Universal Coverage and Universal Coverage and Equity in Integrated Health Equity in Integrated Health SystemsSystems

David McCoyDavid McCoyPeople’s Health Assembly, Cape TownPeople’s Health Assembly, Cape Town

Public Finance Public Budgets

Public Provision

Private Finance Private Insurance

Private provision

The National Health Service (NHS)

Public Finance Private Management of Public Budgets

Public Provision

Private Finance

Co-payments

Private Insurance

Private provision

The National Health Market

How and why did this happen? Finance capital - looking for new markets and profitsFinance capital - looking for new markets and profits

A government that lied, bribed and threatenedA government that lied, bribed and threatened

Politicians (and doctors) with conflicts of interestPoliticians (and doctors) with conflicts of interest

Neoliberal occupation of mainstream political partiesNeoliberal occupation of mainstream political parties

Neoliberal and managerialist occupation of the Department Neoliberal and managerialist occupation of the Department of Healthof Health

A servile and captive mainstream mediaA servile and captive mainstream media

The lack of a social movement and consciousness to defend The lack of a social movement and consciousness to defend the public sector; demand accountabilitythe public sector; demand accountability

FearFear

So the point is ....

We know what works; what ingredients are requiredWe know what works; what ingredients are required

We have enough evidenceWe have enough evidence

The goal of universal and equitable health systems The goal of universal and equitable health systems is a political struggleis a political struggle

We need to be clear about what we are up againstWe need to be clear about what we are up against

{{

Factors undermining the PHC ApproachFactors undermining the PHC Approach

Political Economy

Health sector reform

Commercialisation and segmentation

Selective health care

Biomedicalisation

Government and bureaucratic

failure

Donor and international programmes

Inequity Inefficiency

Fragmentation, verticalisation and disintegration of

health care systems

Impoverished households

User fees

Lack of community and

public accountability

Economic Inequality

Impoverishment of public sector health

care systems

Inadequate domestic public

revenue

Making the case: Health systems are social and political institutionsMaking the case: Health systems are social and political institutions

Language and concepts: Public – Private Dichotomy Language and concepts: Public – Private Dichotomy

PublicPublic monitoring of health systems monitoring of health systems

Tax and FinancingTax and Financing

Following the moneyFollowing the money

Four thoughtsFour thoughts

Not just a machine for the delivery of clinical services and Not just a machine for the delivery of clinical services and public health programmes .......public health programmes .......

They shape patterns of social and economic inequalityThey shape patterns of social and economic inequality

They shape the experience of poverty and exclusionThey shape the experience of poverty and exclusion

They can define the experience of being powerless and poorThey can define the experience of being powerless and poor

Inequity in access to health care is one of the most potent expressions Inequity in access to health care is one of the most potent expressions of social injustice of social injustice

Medical impoverishment and medical insecurityMedical impoverishment and medical insecurity

1. Health systems are social and political 1. Health systems are social and political institutionsinstitutions

A vehicle /platform for community empowerment and participatory democracyA vehicle /platform for community empowerment and participatory democracy

Active participants, not passive recipients of selective health careActive participants, not passive recipients of selective health care Citizens, not consumersCitizens, not consumers

Shape the experience of fundamental life events of birth and deathShape the experience of fundamental life events of birth and death

A space in society which is not governed by the dictates of the market, commercialisation and the pursuit of wealth and profitA space in society which is not governed by the dictates of the market, commercialisation and the pursuit of wealth and profit

where social solidarity is prioritisedwhere social solidarity is prioritised

1. Health systems are social and political institutions

CommercialisationCommercialisation

Public-Public PartnershipsPublic-Public Partnerships

CommunitisationCommunitisation

2. Language and concepts: Public-Private 2. Language and concepts: Public-Private DichotomyDichotomy

3. Public monitoring of health systems3. Public monitoring of health systemsFinancingFinancing

Level of tax revenue to be Level of tax revenue to be at least at least 20% of GDP 20% of GDP

Public sector health expenditure (government and donor finance) to be Public sector health expenditure (government and donor finance) to be at least at least 5% 5% of GDP of GDP

Public sector health expenditure (government and donor finance) to be Public sector health expenditure (government and donor finance) to be at least 7at least 75% 5% of Total Health Expenditureof Total Health Expenditure

Government expenditure on health to be at least 15% of total government Government expenditure on health to be at least 15% of total government expenditureexpenditure

Direct out-of-pocket payments less than 20% of total health care expenditure Direct out-of-pocket payments less than 20% of total health care expenditure

Expenditure on district health services (up to and including Level 1 hospital services) Expenditure on district health services (up to and including Level 1 hospital services) to be at least 50% of total public health expenditure, of which half on primary level to be at least 50% of total public health expenditure, of which half on primary level health carehealth care

Ratio of total expenditure on district health services in the highest spending district Ratio of total expenditure on district health services in the highest spending district to lowest spending district < 1.5to lowest spending district < 1.5

3. Public monitoring of health systems3. Public monitoring of health systems

Inequities in access and consumptionInequities in access and consumption

Denial of careDenial of care

IncomesIncomes Excessive profiteeringExcessive profiteering Conflicts of interestConflicts of interest

4. Tax4. Tax

Make it a key public health issue of the next ten yearsMake it a key public health issue of the next ten years

for effective health systemsfor effective health systems

But linked to other struggles for health, development But linked to other struggles for health, development and equity and equity

ThankyouThankyou