In Sickness and In Wealth

In the time it takes you to read the title of this blog, three more people in the world will have fallen below the poverty line. Not because of anything to do with global economics but simply because they've had to pay for medical care. What a terrible choice: Do you use your last few cents to buy medicine for your child or to put food on the table? But this is the choice facing many families in poor countries on a daily basis.

In the countries where Oxfam works we hear stories like this all too often -- from the father in Ghana who lost his wife and unborn child because they couldn't afford to go to hospital when she was in labor, to the mother in Georgia, recovering from cancer, who buys medication one day and bread to feed her daughter the next, whilst she herself goes hungry.

It's no wonder then that finding a way to reach Universal Health Coverage (UHC) -- the goal of all citizens being able to get the health services they need without suffering financial hardship -- has risen to the top of the global health agenda. This momentum is welcome, exciting and challenging.

UHC could transform the lives of millions of people by bringing life-saving health care to those who need it most. But some donors and developing country governments have been promoting health insurance schemes as the solution to reaching UHC. Oxfam believes this is misguided. We are worried that in some cases this is actually increasing inequality, because these insurance schemes prioritize those who are already better-off and leave the poorest and most marginalized people -- especially women -- behind.

For those African countries that have introduced health insurance, low levels of enrollment are proving to be a major and recurring challenge. Ghana's National Health Insurance Scheme has been labelled a success even though it excludes 64 percent of the population -- most of whom are simply too poor to pay. Ten years after being introduced in Tanzania, only 17 percent of the population has health insurance there. Similarly Kenya's National Hospital Insurance Fund covers only 18 percent of Kenyans, despite the being established nearly 50 years ago.

Rather than trying to extract contributions from poor people, Oxfam argues that governments and donors should focus on financing that genuinely works for all. This preoccupation with health insurance has left the crucial question of how to generate more tax revenues for health largely unexplored. This blind spot should be urgently addressed.

On the flip side, a growing number of developing countries including Brazil, Malaysia, Mexico and Thailand have built home-grown health financing systems that are actually working well. Rather than trying to collect insurance premiums from those who are too poor to pay, they have prioritized general government spending for health.

In fact, the only low-income countries to have achieved universal and equitable health coverage have done it by relying mainly on tax, rather than insurance.

Donors need to recognise that health insurance schemes do not tend to reach poor people and are typically bad for the health of poor countries. Developing country governments should focus instead on home-grown financing solutions that make health care available to all, regardless of their financial status.

Let's put an end to the terrible choice for those who are too poor to pay for health care.