Correspondence
Investing in health As public health professionals devoted to global health equity, we would like to express our deep concern with the The Lancet Commission Global health 2035: a world converging within a generation (Dec 7, p 1898),1 a re-run of the 1993 World Development Report, whose policies contributed to the shrinkage of government institutions and massive privatisation and fragmentation of health-care systems, effectively decreasing coverage and accessibility.2,3 The Lancet Commission on Investing in Health comprised mostly of individuals affiliated with or funded by international financial institutions, corporations, public–private partnerships, bilateral donor agencies, and their philanthropic and academic partners, mostly from high-income countries, presents a biased perspective reminiscent of failed neoliberal prescriptions rooted in the reinvention of formulas by co-opting terms like universal health care and access. The recommendations are based on the principle of return on investment, not on health equity, while creating a double standard: one for the rich and another for the rest of us. Any policy for the poor is by definition a poor policy. The Lancet Commission’s recommendations do not represent the global health community and are fundamentally flawed by neglecting the principle of the right to health. The report analyses Millennium Development Goals progress without reference to stagnant levels of health inequity: 20 million deaths each year, more than a third of all deaths, are avoidable and caused by socioeconomic injustice—a number and a proportion that have not changed for the past 40 years.4 Every individual, organisation, or government working to promote heath equity and WHO´s objective of enjoyment by all peoples of the best attainable level of health should be on their guard. We declare that we have no competing interests.
www.thelancet.com Vol 383 March 15, 2014
*David Chiriboga, Paulo Buss, Anne-Emanuelle Birn, Juan Garay, Carles Muntaner, Laura Nervi, on behalf of 42 signatories [email protected] Hospital de Zumbahua, Zumbahua, Cotopaxi, Ecuador (DC); Oswaldo Cruz Foundation’s Center for Global Health, Rio de Janeiro, Brazil (PB); Dalla Lana School of Public Health, Centre for Critical Development Studies, University of Toronto, ON, Canada (A-EB); Andalusian School of Public Health, Granada, Spain (JG); Bloomberg Faculty of Nursing, Department of Psychiatry and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CM); and Human Ecology Institute, Concepcion, Chile (LN) 1
2
3
4
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55. Laurell AC, Arellano OL. Market commodities and poor relief: the World Bank proposal for Health. Int J Health Serv 1996; 26: 1–18. Lister J. Globalization and health systems change. WHO Commission on Social detetminants of Health. University of Ottawa, 2008. http://www.globalhealthequity.ca/ webfm_send/14 (accessed March 1, 2014). Garay J, Harris L, Beam M, Zompi S. Global inequity death toll: targeting global health equity and estimating the burden of inequity. 141st American Public Health Association Annual Meeting; Boston, MA, USA; Nov 2–6, 2013. Abstr 291133.
Public financing is the path to universal health coverage (UHC). UHC is rapidly becoming the overarching goal for national health systems and two recent events mark a new consensus that public financing is the way to get there.1 The Lancet Commission on Investing in Health2 focused on public financing mechanisms (including aid) in reaching UHC and explicitly rejected the 1993 World Development Report’s emphasis on private health financing, including user fees.2,3 Similarly all 11 countries that presented at the Global Conference on UHC (Dec 6, 2013, Tokyo, Japan) hosted by the World Bank and Government of Japan, highlighted their use of public financing to increase service coverage and improve financial protection. None had used private voluntary financing to any significant extent. What is the basis for this consensus? UHC is fundamentally about rights and equity. It requires that the healthy and
wealthy subsidise health services for the sick and poor. This cannot happen through private market-based systems of user fees and private insurance, including voluntary community-based schemes.4 Across the world, countries are instead realising that the only way to secure the cross-subsidies needed for UHC is through compulsory contributions into redistributive risk pools. In particular, tax financing is proving essential to close coverage gaps for households in the informal sector. Since only the state can mandate progressive payments and ensure that benefits are allocated according to need, only public financing systems can achieve the combination of universality, equity, and financial protection needed for UHC. Many of the governments that have learnt these lessons are now the ones leading the charge for UHC to be included in the post-2015 agenda. As noted by the World Bank President, one of these countries, Thailand, achieved UHC by rejecting the advice of the World Bank in the 1993 World Development Report to not rely on public financing. These countries represent the new consensus on health financing: universal coverage can only be accomplished through public financing systems in which the state plays a leading part in raising revenues, pooling funds, and purchasing services.
See appendix for a full list of signatories
We declare that we have no competing interests.
*Robert Yates, Ranu S Dhillon [email protected] Health Systems Financing, WHO, 1021 Geneva, Switzerland (RY); Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA (RSD); and Earth Institute, Columbia University, New York, NY, USA (RSD) 1
2
United Nations. United Nations Grand Assembly Draft Resolution (A/67/L.36) Global health and foreign policy, 2012. http://www. un.org/ga/search/view_doc.asp?symbol= A/67/L.36& referer=http://www.un.org/en/ ga/info/draft/index.shtml&Lang=E (accessed Dec 8, 2013). Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55.
For more on Global Conference on UHC see http://www. worldbank.org/en/news/pressrelease/2013/12/06/politicalleadership-universal-healthcoverage-world-bank-japan
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
949
Correspondence
3
4
World Bank. World Development Report, 1993. http://files.dcp2.org/pdf/World DevelopmentReport1993.pdf (accessed Dec 8, 2013). McIntyre D. EQUINET Discussion Paper 95: Health service financing for universal coverage in east and southern Africa. Harare: University of Cape Town Health Economics Unit, 2012.
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
For data revolution see http:// post2015.org/tag/datarevolution/
950
A section of The Lancet Commission on Investing in Health1 that will no doubt be of particular interest to Ministries of Finance and Treasuries the world over is the one entitled “Avoiding unproductive cost escalation”. A comprehensive review of the evidence is summarised and an important range of policy options are provided with a particular emphasis on using hard budget constraints, reducing fee-for-service payments, and the use of reference pricing.1 The report also discusses the role of single payer systems, health technology assessment, strategic purchasing, gatekeeping, preventing chronic disease, and, with some caveats, cost-sharing schemes for patients with high incomes. However one area that gets little mention, despite a growing body of evidence, is the role of health information in both improving quality of services and keeping costs down. All countries need to understand and measure three key domains of health— the determinants of health, health status, and the health system.2 Investing in health information is essential for containing costs for three reasons. Providing sound epidemiological and health system performance knowledge can lead to cost savings by making the right health investments. Up to date information about the performance of health services can lead to greater efficiency and data driven continuous quality improvement techniques are well established in high-income countries and of growing importance in low-income settings.3 Lastly, health information technology itself leads to considerable savings in the health sector. Again this is well established in high-income settings, where health information technology brings
efficiency through increasing adherence to evidence-based guidelines, improving surveillance and monitoring, and reducing prescribing errors. 4 Similar evidence is also now growing in low-income and middle-income settings.5 The difficulties in scaling up such systems are well known, with calls for incentives that reward the sharing of data,6 for less reliance on commercial marketing, and for more use of evaluations. However, despite these problems of scaling up, the message that investment in and use of good health information can help reduce costs as well as improve individual care is an important one. With the new emphasis on the need for a “data revolution” in the post-2015 agenda, commissioners should not miss this opportunity to promote investment in health information to help a more efficient delivery of the “grand convergence” in health by 2035. I declare that I have no competing interests. I thank Ties Boerma (WHO, Geneva, Switzerland) for providing comments on a first draft.
Robert Fryatt [email protected] 175 East 96th, New York, NY 10128, USA 1
2
3
4
5
6
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55. Health Metrics Network. Framework and Standards for Country Health Information Systems. Second Edition. WHO, 2008. Stringer JS, Chisembele-Taylor A, Chibwesha CJ, et al. Protocol-driven primary care and community linkages to improve population health in rural Zambia: the Better Health Outcomes through Mentoring and Assessment (BHOMA) project. BMC Health Serv Res 2013; 13: S7. Shekelle PG, Morton SC, Keeler EB. Costs and benefits of health information technology. Evid Rep Technol Assess 2006; 132: 1–71. Lewis T, Synowiec C, Lagomarsino G, Schweitzer J. E-health in low- and middle-income countries: findings from the Center for Health Market Innovations. Bull World Health Organ 2012; 90: 332-40. Miller AR, Tucker C Health information exchange, system size and information silos. J Health Econ 2013; 33: 28-42.
Authors’ reply The publication of The Lancet Commission 1 sparked intense discussion and debate at country, regional, and international levels. This
extraordinary response is perhaps not surprising, given that the report lays out an extremely ambitious global health investment framework and claims that investing in this framework would achieve very dramatic health gains within a generation. Our claims are bold, but we are confident that they are based on rigorous and replicable analyses. We argue that with the right investments, the world’s starkest inequity—the appalling rates of avertable child and infectious deaths in low-income and middle-income countries—could end within a generation. With aggressive scaleup of current and new measures, the under-5 mortality rate in almost all low-income and lower-middle-income countries could be reduced to levels seen today in the best-performing middle-income countries, achieving a grand convergence in health. The returns on investment would be enormous. As The Lancet Editors recently noted in their Editorial, 2 “The economic rigour of the work that underpins grand convergence, together with the economic calculus that measures the value of health to individuals and societies, can give decision makers confidence that the claims being made for the next 15–20 years are neither special pleading by the health community nor overoptimistic advocacy.”2 A grand convergence cannot be achieved without health systems strengthening, which should certainly include improving health information systems. It also cannot be achieved without universal health coverage (UHC). Global Health 2035 lays out two progressive pathways towards UHC—progressive universalism—that are publicly financed and that ensure that the poor get equal treatment from day one. We make no apologies for promoting policies that protect the poor. We argue forcefully for a major increase in prepayment and pooling of funds to extend publicly financed insurance. We also argue for zero www.thelancet.com Vol 383 March 15, 2014
Investing in health As public health professionals devoted to global health equity, we would like to express our deep concern with the The Lancet Commission Global health 2035: a world converging within a generation (Dec 7, p 1898),1 a re-run of the 1993 World Development Report, whose policies contributed to the shrinkage of government institutions and massive privatisation and fragmentation of health-care systems, effectively decreasing coverage and accessibility.2,3 The Lancet Commission on Investing in Health comprised mostly of individuals affiliated with or funded by international financial institutions, corporations, public–private partnerships, bilateral donor agencies, and their philanthropic and academic partners, mostly from high-income countries, presents a biased perspective reminiscent of failed neoliberal prescriptions rooted in the reinvention of formulas by co-opting terms like universal health care and access. The recommendations are based on the principle of return on investment, not on health equity, while creating a double standard: one for the rich and another for the rest of us. Any policy for the poor is by definition a poor policy. The Lancet Commission’s recommendations do not represent the global health community and are fundamentally flawed by neglecting the principle of the right to health. The report analyses Millennium Development Goals progress without reference to stagnant levels of health inequity: 20 million deaths each year, more than a third of all deaths, are avoidable and caused by socioeconomic injustice—a number and a proportion that have not changed for the past 40 years.4 Every individual, organisation, or government working to promote heath equity and WHO´s objective of enjoyment by all peoples of the best attainable level of health should be on their guard. We declare that we have no competing interests.
www.thelancet.com Vol 383 March 15, 2014
*David Chiriboga, Paulo Buss, Anne-Emanuelle Birn, Juan Garay, Carles Muntaner, Laura Nervi, on behalf of 42 signatories [email protected] Hospital de Zumbahua, Zumbahua, Cotopaxi, Ecuador (DC); Oswaldo Cruz Foundation’s Center for Global Health, Rio de Janeiro, Brazil (PB); Dalla Lana School of Public Health, Centre for Critical Development Studies, University of Toronto, ON, Canada (A-EB); Andalusian School of Public Health, Granada, Spain (JG); Bloomberg Faculty of Nursing, Department of Psychiatry and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CM); and Human Ecology Institute, Concepcion, Chile (LN) 1
2
3
4
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55. Laurell AC, Arellano OL. Market commodities and poor relief: the World Bank proposal for Health. Int J Health Serv 1996; 26: 1–18. Lister J. Globalization and health systems change. WHO Commission on Social detetminants of Health. University of Ottawa, 2008. http://www.globalhealthequity.ca/ webfm_send/14 (accessed March 1, 2014). Garay J, Harris L, Beam M, Zompi S. Global inequity death toll: targeting global health equity and estimating the burden of inequity. 141st American Public Health Association Annual Meeting; Boston, MA, USA; Nov 2–6, 2013. Abstr 291133.
Public financing is the path to universal health coverage (UHC). UHC is rapidly becoming the overarching goal for national health systems and two recent events mark a new consensus that public financing is the way to get there.1 The Lancet Commission on Investing in Health2 focused on public financing mechanisms (including aid) in reaching UHC and explicitly rejected the 1993 World Development Report’s emphasis on private health financing, including user fees.2,3 Similarly all 11 countries that presented at the Global Conference on UHC (Dec 6, 2013, Tokyo, Japan) hosted by the World Bank and Government of Japan, highlighted their use of public financing to increase service coverage and improve financial protection. None had used private voluntary financing to any significant extent. What is the basis for this consensus? UHC is fundamentally about rights and equity. It requires that the healthy and
wealthy subsidise health services for the sick and poor. This cannot happen through private market-based systems of user fees and private insurance, including voluntary community-based schemes.4 Across the world, countries are instead realising that the only way to secure the cross-subsidies needed for UHC is through compulsory contributions into redistributive risk pools. In particular, tax financing is proving essential to close coverage gaps for households in the informal sector. Since only the state can mandate progressive payments and ensure that benefits are allocated according to need, only public financing systems can achieve the combination of universality, equity, and financial protection needed for UHC. Many of the governments that have learnt these lessons are now the ones leading the charge for UHC to be included in the post-2015 agenda. As noted by the World Bank President, one of these countries, Thailand, achieved UHC by rejecting the advice of the World Bank in the 1993 World Development Report to not rely on public financing. These countries represent the new consensus on health financing: universal coverage can only be accomplished through public financing systems in which the state plays a leading part in raising revenues, pooling funds, and purchasing services.
See appendix for a full list of signatories
We declare that we have no competing interests.
*Robert Yates, Ranu S Dhillon [email protected] Health Systems Financing, WHO, 1021 Geneva, Switzerland (RY); Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA (RSD); and Earth Institute, Columbia University, New York, NY, USA (RSD) 1
2
United Nations. United Nations Grand Assembly Draft Resolution (A/67/L.36) Global health and foreign policy, 2012. http://www. un.org/ga/search/view_doc.asp?symbol= A/67/L.36& referer=http://www.un.org/en/ ga/info/draft/index.shtml&Lang=E (accessed Dec 8, 2013). Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55.
For more on Global Conference on UHC see http://www. worldbank.org/en/news/pressrelease/2013/12/06/politicalleadership-universal-healthcoverage-world-bank-japan
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
949
Correspondence
3
4
World Bank. World Development Report, 1993. http://files.dcp2.org/pdf/World DevelopmentReport1993.pdf (accessed Dec 8, 2013). McIntyre D. EQUINET Discussion Paper 95: Health service financing for universal coverage in east and southern Africa. Harare: University of Cape Town Health Economics Unit, 2012.
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
For data revolution see http:// post2015.org/tag/datarevolution/
950
A section of The Lancet Commission on Investing in Health1 that will no doubt be of particular interest to Ministries of Finance and Treasuries the world over is the one entitled “Avoiding unproductive cost escalation”. A comprehensive review of the evidence is summarised and an important range of policy options are provided with a particular emphasis on using hard budget constraints, reducing fee-for-service payments, and the use of reference pricing.1 The report also discusses the role of single payer systems, health technology assessment, strategic purchasing, gatekeeping, preventing chronic disease, and, with some caveats, cost-sharing schemes for patients with high incomes. However one area that gets little mention, despite a growing body of evidence, is the role of health information in both improving quality of services and keeping costs down. All countries need to understand and measure three key domains of health— the determinants of health, health status, and the health system.2 Investing in health information is essential for containing costs for three reasons. Providing sound epidemiological and health system performance knowledge can lead to cost savings by making the right health investments. Up to date information about the performance of health services can lead to greater efficiency and data driven continuous quality improvement techniques are well established in high-income countries and of growing importance in low-income settings.3 Lastly, health information technology itself leads to considerable savings in the health sector. Again this is well established in high-income settings, where health information technology brings
efficiency through increasing adherence to evidence-based guidelines, improving surveillance and monitoring, and reducing prescribing errors. 4 Similar evidence is also now growing in low-income and middle-income settings.5 The difficulties in scaling up such systems are well known, with calls for incentives that reward the sharing of data,6 for less reliance on commercial marketing, and for more use of evaluations. However, despite these problems of scaling up, the message that investment in and use of good health information can help reduce costs as well as improve individual care is an important one. With the new emphasis on the need for a “data revolution” in the post-2015 agenda, commissioners should not miss this opportunity to promote investment in health information to help a more efficient delivery of the “grand convergence” in health by 2035. I declare that I have no competing interests. I thank Ties Boerma (WHO, Geneva, Switzerland) for providing comments on a first draft.
Robert Fryatt [email protected] 175 East 96th, New York, NY 10128, USA 1
2
3
4
5
6
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–55. Health Metrics Network. Framework and Standards for Country Health Information Systems. Second Edition. WHO, 2008. Stringer JS, Chisembele-Taylor A, Chibwesha CJ, et al. Protocol-driven primary care and community linkages to improve population health in rural Zambia: the Better Health Outcomes through Mentoring and Assessment (BHOMA) project. BMC Health Serv Res 2013; 13: S7. Shekelle PG, Morton SC, Keeler EB. Costs and benefits of health information technology. Evid Rep Technol Assess 2006; 132: 1–71. Lewis T, Synowiec C, Lagomarsino G, Schweitzer J. E-health in low- and middle-income countries: findings from the Center for Health Market Innovations. Bull World Health Organ 2012; 90: 332-40. Miller AR, Tucker C Health information exchange, system size and information silos. J Health Econ 2013; 33: 28-42.
Authors’ reply The publication of The Lancet Commission 1 sparked intense discussion and debate at country, regional, and international levels. This
extraordinary response is perhaps not surprising, given that the report lays out an extremely ambitious global health investment framework and claims that investing in this framework would achieve very dramatic health gains within a generation. Our claims are bold, but we are confident that they are based on rigorous and replicable analyses. We argue that with the right investments, the world’s starkest inequity—the appalling rates of avertable child and infectious deaths in low-income and middle-income countries—could end within a generation. With aggressive scaleup of current and new measures, the under-5 mortality rate in almost all low-income and lower-middle-income countries could be reduced to levels seen today in the best-performing middle-income countries, achieving a grand convergence in health. The returns on investment would be enormous. As The Lancet Editors recently noted in their Editorial, 2 “The economic rigour of the work that underpins grand convergence, together with the economic calculus that measures the value of health to individuals and societies, can give decision makers confidence that the claims being made for the next 15–20 years are neither special pleading by the health community nor overoptimistic advocacy.”2 A grand convergence cannot be achieved without health systems strengthening, which should certainly include improving health information systems. It also cannot be achieved without universal health coverage (UHC). Global Health 2035 lays out two progressive pathways towards UHC—progressive universalism—that are publicly financed and that ensure that the poor get equal treatment from day one. We make no apologies for promoting policies that protect the poor. We argue forcefully for a major increase in prepayment and pooling of funds to extend publicly financed insurance. We also argue for zero www.thelancet.com Vol 383 March 15, 2014
