Position Paper ANRSP on access to health care

Preambule

The Asian Network on the Right to Social Protection (ANRSP) is composed out of various trade unions and social movements in Asia, supported by the Belgian organisation World Solidarity (WSM). All these social movements strive in their own way for social protection, job creation and decent work, which are essential for sustainable and inclusive development. The ANRSP focuses on promoting the right to social protection on a regional, continental and global level, as part of the efforts for Decent Wages and Work worldwide. It is currently discussing this position paper regarding the access to health in Asia. Health care is only one element to ensure the general health condition of a population, with other social determinants which are often linked to the lack of a dignified life. This includes unsafe working conditions, inadequate housing, lack of income etc., which the network also tackles.

The ANRSP demands that health care should cover all, and special efforts made to include workers and populations currently not covered by social security systems, such as the young, garment workers, construction workers, health workers, migrant workers and people living below the poverty threshold. Work is urgently needed to make the right to health a reality for all.

Social protection and disasters illustration: Nepal's earthquake

After the earthquakes hitting Nepal in April and May 2015, which killed 9.000 people, injured 25.000 and hundreds of thousands of people were made homeless. Over 4,4 billion USD was promised in aid for the relief and reconstruction, but implementation by the Nepali government was too slow and failed to materialize: only a year and a half after the earthquake did some 75% of over 1.000 affected households receive a 450€ grant to rebuild their houses. Should there have been systems of social security in place, with registered beneficiaries, this aid could have come much sooner and could have saved many lives.

Gonoshasthaya Kendra (GK) medical Team helped Nepal earthquake victims

By Mr. Rammani Pokharel, NTUC

After learning about the devastation, Gonoshasthaya Kendra (GK) from Bangladesh came to Nepal and linked up with another WSM partner, Nepal Trade Union Congress (NTUC) to offer medical help. A team of one doctor and five medical students, some with Nepali origins but studying at GK, came by truck, bringing medicines and supplies. NTUC facilitated the hosting of two medical camps in and around Laliptur for construction, commercial and carpet workers. The remaining medication and material was handed over to the Bangladesh Embassy in Kathmandu. During their mission, 971 (among which 398 male and 573 female) patients were treated. Head of the team, Dr. Halimour was glad he didn’t have to perform any major amputations. He remembered treating a little girl whose mother had died while shielding her from falling debris and who was still very afraid.

Social protection, disaster risk reduction and climate change

Many organisations work with the vulnerable groups to increase their resilience to withstand shocks, improve their ability to reduce/manage risk and to reduce their poverty, which is a risk factor in itself. Why do we consider these groups are more vulnerable:
• The poor/socially marginalised often live in places more exposed to hazard risks
• They have less ability to cope with and recover from disaster impacts
• They have less voice and influence
• They depend on informal safety nets that become stretched after major shocks
• They are adversely affected by delays in, or lack of access to, relief/early recovery responses

Social protection approaches have been successfully used to:
• Reduce disaster and climate-related impacts
• Protect from total destitution
• Enhance abilities to reduce existing disaster impact risks and adapt to new/increased risks as a result of climate change

What is meant by Universal Health Coverage?

The WHO defines Universal Health Coverage as “access to health services, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. UHC is a “concept that is deeply rooted in its 1946 Constitution, which declares health to be a fundamental human right”.

UHC is designed as a three-dimensional system that progressively moves towards:
i) the coverage of the entire population by a package of services,
ii) inclusion of an increasing range of services, and
iii) a rising share of pooled funds as the main source of funding for healthcare, and thereby a decrease in co-payments.

This model is gaining in popularity and the current discourse on UHC is dominating the majority of inter- national discussions on health care. UHC is presented as the response to urgent needs in health in low and medium income countries. Some enthusiastic backers have named it the “third great transition” in health, by changing the way in which services and the organisation of systems are financed.

The privatisation of health in the Philippines

Today, 8 people out of 10 in the Philippines report never having had a medical check-up or physical examination in their life. 28% of all Filipino women have no skilled birth attendance care. Due to poverty, 6 out of 10 people die in the Philippines without ever having seen a doctor. Health care utilisation rates in the Philippines show worse access to health than the regional average. The primary reason is a lack of financial means. Free health services are very limited and the poorest cannot afford treatment or medicine.

A long history of privatization...
Health care in the Philippines became increasingly inaccessible for the poor majority since the policy of privatization which started in the 1970s during the Marcos era. Philippine foreign debt became insurmountable and the IMF-World Bank imposed the Structural Adjustment Program, leading to privatizing state assets for more income. This practice was followed by succeeding presidents and governments, like in 2000 by President Joseph Estrada under the Health Sector Reform Agenda (HSRA) and Executive Order 366. This program was to provide fiscal autonomy and expanding the coverage of the national health insurance, also called Philhealth. The policy included the corporatization of public hospitals and integration of the four Government Owned and Controlled Corporation (GOCC) Hospitals to cater to medical tourism. The aim of the government is to relegate its responsibility of providing people’s right to health to the private sector. What happened is that since people have to pay for their treatment, rates increased so much higher that in the GOCC hospitals specializing on the heart, kidney, lung and children, health services are no longer free. In fact, a kidney transplants cost more than one million PHP or 19.000€.
This privatization policies continued under different names from President Benigno Aquino III under the “Philippine Development Plan” (2011-2016) which strengthened implementation of the National Insurance Policy or Philhealth, public-private partnership (PPP) and the millennium development goals in health. Health Services in public hospitals became a commercial product and Philhealth covers only 9% to 11% of total costs, except for 23 selected cases only. According to the Department of Health data, 54% of the total cost of health services is out-of-pocket.

Fight against privatization
Under PPP, Philippine Orthopedic Center, the only public bone specialization in the Philippines was a pilot project. The government plan was to bid the modernization of the hospital to private funds of 5.6 Billion PHP or 106 million € with a concession of 25 years private operation of the hospital, with an option to renew for another 25 years of private operation. The ugly side of this business is that only 70 beds out of the 700 bed capacity will be allocated to service patients, and not indigent patients. The private investor, Megawide, also has an option to terminate the health workers.

Public or private?

 Who is best placed to deliver quality health care services if we want to achieve accessible, good quality health care for all? Public or private providers? There is no easy answer to this question, firstly because defining what is private and what is public is complex. Private providers are heterogeneous, consisting of formal for-profit entities such as independent hospitals, individual care workers working on a self-employed basis, informal entities that may include unlicensed providers, and not-for-profit providers, such as community and social enterprises, non-governmental organisations, civil society etc. In many countries, individual health workers, like doctors, are often self-employed, but hospitals and health centres are mostly (or all) in the hands of the government or run by social, not for profit, organisations. Elsewhere, health services are provided by a mix of for profit and not for profit enterprises and institution, subsidised by the government or otherwise. So, we can’t make a simple distinction between public and private, but we can say that there are some clear structural reasons why for-profit health care and competition do not promote efficiency or quality, and impede universal and equitable access to health care.

Access to medication

Access to medicines at an affordable price is a key factor in addressing these challenges in developing countries, where a large part of the spending on health is allocated to pharmaceutical products. Rules on commerce and free trade agreements (FTAs) have a direct impact on the prices of medicines as we will go on to see, and can lead to the economic and financial interests of pharmaceutical giants taking precedence, at the expense of the right to health care.

Illustration: India
India, once nicknamed the “pharmacy of the developing world” played and continues to play a crucial role in falling medicine prices in the developing world. The country has opted for a balanced intellectual property system which protects public health and only grants patents where there is genuine innovation. This allowed India’s generic pharmaceutical industry to supply 20% of generic medicines in the world and 80% of all medicines used to treat HIV/Aids64. The price of first generation antiretrovirals went from 10,000 dollars per patient per year to 100 dollars thanks to competition from India65 and allowed over 5 million patients to benefit from this treatment.

AREDS’ health interventions for adolescent girls

Adolescent age is a critical stage in the life cycle of girls in particular. Until they reach this stage, their life revolves around their family. Once they reach adolescent age, they tend to extend their relationship outside their family circle to include friendships with the peer members of their own sex or opposite sex and other adults like respected teachers or tutors. They face conflicts between their personal aspirations and social pressure.  It is at this stage, they become rebellious, ignoring social stigmas and taboos.


Therefore, it is important to show them the right path, as they are at a stage which is full of inexplicable and new things. Hence, the AREDS Health Team sensitizes the adolescent girls on the physiological and psychological changes that they experience during this stage and answers their fear and doubts.

Physical development
Adolescence extends from puberty to adulthood. Puberty marks different biological changes in girls. For many of them, the natural phenomenon puberty is mysterious. The physiological growth in most of the adolescents reaches its zenith by mid-adolescence. At this stage, they will be close to their adults by height and weight and now, they will be physically capable of conceiving and producing babies. Many girls find the changes in their physique enigmatic. AREDS Health Team help the adolescent girls understand this natural phenomenon through trainings and personal interactions.

Statistic on health: Strength in numbers

It is currently estimated that 1.3 billion people do not have access to affordable and good quality health care in the world while 56% of the global rural population has no health coverage.
One in three households in South East Asia borrows money or sells assets to pay for health. The WHO suggests that health care expenditure is considered catastrophic whenever it is higher or equal to 40% of the non-subsistence income of a household, in other words, the income available once the basic needs have been covered. Each year, approximately 44 million households, i.e. over 150 million people in the world have to deal with catastrophic expenditure and approximately 25 million homes or over 100 million individuals find themselves in a situation of poverty on account of having to pay for these services.

Access to health is also about people in it: the Health workforce

Access to health isn't simply about infrastructure, hospitals and medication, it is also about the nurses, doctors and other health practitioners that are a part of it. A key advice for the WHO Workforce 2030 and the actors working on it would be to move away from focusing on the instrumentalist, utilitarian role of the health workforce in economic growth and labour markets, and rather emphasise the intrinsic value of a competent workforce in improving health outcomes and reducing health inequalities.


The migration of health professionals is at the junction of the right to mobility, right to health and the right to decent work. It is about finding an acceptable compromise between the rights and obligations of migrant workers, employers and governments based on sound research findings

Illustration: Thailand
Thailand has four decades of experience with strategies for solving the inequitable distribution of human resources for health (HRH) between urban and rural areas. There are four key components in these strategies: (1) Development of rural health infrastructure. (2) Educational strategies including rural recruitment, training and hometown placement. (3) Professional-replacement strategies such as training in basic medical care capacities for rural health personnel. (4) Financial strategies such as a compulsory public service, incentives for working in rural services, payback for tuition fees by rural public work, reform of the health care financing system to Universal Coverage Health Scheme.

Quotes on access to health

Health protection is central to decent work and must be a reality for all.
Guy Ryder, Director-General, ILO

Universal health coverage is one of the most powerful social equalizers among all policy options.
Dr Margaret Chan, Director-General, World Health Organization

Where is the right to health enshrined?

Health is a fundamental human right that is indispensable for the exercise of other human rights. It is enshrined in several instruments, like the Universal Declaration of Human Rights of 1948 (Art.25) and in the International Covenant on Economic, Social and Cultural Rights of 1966.

For the World Health Organisation (WHO), the right to health contains both freedoms and rights: the right to control one’s own health and one’s own body (for example sexual and reproductive rights) and the right to physical integrity (for example the right not to be subject to torture and not to be subject to any medical experimentation without consent); the right to access a health protection system which guarantees equal possibilities to all to enjoy the best possible state of health.
The key to health is a functional health care system i.e. one that is available, accessible and acceptable to all without any form of discrimination and of high quality.

According to ILO Recommendation 202 on social protection floors, the minimum requirements in the area of social protection must include:
• basic income security (especially in cases of sickness, unemployment, maternity or disability).
• access to a nationally defined set of goods and services, constituting essential health care and including maternity care, that meets the following criteria:

• Availability: the facilities, goods, public health programmes and health care services are functional and in sufficient supply.
• Accessibility: the facilities, goods and health care services are accessible to all without any form of discrimination. Accessibility is made up of four interdependent dimensions: non-discrimination, physical accessibility, economic accessibility or being sufficiently affordable, accessibility of information.
• Acceptability: all facilities, goods and services in the domain of health care must respect medical and appropriate ethics from a cultural point of view, in other words, should respect the culture of individuals, minorities, people and communities, be receptive to the specific requirements linked to sex and stages of life and must be designed so as to respect confidentiality and improve people’s state of health.
• Quality: as well as having to be acceptable from a cultural point of view, installations, goods and services in the domain of health care must also be scientifically and medically appropriate and of a high quality.

W-Connect on Health: editorial

On the 12th of December, the International Day for Universal Health Coverage, the Asia Network on Right to Social Protection presents this thematic edition of W-Connect on Access to Health. A high quality health care system is one of the pillars of social protection and is a necessary condition for a global population with better health. This third 2016 W-Connect newsletter starts by detailing what access to health means and refers to some of the relevant legal international instruments. While many of the World Solidarity partners in Asia focus on labour rights, some work on the access to health, like the two in charge of the editorial oversight of this edition: Gonoshasthaya Kendra (GK) in Bangladesh and the Alliance of Health Workers (AHW) in the Philippines. Women and adolescents have their specific health needs, as demonstrated by the article from AREDS in India. The 1st of October is also the International Day for older people and 2016 is the year to take a Stand Against Ageism, so we look at what came out of the exchanges between GK in Bangladesh and OKRA in Belgium regarding elderly. In another article, Social Protection is also linked to disaster risk reduction and climate change. It is calculated that we could’ve built up health systems in West Africa at one third of the Ebola response cost.
Building on the dossier “Health, a commodity” from the Belgian campaign Social Protection for All, this edition also lists the areas in which demands are being formulated by the WSM supported Asia Network on the Right to Social Protection.

Bruno Deceukelier, WSM Asia Coordinator 

Dr Kadir, GK Bangladesh

Angela, AHW Philippines

Stop the Killings!

Pensioenen, veilige werkomgevingen, toegankelijke gezondheidszorg, moederschapsverlof, kortom: Sociale Bescherming. In vele landen in het Zuiden is dit geen vanzelfsprekendheid. Activisten en sociale organisaties die opkomen voor de uitbouw van een inclusief systeem van Sociale Bescherming zijn vaak het slachtoffer van repressie. Om hun strijd in de kijker te plaatsen, organiseert het campagneplatform Stop The Killings dit jaar samen met de campagne Sociale Bescherming een actiedag op 8 december in Brussel aan Brussel-Centraal!

Neem deel aan de actie & stuur een brief naar de betrokken ambassades hier!
Participez à l'action & envoyez une lettre aux ambassades concernées ici!

Les pensions, un environnement de travail sûr, des soins de santé accessibles, le congé de maternité, bref: la Protection Sociale. Dans de nombreux pays du Sud, elle est loin d'être une évidence. Les activistes et organisations sociales qui se battent pour mettre en place un système inclusif de Protection Sociale sont souvent victimes de répression.

Afin de mettre en lumière leur lutte, la plate-forme de campagne Stop The Killings organise cette année, en collaboration avec la campagne Protection Sociale, une journée d'action le 8 décembre.