable development goals. Other countries where this could be highly relevant are Nigeria, where there are to be elections in February, 2015, which now has a GDP of $3000 dollars per capita, relatively high and higher than Thailand had when it introduced universal health coverage 12 years ago. And Nigeria has a lot of oil resources that really one feels ought to be made available for providing universal health coverage. India is another country that spends a lot of money on fuel subsidies and surprisingly little on its health sector. Only about 1%, 1.2% of GDP. And it would be interesting to see as a, as a political strategy where the Indian population would be like other countries in recognizing that them getting better access to health services is a good deal as fuel subsidies are removed. Now one can’t really talk about health financing and universal health coverage without mentioning the United States as well, where President Barack Obama has invested enormous amounts of political capital in trying to improve the health financing situation in the U.S.’s notoriously inefficient and inequitable health financing system. And he’s taken big steps moving towards more of a mandatory health financing system which may indeed form a precursor towards more of a socialized health financing system in the future. So in concluding, universal health  coverage is really as political as it is anything to do with technical issues, especially in moving towards a more equitable public financing system. Universal health coverage is also popular with people and politicians across the world. It really brings politics in to the health systems debate. And worldwide political actors and not really technocrats are the driving force behind universal health coverage. And really looking to the future that health developmental agencies should engage much more in the political economy of these health reforms and promote these health benefits and political benefits to political leaders.

Health Systems – III

Health Systems Financing

In this third lecture on health systems I’m going to talk about a very important function of a health system and that is how the health system is financed. You’ll remember from previous lectures that one of the primary objectives of a health system is to achieve universal health coverage whereby all people receive the quality health services they need without suffering financial hardship.

731 Now health financing is extremely important. You’ll notice in that definition there’s a reference to not only people being covered by health services, but them not being financially compromised when they access these services. So there is this aspect of health financing built in to universal health coverage. And in recognizing this, the World Health report in 2010, produced by the World Health Organization, specifically addresses this issue of health systems financing. And if one looks at that definition of universal health coverage, you’ll see it’s  fundamentally about equity. Firstly, that because it’s universal, everybody should be covered. Nobody should be left behind. Secondly, that the definition talks about health services being allocated according to need, with some people needing more health services than others. Thirdly, and this is the financial aspect, the financial contributions for paying for the health system are made according to one’s ability to pay. Now if one combines those two elements you can see that the health financing is really about healthy wealthy people cross-subsidizing the sick and the poor. So what are the major challenges facing countries as they try and finance their health systems to achieve universal coverage? First of all, they clearly need to raise sufficient funds to finance the health system. One needs a certain quantum of financing and recent estimates suggest that around $87 per capita is required as an absolute basic minimum to achieve universal health coverage. But secondly there’s this vital element of risk protection, financial risk protection so that people don’t face financial barriers which prevent them accessing the health services that they need. Also, that they don’t suffer financial ruin when accessing health services. And the third major challenge is ensuring that one maximizes efficiency in the use of these resources and also making sure that resources are allocated equitably, fairly. Now this whole issue of health financing has been extremely contentious over the years and continues to be so across the world. But the good news is that there really does appear to be a consensus emerging now on how countries should finance their health systems  to achieve universal health coverage. The first point and very importantly is that market driven health systems which are privately financed never reach universal health coverage. And this is a realization from countries across the world now. Instead there’s a very high role for the state in organizing the way that the health financing system is organized, particularly enforcing healthy and wealthy people to cross-subsidize the sick and the poor. This doesn’t happen naturally in markets. Now achieving this of course is inherently political because not surprisingly, a lot of the healthy, wealthy people don’t necessarily want to cross-subsidize the sick and the poor. So this means that there is a very big role for the state in all the main functions of health financing, both in terms of raising the revenues to pay for the health system, in pooling of those revenues to create a big risk pool to buy services and in the allocation of those resources and the way that services are purchased. Now despite this big role for the states in, in health financing this doesn’t necessarily mean there’s no role for the private sector. Either in the administration arrangements of some of those financing arrangements, but also in the provision of services. What we’re talking about is public financing, but when it comes to the provision of services, this can be either done in the public or the private sector. Now other areas where a consensus is emerging, where there’s been tremendous controversy is in what are the best financing mechanisms to raise funds to finance the health sector? Now the most obvious way to finance a health sector is people just paying for services as and when they need them, through user fees. But really this is a terrible way to finance a health system because it involves no pooling of resources and is grossly inequitable in that poor people are excluded from getting the care that they need. And in fact, the president of the World Bank has recently said that user fees are unjust and unnecessary. Now other people have been suggesting that maybe a way to finance a health system would be through private voluntary insurance, including community based insurance, which is a mechanism that’s being piloted in a number of developing countries. But again, the evidence shows that this isn’t really a viable route to reach universal health coverage, because private insurance tends to be ineffective. It often doesn’t raise enough money. It’s inefficient, it has extremely high administration costs and it’s also inequitable because it excludes the poor. Now what does that leave? Quite simply the best way to finance the health system is through public financing. Now here there are two major mechanisms. Firstly, tax financing, out of general revenues, but then also through compulsory social health insurance contributions which in effect are a tax on wages. And you can see that the difference between the two is quite subtle. And in fact, what many countries are doing now is actually mixing those mechanisms of tax financing and social health insurance contributions. But the key point is that they’re compulsory and that they’re publicly governed. And another thing that countries are recognizing though is that where there are large informal sectors, it’s actually very difficult to get health insurance contributions from the informal sector. And really if you want to cover the entire informal sector you’ve got to predominantly use tax financing. Now as I mentioned, this has been quite a controversial area over the years and there have been great disagreements about the roles of these different mechanisms. But even people who 20 or 30 years ago were advocating a more privately financed health system are now recognizing that in fact public financing is better. And in a recent Lancet commission report called ‘Investing In Health’, the authors of the 1993 world development report that were advocating a more privately financed health system now  acknowledge that public financing is best. And in fact they, a quote from one of the lead authors saying that, ‘the path to universal health coverage cannot work with reliance on voluntary private insurance.’ So there is this consensus now that public financing is best. Now given that, how can countries increase their public financing? And here there are a variety of methods that countries might look to do. Firstly, to improve existing tax collection, making sure people pay their taxes and clamp down on tax avoidance schemes. But also of course, introducing new taxes, particularly in developing countries, it’s often difficult to tax people’s income. In which case it’s a good idea to introduce new taxes on things like alcohol and tobacco, so-called ‘sin’ taxes, which actually these are products that adversely affect people’s health. So to tax them is a very good idea. But also potentially taxing remittances sent from abroad, or introducing a new value added tax like has been done in Ghana which is funding its national health insurance scheme largely out of this VAT levy. Another way of course is for governments to reallocate funds within the budget from less productive and less useful areas. For example, in reducing military spending or maybe trying to reduce subsidies that don’t make sense, either economically or for the environment, for example, in reducing fuel subsidies. And the third major area where countries can free up more resources for the health sector is in improving efficiency. WHO estimates that the countries can realize efficiency gains in the order of 20% to 40% and therefore get more health for the money that they have. And here, mechanisms can be reallocating money from specialist hospitals towards primary healthcare services and more cost effective community services. The area of medicines, where there are tremendous savings to be made in switching from branded medicines to generic medicines and improving procurement systems and reducing prices. And also in adjusting the skill mix and for example, investing more in community health workers who are very effective at reaching people in remote areas. These are good mechanisms for countries to follow, but how might a country start off on this route towards financing its health system? And a typical situation that countries find themselves in when they’re starting this process is that the richest quintile of the population are covered, maybe through social insurance schemes or they’re so rich that they don’t mind paying user fees. Also governments often make an attempt to cover the absolute poorest strata of society, maybe giving them a free health card. But unfortunately, these services often tend to be very poorly financed and really not adequate for, for people’s needs. But of course the major problem is that the majority of the population are still uncovered. And this is clearly not good for their health status, but also politically it’s not a good idea to leave these people in the cold. Now how do countries move away from this situation? One approach is to do it quite slowly and incrementally and from the top, down, maybe extends the health insurance schemes. Also from the bottom up, one can perhaps be a bit more generous with these basic safety nets as schemes. But unfortunately this process can take an awfully long time and leave a lot of people still uncovered. And what a number of countries are finding for example, in Indonesia or in Vietnam and the Philippines is that about a third of the population remain uncovered. Now another approach is to move much more rapidly to basically cover the entire informal sector at a stroke by injecting a large amount of tax financing into the system and not differentiating in the informal sector between the poor and non-poor. Now this is a strategy that’s been employed in many countries worldwide in the last 20 years, particularly right across Latin America and in Sri Lanka and in Turkey. And one very good example, which figures prominently in the World Health report is in Thailand. Thailand in 2002 had a situation where they hadn’t reached full coverage and a large proportion of the informal sector were uncovered. But on one particular day the government announced they were going to introduce a universal coverage scheme. And this at a stroke basically covered the rest of the informal sector and meant that everyone was now part of the health insurance program. This had the impact of increasing the utilization of services dramatically across the population and reducing unequal acecss. It also had the impact of reducing out-of-pocket expenditure and medical impoverishment which went down 82%. Also, satisfaction with this universal coverage scheme increased from 83% when it started to over 90% now. So you can see on all these measures of a health system that we’re tracking of utilization of services, financial protection, and satisfaction with this system, this is a very sensible thing to do. And it’s this type of approach that other countries seem to be looking to as they move towards universal health coverage.


Health Systems – II

Delivering Health Services

In the previous lectures we were discussing the various influences on health and the role of the health system in achieving universal health coverage. There are many influences on people’s health, not only within the, the health sector, but also other sectors  concerning agriculture, education, water and sanitation, housing, income levels. So the broad health system includes all those social determinants of health, which those of us interested in improving public health must get involved in. However, it clearly is the case that the health sector, delivering health services has an impact on people’s health[1]. And the whole movement towards universal health coverage recognizes this. In stressing that people should be covered by a broad spectrum of health services from preventive health services to curative services, rehabilitative services, and palliative care for people’s ends of lives. And it’s also important that we look not only at people consuming services, but that this is a mechanism to them reducing impoverishment. Now looking at the way that health services impact on health outcomes, one would have thought intuitively, it’s the case that the more that people consume health services, the better impact there is on health outcomes. But surprisingly, the, the evidence on, on that score has been relatively limited. But recently some pioneering research done by Peter Smith and Rodrigo Moreno-Serra, written up in, in The Lancet showed that in a 153 countries, countries that have higher coverage of services actually do indeed have better health indicators, lower mortality rates. Also, more recent research has showed that rapid reductions in child mortality in Africa in the last decade were largely due to scaled up health service coverage. And in particular, coverage of one preventive health measure of mass distributions of bed nets to, to counteract malaria. So literally children being covered by these important preventive health measures has reduced mortality. Now WHO have done more work looking at the way that the health system functions and how health services impact on health outcomes. And building on their previous work, they now identify six basic building blocks or functions that lead to improved performance. Firstly, the leadership and governance issue that I’ll describe in a subsequent lecture. Then around the information that is required to run the health sector efficiently. Also, health workforce and human resources for health, vital inputs to running health systems properly. Medicines and medical products and technologies are also vital elements in the armory in improving health system performance. Combining those inputs efficiently through improved service delivery is another key function of the health system. And finally and I’ll deal with this topic in another lecture, financing the health system, another key function that needs to be taken into account. WHO and many in the public health world also emphasize the vital importance of primary healthcare in improving health systems. And here we’re talking about essential healthcare based on values of universal access, equity, participation and intersectoral action, working with other sectors that impact on health. With this particular emphasis on the primary or first contact level where people first interact with the overall health system. So looking at service delivery, we’re really talking about how these inputs are organized and managed to ensure improved access to services, that services are of good quality, that they’re safe for people to consume. And also that there’s a continuity of care across services as people interact with the health system. So for example, making a primary healthcare contact, being referred to more specialist care, and then maybe continuing rehabilitative care back in the community. But it’s not just really about the supply side. We should also be concerned about raising appropriate demand for services so people access services when they need them. But also that people don’t inappropriately use services. For example, consuming antibiotics when they don’t need them. It’s vital too that the services are integrated. And as you can see, there’s a broad spectrum of services and it’s important that all the elements work well together and efficiently together. Government should also be concerned about the overall management of the provider network and making sure that it’s supervised properly and people doing the jobs that they’re meant to do and not providing inappropriate services or for example, charging for services that they shouldn’t be doing. And finally the other important element is making sure that the whole infrastructure is organized properly and distributed so that everyone can benefit from the health services that they need. And that the logistical systems work so that medicines are, are available in the health centers and health workers are paid on time. And mentioning health workers, one of the key inputs and functions of the, of the system that I was mentioning with human resources for health, which WHO identified recently as what they regard as the most important input for the health system. One of the main reasons for this is it’s the most costly and typically governments are spending over 50% of their health expenditure on human resources. And it’s vital for an effectively running health system. But unfortunately in many countries the, the availability of health workers is inadequate. And in fact 83 countries have been identified as not having the basic minimum of around 23 skilled health workers per 10,000 population. So it’s very important that we scale up the availability of qualified health workers and improved their distribution across the country so that health workers aren’t just working in say urban centers, catering for the elite but are reaching populations right across the country. It’s also important that there’s an appropriate skill mix between you know the different professions of doctors and nurses and midwives and ancillary staff as well. And maybe the countries you know trying to improve the efficiency of the system should look to shift tasks that can be done by lower paid workers and free up time for specialists to do the services that they’re trained to do. Now in ensuring that the health workers are you know working efficiently and safely, it’s very important that they’re trained adequately, both before they start their work, but also that there’s regular in service training so people are kept up to date with the developments in their field. And the whole health workforce requires extensive management of the health labor market and governments to be involved in the recruitment of health workers, retaining them and making sure that they’re working in places where they benefit the population, providing incentives for them to do the correct work and you know making sure that they don’t do things that are going to adversely affect people’s health. And this also requires keen supervision of the work that health workers do and making sure that when health workers don’t behave appropriately, that there are sanctions as well. Now one area that, that a number of countries are looking to expand is, is that of community health workers to insure that health services really do reach remote rural populations. Community health workers are usually recruited from local communities and provide particularly primary healthcare services, both of preventive and curative nature as well. And it’s been estimated there are around 1.3 million community health workers at the moment and there’s a growing campaign for there being lots of more of the community health workers. Some very good examples of those have been in China where there are the famous barefoot doctors program which started in the 1960s and ’70s, was very effective and efficient way of getting primary healthcare services to rural populations. More recently in Ethiopia, they’ve recruited over 30,000 community health workers and they’ve been extremely effective in improving child health outcomes and indeed Ethiopia is on track to achieve its child health MDGs. Another very important area is insuring that there are efficient health information systems, because the generation in strategic use of information is an integral part of the stewardship function. It’s practically impossible to run an efficient health system if you don’t know what’s going on and you therefore need good information. So countries need to generate both population data about the health status and health needs of the population, but also information on the way that the health system is responding and facility based data, tracking where people are being treated and whether these services are having an impact. And there are a number of ways of generating this information through censuses, surveys, civil registration systems, public health surveillance systems, medical records and also, systems that measure the performance of health units. Now one area where it’s obviously vital to be detecting and using information is, is that looking at public health security. And the recent Ebola outbreak in West Africa is a very good example of needing rapid information about the spread of communicable disease. But it’s also vitally important that in generating all this information, that it’s synthesized and used strategically. And therefore that the management really uses this information to change systems performance. And finally, when one looks at service delivery and improving services, it’s vital to address the issue of the quality of services, because just measuring whether people come to an outpatient clinic or they deliver their babies in a health unit, isn’t good enough, because these services will only have an impact on people’s health if they are effective, they work. And therefore they must be of good quality. And in measuring the quality of services, it’s also not just good enough to look at the technical quality, whether the medicines work, but also there’s vital elements about the consumer’s perception of quality. Are they treated with dignity? Are they seen on time? Those more sort of customer friendly aspects. Because unless health systems look at those, those customer perceptions, people simply won’t go to the health facilities and use the services and therefore they’ll be useless in impacting people’s health.


Health Systems – I

Introduction to Health Systems

Today I want to talk about health systems and in particular, the role of health systems in delivering universal health coverage which you’ve heard about in another lecture[1]. So what is a health system? According to the World Health Organization, a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.

712This includes efforts to influence determinants of health as well as more direct health improving activities. So you can see this is really quite a broad definition. And the health system is certainly much bigger than really just talking about public health units and hospitals. And in fact, if one thinks about the entire health system, it also includes the private health sector providers, both in terms of commercial, for-profit providers, but also non-government organization providers of services. But it also includes people caring for sick relatives at home. Another big area of course is in preventive healthcare and things like vector control programs to control mosquitoes for example. Behavior change programs would also be in the health system, encouraging people to lead healthier lifestyle by reducing the amount of fat intake and tobacco and taking more physical exercise. The health system also includes occupational health and safety legislation. Those are all activities that one would typically associate with the health sector, but also in really thinking about the much broader health system, it also includes intersectoral action to promote interventions that improve health. For example, the education of girls is very important for improving health status. Encouraging legislation to reduce tobacco, alcohol and sugar consumption and road safety measures. These are all what we’d call part of the broader health system. So that’s what a health system is. Now what should a health system be trying to do? Now here the World Health Organization have been extremely helpful and back in 2000, produced a memorable World Health report all about health systems and improving the performance of health systems.712

In this document, they stated that there are three major goals for, for a health system. Firstly, to improve health indicators. Measures such as life expectancy, mortality rates, but also associated with people leading healthier lives. Here we’re not only interested in the overall levels of these indicators, but their distribution as well, to avoid the situation of there being big health inequalities between different population groups. Another goal for the health system is that it should be responsive to people’s non-medical expectations. That when people interact with the health system they’re treated courteously and in a timely manner and with respect as well. And the third major area is that the health system should be fair, particularly in terms of the financial contributions that people make towards financing the health system. So we’ve described what a health system is trying to achieve, now how does it go about trying to do that? And again the World Health report provided good structure in terms of describing four key functions of a health system. Firstly, in creating the resources that are required to run the health system, the inputs that go into the health system. Here one can think of things like medicines and health workers and computers, the basic inputs that go into the system. The next major area of course is in combining those inputs in delivering services. And this whole issue of how does one deliver efficient and equitable services? This will be the topic of the next lecture. The third major function concerns the financing of the health system. Again, we’ll discuss this in another lecture, but here one should consider the functions of how one raises the finances for the health system, how one pools resources, and then also the very important issue of purchasing services efficiently. And the final major function concerns stewardship. The overall management and oversight of the health system, where it’s an extremely important role for the state. Now when these functions combine effectively together and work well in an efficient and equitable way, this is how one improves the health system and delivers those outcomes that one’s looking for of improved health indicator figures, better fair financial contributions and also a system that is responsive to people’s needs. I’d like to just dwell briefly on this very important issue of stewardship and why it’s so important that the state gets involved in the running of the health sector. Now why should this be the case? Well firstly because health should be a national priority, all countries everywhere, people, it’s very important for them and the welfare of their families that they lead long, healthy lives and don’t suffer financial hardship in accessing services. So health really should be a national priority that good governments are concerned about. Secondly, it’s clear that free markets in health services don’t deliver equitable health systems. And really this is to do a lot with what they call market failures in the way that health systems worked. And the, the providers and suppliers of health services have a lot more information than the users of services. And in this type of situation, it’s very easy for people to be exploited by unscrupulous healthcare providers. And really this is one of the major reasons that it’s very important for the state to be heavily involved in the stewardship of the, of the health system. So the state really should be involved in setting the rules of the game of running the health system. And also in monitoring the performance of providers of services and improving accountability to the population who are paying for them. Now one area that has attracted quite a lot of controversy over the years is the role of the public and private sectors in, in a health system. And here, Professor Julio Frenk at the Harvard School of Public Health has provided a very useful description of the different roles of the public and private sectors, looking at those functions I was describing before. So thinking of that overall stewardship and accountability function, clearly that lies predominantly within the public sector, to set the rules and regulations to the system, with only perhaps a very small role for the private sector there. Likewise, it’s becoming increasingly clear that to achieve universal health coverage in an equitable health system, one needs to predominantly be looking at a publicly financed system. However, looking at the issue and function of service provision, it’s slightly less clear. And indeed, many countries the, the majority of health service providers are actually in the private sector, contracted, using public financing. So here there tends to be more of a mix of public and private providers. But when one looks at that final function or resource generation, manufacturing the inputs that go into the health sector, here the tendency is more for the private sector to produce the medicines and the computers and the basic inputs that go into the system. Now another area that’s attracted quite a lot of controversy over recent years is how one measures health service performance. And countries are very keen to match, to identify how their health sector is performing against others. Now how does one do this? How do you measure performance? Well clearly the indicators you should be trying to use are those around those objectives we were talking about of improved health status, better financial protection, and a more responsive system. And again, we don’t want just to be looking at absolute levels of those measures, but how they’re distributed across society. Now the World Health report in 2000 did this and ranked health systems across the world and created an index and therefore created a lead table. This was quite a controversial exercise and in that, at that time it was the French system that was deemed to be the best performing. Other organizations have been doing this as well. Most notably the Commonwealth Funds that assesses the performance, particularly of high income countries looking at measures of quality of care, access to health services, the efficiency of the system, equity and also those all-important health indicators. And in the most recent study that the Commonwealth Fund done, they showed that the British National Health Service scored the highest, was ranked the highest performing sector. Of course the system that is predominantly publicly financed and interestingly, the United States, of the eleven countries surveyed was actually bottom of the lead table, largely due to problems with inequitable access to services. Now what was striking is that the United States’ health system spend more than twice what a number of other OECD countries are doing, are spending. So it’s interesting therefore that necessarily spending more money on a health system doesn’t always improve performance. And therefore governments can learn about improving efficiency and doing more with the money that they have available. Thank you.