Issues paper: The EU role in global health Comments from the Institute for Global Health, University College London 9 December 2009

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1 Issues paper: The EU role in global health Comments from the Institute for Global Health, 9 December 2009 IGH is submitting answers to 14 of the questions posed in the consultation document. Question 3: Do you consider the health-related MDGs a sufficient framework for a global health approach? If not, what else should also be considered? We believe that they do not supply a sufficient framework for a global health approach. In the health related MDGs there is a lack of an emphasis on equity and on the social determinants of health. In addition, the MDGs foster verticalised approaches to problems. The MDGs are an important start, but on their own, they are not a sufficient framework for global health. While the MDGs have been important in bringing together a great number of resources around a targeted series of issues, they have left out significant parts of the population - for example, gender was only recently included in the MDGs after a significant campaign to ensure more attention to gender inequalities in the various MDGs, targets and indicators. Nowhere in the 8 Goals and accompanying 21 Targets and 60 Indicators are people with disabilities - some 650 million people, implicitly or explicitly included, which has meant that they have been bypassed by many of the MDG programmes and campaigns. (The idea often being that these people will be reached after the needs of others have been addressed). This has only further marginalized an already marginalized population. In the same vein, the issues and health concerns that have NOT been prioritized by the MDGs - for example, the health needs of the elderly have been low on the list of priorities, and many efforts for health conditions and development needs that have not been prioritized have been drained of funds because they are not listed in the MDGs. Clearly, the need to prioritize, to bring together hundreds of previously uncoordinated projects and programmes etc., is an important first step and the MDGs have done this to some extent. What is currently missing and what we could suggest - is a mechanism within the EU framework that would allow the EC to address issues that have been overlooked by the MDGs; issues that are not part of the MDGs - possibly because these are smaller issues or address the needs of limited populations, but populations which nonetheless are still in need of help or medical aid; or new issues which arise after goals and targets have been set, but which still need to be addressed. So for example, right now if a new global health threat arose that did not fit into the MDGs, there's no obvious mechanism to address this within the MDGs. We would either have to put the MDGs aside, ignore the health threat for the time being, or - as has happened with swine flu - pull in medical resources and funding from pools of money and organizations outside the realm of the MDGs. Page 1 of 5

2 Question 4: In your opinion, which are the main strengths and weaknesses of the current EU policy on health and development cooperation, and which dimensions should be given greater attention in order to face the challenges ahead? Too much of the EU Policy on health and development cooperation is oriented towards clinical trials. When these trials take place they can appear to serve the business interests of the EU in the developing world. Question 5: Could you identify health problems that have been neglected by the EU and international health research agenda and propose the best means to support innovation to address them, especially in low and middle-income countries? The big gap in EU and international health research is health policy and systems research, and in management and governance (of local and international actors). Question 7: How do you think fragmentation of aid for health could be reduced, with a view to increasing aid effectiveness and preventing detrimental health spending? The EC could include more support for SWAPS, the IHP and budget support - but with stricter and better independent monitoring and surveillance to ensure aid effectiveness. Question 8: In the context of aid effectiveness and alignment of financing to national priorities, what can be done to make sure that adequate attention is paid to health priorities and providing support for developing health systems? The first way to ensure that health priorities are maintained in a shifting global landscape is to ensure a hypothecated flow of funds to health ministries. When negotiating national priorities, health priorities should be clearly delineated within broader national plans. Where possible, these priorities should be accompanied by proposed strategies for addressing local health needs and these may of course extend beyond the boundaries of what might be conventionally considered health. For example, reducing maternal or neonatal death may be a national health priority; however, it may be achieved through a range of strategies including increasing (and prolonging) female enrolment at school i.e. an education aim. Past experience has demonstrated that, in the short run, progress towards the achievement of health priorities is easiest to measure when the strategies employed are vertical and success is measured in outputs e.g. the number of vaccinations delivered to under 5s. However, there is a risk that this approach will undermine health systems strengthening as resources are pulled towards the best-funded vertical column in the health ministries balance sheet, thus undermining the delivery of essential services, which may be harder to measure. It is unlikely that this can ever be entirely avoided as funders need to report on the success of their funding initiatives. Finally, it is important to caution that national priorities (health and otherwise) are often victim to shifting global notions of aid-effectiveness. Question13: What should be the role of civil society in the health sector, at national and local levels? Civil society has many roles to play. As the local level, they are crucial in organizing and mobilizing people, where such mobilization is unheard off and/or actively discouraged. At the local level, some civil society organizations act as mediators and interpreters for the uneducated and illiterate in accessing the health sector. Other organizations fight for health and human rights at the state or national level. We are now seeing the emergence of civil society organizations as brokers between the health sector and local people, either in terms of health care financing or as health insurers. Page 2 of 5

3 The success of these civil society banks and health insurers is crucial in poorer groups gaining access to quality health services. Question 14: Which action do you think the EU should take to stem the brain drain of health workers, while respecting their freedom of movement? It's good that the EU is showing concern for coherence of its internal and external policies. However, the WHO code of conduct is not necessarily the best mechanism for addressing the negative impacts of the health worker crisis. The most substantive attempt at implementing a code was by the Department of Health in England. But evaluations have shown that it probably had little effect on the inflow of workers into the English National Health Service (NHS). This was because although the code stopped "active recruitment" of health workers in a large number of developing countries, it did not stop citizens of those countries finding jobs in England of their own accord. In a highly integrated global market of health professionals, driven by technological and demographic changes, which are outside the control of policy-makers, attempts to restrict levels of inward migration may be difficult. A more positive approach is needed which focuses on creating "incentives to stay" in poorer countries by addressing the issues that cause workers to move, i.e. poor pay, poor health system governance, bad working conditions etc. This will require financing, which the EU can address through its aid budget. They should also acknowledge that this is in part repayment for the "skills gained" from workers from developing countries coming to work in EU member states. All health institutions within the EU have a role to play in facilitating the growth of incentives to stay, not just governments or the Commission. Hospitals can promote twinning to build capacity in poorer countries; professional bodies from EU nations can work with their counterparts in poorer countries to strengthen their hands in pay negotiations. EU policy in health and education could also help strengthen health systems in poorer countries by facilitating professional exchange and educational opportunities in the EU. Post-qualification education and training experience for health professionals is lacking across much of sub-saharan Africa, and continuing access to further learning for migrant health professionals would be very valuable. Question 16: What are the keys to ensuring equitable access to medicine and how could the EU help to do more on this, including by supporting innovation and management of intellectual property rights? The active acknowledgement of the large role private medicine plays in health care access for poor people is key to ensuring equitable access to medicine. Private sector doctors, chemists and other health care workers fill the gap where the government health sector does not operate or operates inefficiently, often in rural and deprived areas. Equitable access to medicines will only come about when the role of the private health sector in deprived and rural communities are acknowledged. Question 18: How, in your opinion, could the EU research funding effectively address the systemic weaknesses of health systems worldwide? The EU could fund more action and operational research linked to health systems strengthening; by supporting the use of research to hold key actors to account; and by encouraging the role of local universities in low-income countries to play an active role in supporting health systems development. Page 3 of 5

4 Question 20: Which kinds of global public goods for health should be given priority and how should they be financed and managed? One of the main public goods that could be given priority is banking and financial regulation where a more accountable and transparent system should be put in place. Question 24: What, in your opinion, should be the main principles guiding equitable social protection for health? Apart from the principles mentioned in the document, the fair and equitable treatment of patients once health care has been accessed is crucial. Equal and universal access is only the start of the process of patient experience. Fair and equitable patient experience is an important guiding principle for achieving equity in health care. Question 25: Which fair financing principles and mechanisms should apply to health system financing to ensure equitable and universal coverage of basic healthcare? On the demand side, fair financing principles might include horizontal and vertical equity, which can only be achieved through progressive financing mechanisms. These principles might also include universal access and, where possible, a choice of culturally acceptable providers. Risk protection (including protection from the financial risks of care seeking) should also be considered within the remit of fair financing. On the supply side fair financing might aim to strengthen health systems and decentralise control to ensure that systems are responsive to local needs. Fair supply side financing should also consider the necessity of disease containment and cost recover where that recovery does not undermine the equity of service provision. Cost recovery may only be necessary in those cases where failure to recover costs would result in service non-delivery. Those aiming to recover costs should bear in mind that exempting the poor from cost recovery has not worked effectively in the past. It may be more effective to give the poor vouchers/credits ahead of time, which can be used to purchase services from any provider. These financing principles necessarily exclude user fees and private health insurance as funding mechanisms. Direct tax based financing is the most likely to adhere fair financing principles ensuring progressive financing with the widest possible risk pool. However, in many low-income countries the tax base is simply too small to generate sufficient funds for health service provision and a tax based regimen may undermine newly emergent capacities in decentralised systems. As such it is most likely that a mixed methods approach will enable health systems to balance equitable and universal coverage, with effective financing. Question 26: What is the role of civil society in global and national health governance and how can potential conflicts of interest between advocacy and service provision be avoided? Although this is an extremely broad question, here is a brief answer: Civil society and national health governance are key components of the global health agenda. Civil society and national health governance exist in a type of feedback cycle - civil society influences governance decisions at a national level and vice versa. The question divides them into two distinct camps, but they're not as clearly delineated in the real world. For example, if the population is outraged about children in institutions in country X, they will make their government officials pay attention. Government officials are also part of civil society. The issue relevant to the question here is that civil society and national health governance are not two distinct categories; they are inter-related and should be considered as such. Page 4 of 5

5 The type and intensity of advocacy rises and falls in countries based on a number of different political and economic factors. (So advocacy in the 1970s and 80s was more intense in many countries than in recent years). However, the question is: How can potential conflicts of interest between advocacy and service provision be avoided? Some related questions are: Do we always want to avoid such conflicts? Doesn't advocacy often serve as a way of providing oversight to service provision efforts? Perhaps a better way to state this question is to ask: 'What should be put in place to facilitate dialogue between advocates and service providers? Also, What reporting (monitoring/evaluation) systems are needed to make service provision systems accountable to advocacy groups? (And what similar systems are in place to ensure that advocates are making demands that are in the best interests of everyone and not just their own organizations or other personal interests?) Question 28: Do you think that an EU social model could inspire global health equity? In its current state, an EU social model could not inspire global health equity. However, if a coherent EU social model can be developed for ALL aspects of the economy and society, not just the health sector, then such a model could be an inspiration for global health equity. Page 5 of 5

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