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
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
