Right to health and finance in developing countries

1. �Right to health� and �finance� in developing countries Merel Mattousch, MD, MPH Wemos The Netherlands

2. Outline Wemos: goals, strategies and themes Right to health framework Case study on health budgets, Wemos and partners What is happening at country level in costing, budgets and financing: are �right to health� principles followed? Health Care Fund for the Poor, VietnamAn example of a �right to health� approach 

3. Wemos: goals, strategies and themes Envisages a world in which every person can realize his/ her right to the highest attainable standard of health Strategies: lobbying, collaboration with Southern Partners, campaigning and awareness raising Levels: South (Bolivia, Bangladesh, Kenya and Zambia), North and Global Themes: health budgets, human resources for health, nutrition, medicines �Strengthening national health systems that are accessible, available and sustainable is of vital importance and will form the focus of the work of Wemos in the coming five years� Breaking the vicious circle, Wemos program 2006-2010 While working at all levels Wemos specifically focuses on �nfluences of global policies such as IMF/WB policies, WTO, GATT, TRIPS etc. While working at all levels Wemos specifically focuses on �nfluences of global policies such as IMF/WB policies, WTO, GATT, TRIPS etc.

4. Right to health �the right of everyone to the enjoyment of the highest attainable standard of physical and mental health� International Covenant on Economic, Social and Cultural Rights, 1966 The right to health is embodied in a variety of international declarations, covenants and plans of actions, such as Universal Declaration of Human Rights (1948), International Convention on the elimination of all forms of racial discrimination (1963), Convention on the elimination of all forms of discrimination against women (1979), Convention on the right of the child (1989). Most notably, the International Covenant on Economic, Social and Cultural Rights (ICESCR) proclaims �the right of everyone to the enjoyment of the highest attainable standard of physical and mental health� (1966). Over 70% of all nations have ratified the ICESCR which makes the right to health an International legal obligation that must be progressively realized at the national levelThe right to health is embodied in a variety of international declarations, covenants and plans of actions, such as Universal Declaration of Human Rights (1948), International Convention on the elimination of all forms of racial discrimination (1963), Convention on the elimination of all forms of discrimination against women (1979), Convention on the right of the child (1989). Most notably, the International Covenant on Economic, Social and Cultural Rights (ICESCR) proclaims �the right of everyone to the enjoyment of the highest attainable standard of physical and mental health� (1966). Over 70% of all nations have ratified the ICESCR which makes the right to health an International legal obligation that must be progressively realized at the national level

5. Goes beyond �right to health care�� The reduction of stillbirth rate and of infant mortality and for the healthy development of the child The improvement of all aspects of environmental and industrial hygiene The prevention, treatment and control of epidemic, endemic, occupational and other diseases The creation of conditions which would assure to all medical service and medical attention in the event of sickness While it didn�t adopt the definition of health contained in the constitution of WHO: � health is a state of physical, mental and social well-being and not merely the absence of disease�, the basic components go beyond �right to health care�.While it didn�t adopt the definition of health contained in the constitution of WHO: � health is a state of physical, mental and social well-being and not merely the absence of disease�, the basic components go beyond �right to health care�.

6. Includes the following essential elements� Availability producing, procuring and distributing sufficient quantities  Accessibility non-discrimination, physical, economic and information accessibility Acceptabilityhealth care must be culturally acceptable to those seeking it Qualityof skills of medical staff, scientific methods, drugs & treatments available and equipment used Firstly, all the goods, services, facilities, technology and information required to meet the health needs of the people should be available. This not only requires producing or procuring sufficient quantities but also ensuring appropriate distribution to all communities. Secondly, everyone should have access to the available services and information. This refers to:- Physical accessibility: access for rural and urban populations alike no matter what the local infrastructure or weather conditions are- Equal accessibility: access for minorities, women or those with disabilities or illnesses- Economic accessibility: access for the poor: making sure that the services that are available are also affordable to all, regardless of levels of income poverty Acceptability relates to particular ethical, cultural or gender sensitivities, and taboos or needs that may otherwise deter some groups or minorities from seeking health treatment or seeking care. It also calls for a certain level of dignity and confidentiality Finally there should be a universal level of quality across the services provided and information distributed. This is particularly relevant to the quality of the skills of medical staff, scientific methods being deployed, the drugs and treatments available and the equipment used. Firstly, all the goods, services, facilities, technology and information required to meet the health needs of the people should be available. This not only requires producing or procuring sufficient quantities but also ensuring appropriate distribution to all communities. Secondly, everyone should have access to the available services and information. This refers to:- Physical accessibility: access for rural and urban populations alike no matter what the local infrastructure or weather conditions are- Equal accessibility: access for minorities, women or those with disabilities or illnesses- Economic accessibility: access for the poor: making sure that the services that are available are also affordable to all, regardless of levels of income poverty Acceptability relates to particular ethical, cultural or gender sensitivities, and taboos or needs that may otherwise deter some groups or minorities from seeking health treatment or seeking care. It also calls for a certain level of dignity and confidentiality Finally there should be a universal level of quality across the services provided and information distributed. This is particularly relevant to the quality of the skills of medical staff, scientific methods being deployed, the drugs and treatments available and the equipment used.

7. Puts immediate obligations on states�. Non-discrimination and equality of all persons Participation of all stakeholders Cessation of any detrimental activity or policy Prohibition of any steps that may be retrogressive in the short term Drafting and implementation of a plan or strategy that clearly maps out how to make progress towards the realization of all obligations Because there is a realization that due to limited resources the governments can not comply to the core obligations immediately, short or even medium term:  Respect the right to health Protect the right to health Fulfill the right to health These core obligations are differentiated under two categories: Those requiring immediate attention Those that can be worked towards progressively, known as the principle of progressive realizationBecause there is a realization that due to limited resources the governments can not comply to the core obligations immediately, short or even medium term: Respect the right to health Protect the right to health Fulfill the right to health These core obligations are differentiated under two categories: Those requiring immediate attention Those that can be worked towards progressively, known as the principle of progressive realization

8. Recently translated into� �a right to an effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all� Report of the Special Rapporteur on the right to health, March 2006 Special rapporteur to health is selected by Commission on Human Rights: Paul Hunt.Special rapporteur to health is selected by Commission on Human Rights: Paul Hunt.

9. Strengthened by� A �human rights approach� to health indicators, ensuring: Certain indicators are disaggregated by at least sex, race, ethnicity, rural/ urban and socio-economic status 5 essential indicators are incorporated measuring the following features: - a national strategy and plan of action- participation- access to health info- international assistance and co-operation of donors- accessible and effective monitoring and accountability mechanisms Strengthened by �a human rights approach to health indicators� meaning: Many existing indicators already have a role to play in measuring and monitoring progressive realization of the right to the highest attainable standard of health but it needs to be ensured that: - Certain indicators are disaggregated by at least sex, race, ethnicity, rural/ urban and socio-economic status- 5 essential indicators are incorporated measuring the following features: 1) A national strategy and plan of action2) Participation3) access to health info4) International assistance and co-operation of donors5) accessible and effective monitoring and accountability mechanisms Strengthened by �a human rights approach to health indicators� meaning: Many existing indicators already have a role to play in measuring and monitoring progressive realization of the right to the highest attainable standard of health but it needs to be ensured that: - Certain indicators are disaggregated by at least sex, race, ethnicity, rural/ urban and socio-economic status- 5 essential indicators are incorporated measuring the following features: 1) A national strategy and plan of action2) Participation3) access to health info4) International assistance and co-operation of donors5) accessible and effective monitoring and accountability mechanisms

10. Enforcing the MDGs� �To improve health systems in developing countries and those with economies in transition with the aim of providing sufficient health workers, infrastructure, management system and supplies to achieve the health-related Millennium Development Goals by 2015� World Summit in September, 2005 The MDGs give a very high prominence to health and realized is that the first goal: to eradicate extreme poverty and hunger, can NOT be reached unless the health goals are. Societies burdened by large numbers of sick and dying individuals can not escape from poverty. In short, the goals can not be achieved without effective health systems that are accessible to all!The MDGs give a very high prominence to health and realized is that the first goal: to eradicate extreme poverty and hunger, can NOT be reached unless the health goals are. Societies burdened by large numbers of sick and dying individuals can not escape from poverty. In short, the goals can not be achieved without effective health systems that are accessible to all!

11. In practice� Special rapporteur �Urges health ministers in LIC and MIC to carefully prepare and cost national programs that reflect what is actually needed to develop effective, integrated health systems to all�

12. What is happening at country level in costing, budgets and financing? Are �right to health� based principles followed?

13. Wemos� case study on health budgets Objective:Provision of country level experience, increasing the understanding of:- The rationale for deciding, maintaining or adjusting ceilings on health budgets and wage bills at country level- The role and positions of different stakeholders in the decision making process Countries included: Bolivia, Ghana, Kenya, Uganda and Zambia

14. Main actors Ministry of Finance Ministry of Health and other sectors Donors IMF/WB Non Governmental/ Civil Society Organizations

15. Ministries � policies & recommendations Policies: Spending needs are determined by MoH (mostly participatory) and macro-economic targets by MoF (mostly non-participatory) Recommendations to fulfill obligations: MoH to forcibly and effective lobby MoF MoH to articulate well its need for more resources MoH to effectively allocate its scarce resources MoH to ensure financial transparency and accountability

16. Donors � policies & recommendations Policies: Hardly invest in strengthening health systems, disease oriented, short-term commitments, vertical initiatives Recommendations to fulfill obligations: �Good donorship� Aid longer time periods Fully honoring aid commitments Providing budget or sector support rather than project support Donor harmonization with joint monitoring and reporting Negotiation of targets/ actions with governments Working with governments to develop plans to phase in higher revenues over the long term before phasing out aid Human rights norms and standards are rarely applied to international cooperation although they are very useful; reinforcing many of the principles now emerging as �good donorship�Human rights norms and standards are rarely applied to international cooperation although they are very useful; reinforcing many of the principles now emerging as �good donorship�

17. IMF/WB � policies & recommendations Policies: Restriction of fiscal space by tight spending limits while there is no consensus on evidence for what constitutes �sound� macro- economic policies on the level of inflation that would endanger economic growth or poverty reduction Recommendations to fulfill obligations: Macro-economic targets need to be loosened to allow greater domestic finance of social sectors and/or greater use of aid resources IMF should encourage wider involvement of ministries in macro-economic policy negotiation processes, to ensure that decisions are based on a bigger picture and fuller awareness of what the various trade-offs will be Trade offs of alternative options in order to allow for choice/ debate.Trade offs of alternative options in order to allow for choice/ debate.

18. NGOs/Civil Society �policies & recommendations Only few NGOs/ Civil Society Organizations are involved in fiscal space Recommendations to fulfill obligations: Push the initiation of a debate and analysis of different macroeconomic policy options at country level Call for effective involvement of health and other line ministries Monitor the process of implementation of the budget Budget process: estimating costs, preparing an appropriate budget/ expenditure framework and mobilizing resourcesBudget process: estimating costs, preparing an appropriate budget/ expenditure framework and mobilizing resources

19. Conclusion Human rights principles can be a powerful tool in helping to shape the main elements of a budgeting process in which all of us have a role to play Wemos can support NGOs and Civil Society Organizations in their effortsWemos can support NGOs and Civil Society Organizations in their efforts

20. Targeting the poor in Vietnam An example of a �right to health� approach

21. Vietnam Shifted from a centrally planned economy to a market economy (1986) Reform of health care system: social health insurance implementation, user charge introduction, public-private mix health care provision and opening pharmaceutical marketDespite being a LIC, vital indicators are comparable with those of middle income countries.But�.

22. High inequalities! Huge disparities exist�.particularly in northern upper mountains, among ethnic groups and within lower socio-economic quintiles the mortality is highest. Maternal Mortality Rate varies by area from 45 � 411 / 100,000 live birthsInfant Mortality Rate in poorest quintiles: 39.3/1000 while in richest quintiles: 13.8/1000 In ethnic minorities, IMR ranges from 30-69/1000 while the majority of the population (Kinh) it is: 21 and therefore the average: Maternal Mortality Rate varies by area from 45 � 411 / 100,000 live birthsInfant Mortality Rate in poorest quintiles: 39.3/1000 while in richest quintiles: 13.8/1000 In ethnic minorities, IMR ranges from 30-69/1000 while the majority of the population (Kinh) it is: 21 and therefore the average:

23. Health Care Fund for the Poor To provide free access to services and financial protection to 14.3 million poor people (under the poverty line) who can not afford to pay user fees Fixed budget allocation GoV (min 5 USD per capita) Provincial governments responsible for management Choice of two schemes: health insurance or directly reimburse the health providers HCFP was established in 2003. Before 2003 the health Insurance coverage of the poor was limited due to lack of well defined financial mechanism (mostly dependant on provincial hunger eradication and poverty reduction fund). Despite this, it was found that health insurance was a better financial mechanism than free health care for the poor. HCFP was established in 2003. Before 2003 the health Insurance coverage of the poor was limited due to lack of well defined financial mechanism (mostly dependant on provincial hunger eradication and poverty reduction fund). Despite this, it was found that health insurance was a better financial mechanism than free health care for the poor.

24. Coverage End of 2004: 11 million (76.7% of the eligible poor population) was covered by HCFP - 3.9 million SHI (24.9%)- 7.2 million direct reimbursement (51.7%) Only 60% of total allocation (appr.33 million USD) was spent in 2004 Direct reimbursement was more used in mountainous provincesDirect reimbursement was more used in mountainous provinces

25. Problems Limited information of benefit package Organizational issues Determining target beneficiaries Strategy to manage and utilize the fund Missing guideline for the near poor Service quality, weak infrastructure Homeless migrant poor without residential status Etc.

26. Future plans Inclusion of all the poor in existing compulsory SHI framework Supporting the near poor to participate in SHI Addressing problems such as: elimination barriers to health service, securing quality of care, implementation of SHI in some remote areas Inclusion of the poor in SHI framework is one of the strategies to achieve universal coverage of health care in Vietnam

27. Everyone has the right to health�. Let�s realize it!