Broad coalitions make a difference
(gesproken woord geldt)
Ladies and gentlemen, distinguished guests,
It is a great pleasure and honour to be with you.
When I became a Minister for Development Cooperation in 2007
my first trip was a shocking one: I went to Mozambique where I lived in the beginning of the 1990’s. Mozambique had made tremendous progress since the end of the gruesome Civil War when I worked in Maputo. Mozambique is currently seen as a good example of post-conflict reconstruction. Peace, jobs, economic development are making great progress. But when I came to Nampula province in the North I was shocked. The health care system was still in disarray. No medicine, not even for malaria. Mozambique was a good and a tragic example of so many women dying when giving birth.
I made one thing sure: this would be an area of my fullest attention and priorities.
I am therefore very pleased to be with you today, and to have the opportunity to exchange views with you on Healthcare Systems in Africa, the important theme of this conference. I find the conference's sub-heading – Mobilising the private sector to develop a sustainable healthcare economy in Africa – particularly appealing. Because I am convinced that sustainable development in Africa will be difficult to achieve without public-private partnerships. At the same time, we must continue to hold government authorities responsible for ensuring that people have access to decent, affordable care services. That is why I would go a step further and say that broad coalitions are what make the difference.
But before I discuss this subject in more depth, I would like to take a look at the bigger picture first.
the bigger picture
This conference on health insurance is taking place in extraordinary times. The past few weeks have been dominated by the financial crisis, with its enormous, direct impact on banks and insurers. More than ever before, people feel the need for certainties to cushion the shocks – at both world and micro-level. There is a great risk that the weakest shoulders will bear the heaviest burden. In our globalising world, financial services and products are subject to too little regulation. The usual oversight agencies – governments, the IMF and the World Bank, for instance – have been unable to control the crisis. Recent events have led to reflection and action to equip them to fulfil their role as overseer more adequately. Like the ongoing food and fuel crises, the financial crisis will hit the poor in Africa disproportionately hard. They are the most vulnerable group in crisis situations. And this is happening just when we thought that we were on the right track towards growth and development. It reflects also the inequality in the world: the Wall Street bonuses in the last year equal the total development aid to Africa. It would be wonderful if we gave the same attention to the health crisis as we do to the financial crisis. It reflects the inequality in the world: the amount for bonusses on Wall Street last year was higher that the total aid for Africa.
On a smaller note, in a recent letter to parliament, I discussed the development of the financial sector in developing countries. I advocated investing not only in micro-credits, but also in savings and insurance instruments that would make the poor and small businesses less vulnerable. This is no quick fix. Here too, it is very important that oversight agencies know the ins and outs of the products offered by formal and informal financial institutions. That lesson has been brought home once again by the current credit crisis.
Fortunately, the financial sector in developing countries is in much better condition than it was ten years ago. But there are signs that even in the least developed countries with very few ties to the western financial sector, private capital flows are quickly drying up. That is why development banks like FMO and IFC are needed. Precisely in times like these when there is a new counter cyclical role for the public sector and development cooperation – and I thank Kees Storm for saying that, they continue working in difficult markets, and supporting innovative instruments like the Investment Fund for Health in Africa. In the next two years, I plan to spend 140 million euros on measures to strengthen the financial sector, including the insurance branch, in developing countries. In this way, we can continue to deliver innovative funding mechanisms for health care when it is so needed.
Also for another reason this is a special moment because we are now at the halfway stage towards the MDG target date. I was in New York exactly a month ago, where 190 world leaders gathered to take a critical look at the progress we have made towards achieving the MDGs. The conclusion was that we have made some progress, but that we still have a long way to go.
current health situation
What is the worldwide picture from the viewpoint of health? For the first time, there have been some visible, positive results. 2007 saw the very first drop in deaths from AIDS-related diseases. This is a milestone to be proud of. It was achieved through improved access to medicines for treatment. What is more, there were fewer new HIV infections in several countries.
There was also some good news on the subject of infant mortality rates: these are falling all over the world, thanks to more widespread vaccination programmes and impressive achievements in the very effective fight against malaria.
Unfortunately, the news isn’t all good. We have not yet succeeded in achieving a permanent reduction in maternal mortality rates. High neonatal mortality is still the main cause of infant deaths. A daily tragedy we see in many villages in Africa. Action needs to be taken, urgently as this calls the world to shame.
The Netherlands has long given priority to MDGs 3, 4 and 5 and sexual and reproductive health and rights. In New York we made an extra commitment of almost 60 million euros to prevent maternal mortality by improving antenatal care and making contraceptives more widely accessible.
Though much remains to be done, we should not ignore our successes. They are the result of our joint efforts. They show that development aid helps. And I will always defend that position.
But let me play devil’s advocate, and say that much of what we have achieved can be described as the low-hanging fruit: short-term improvements. We have handed out mosquito nets and supplied new medicines against malaria, developed together with developing countries. We have introduced affordable medicines against AIDS. We have also launched vaccination campaigns to prevent child mortality and built new clinics. These are excellent initiatives; initiatives we need and must continue, because many areas have not yet benefited, as I discovered during my recent visit to Mozambique.
But we also have to understand that where we have failed to achieve results we are confronted with problems that are more difficult to resolve. Problems that call for structural change, and require a long-term strategy. We are talking here about a lack of political commitment and a lack of accountability to the users of care services. And about matters such as behaviour changes and institutional problems in the healthcare sector.
In areas where health systems are weak, often through inadequate funding, maternal mortality is extremely high, and sexual and reproductive health and rights are poor. Women’s rights and their position of power also tend to be underdeveloped. Homosexuals are isolated and taboos are developed by politicians and powerbrokers.
action needed
What can we do about this? In any event, we mustn't be afraid to tackle problems head on. I am trying to make a personal contribution in various forums by raising controversial issues with our development partners, and underscoring our shared responsibility, for example for sexual and reproductive rights and the stigmatisation of vulnerable groups in our approach to HIV/AIDS.
These are crucial ingredients for today’s theme. How do we achieve a sustainable healthcare economy in Africa, and, equally important, how do we mobilise the private sector to contribute?
more funding
First, we need more funds to strengthen health systems. For years there has been underinvestment in the sector. At the moment, public expenditure on health care in Sub-Saharan Africa is between five to fifteen dollars per capita per year. At levels like that, we cannot expect much to be achieved. Governments in Africa will have to put their priorities right.
It is not surprising that most expenditure on health care is therefore out of pocket, impacting more heavily on the poor than on the more prosperous. It is evident that without a clear, comprehensive and predictable national financing plan for health systems, there will be no progress towards a system that can deliver preventive and curative care.
How do we achieve this? First, - as I said - developing countries must give health more priority. African governments must be held to account for their commitment to the Abuja agreement to spend 15% of national budgets on health. They need to invest in salaries and healthcare personnel. The Health Workers Retention Scheme pioneered by the Netherlands in Zambia shows that this approach has a positive effect on the availability of medical staff in rural areas. But money alone will not solve the problems. We need to ensure that funds are used as effectively and efficiently as possible.
quality of health care
The quality of health care is the central issue. It has received too little attention in the past decades. Those who are fortunate enough to receive care are often confronted with inadequate diagnoses, oversubscription, non-availability of drugs, very long waiting times and, sometimes, inappropriate behaviour on the part of staff in healthcare institutions. Investing in health care means investing in mechanisms and incentives that promote the quality of care. And quality of care is an important incentive for increasing people’s willingness to pay for it.
changing role of governments
Ensuring good health care services is, and will continue to be, the mandate and responsibility first and foremost of the government. Let me make that quite clear. The State is responsible for guaranteeing access to health care, and for quality control and providing the financial and regulatory framework. At the same time, there is a general consensus that to achieve the MDGs the efforts and capacities of every player will be needed. Enlarging the part of (what is so nicely called) non-state actors – meaning everyone else - requires an adequate system of incentives and regulation. This calls for decisions both within the State and elsewhere. Government authorities have a legitimate role in negotiating and – in some cases – enforcing these decisions. But only when they listen to the people. Authorities in many countries are seeking ways of playing this new role. I believe it is the task of donors and financial institutions to assist governments in this.
countries’ roles
Let me start by defining the Governments’ role.
Developing countries are recognizing the need to reform the system of healthcare financing. More and more countries are cautiously exploring alternative systems, as well as social protection systems.
Let me mention a few. Other guests may wish to discuss this subject later in much more depth and with much more expertise.
• Let me start with Ghana. I had the pleasure yesterday to speak to your president, who’s visiting the Netherlands. Your country has made great progress with its national health insurance scheme. Approximately fifty per cent of the population have now registered, and numbers are growing.
• Mozambique is considering abolishing user fees, and a fund has been set up within the national healthcare budget for NGOs that provide healthcare services.
• Other countries are now experimenting with results-driven or performance-based financing in order to raise productivity in healthcare systems. Rwanda in particular has done some groundbreaking work in this field.
• As part of sectoral health policy, parties are concluding joint agreements on performance indicators in an effort to make healthcare services more results-driven. I refer here to the IHP+ initiative, which the Netherlands has signed. This is an agreement between donors and recipient countries which aims is to achieve closer cooperation at country level.
role of the Netherlands
What else can we do to foster this? The Netherlands are contributing to national healthcare policy in 12 countries, often through joint funding mechanisms with other donors. We are also supporting initiatives by NGOs and the private sector, on issues that are important for achieving the MDGs or that receive too little attention within the public sector, such as workplace policies and advocacy.
The Netherlands is also supporting a number of global health initiatives. I have already mentioned the IHP, but initiatives like GFATM, the Global Fund for Aids, TB and Malaria, and GAVI, the Global Alliance for Vaccination and Immunisation, strengthen cooperation between public and private actors. Next year, the Netherlands will be represented on the board of both of these initiatives.
Over the last few years there has been a particularly heated ideological debate on health systems versus HIV/AIDS. But a growing number of countries have managed to use targeted funding to achieve both disease-specific outcomes and broader systems benefits by investing in key areas such as human resources and infrastructure. Ethiopia and Rwanda are two countries that come to mind. We should learn from these experiences and work towards a pragmatic solution. We simply cannot afford to compete for scarce resources. I think the enthusiasm of the AIDS Movement can counter the negative aspects of Vertical Funds and contribute to the development of health systems.
the importance of HIF
What more can we do? As you will have expected, the answer to this questions brings me to the HIF.
For me, the Health Insurance Fund is a good example of a broad coalition between public and private parties. I believe that the HIF can provide important answers to the questions and challenges I mentioned earlier.
Last year, the Dutch government and private parties signed the Millennium Agreements, joining forces to achieve the MDGs. In Dutch we call these agreements ‘Schokland akkoorden’. Let me explain what I mean by that. On 30 June 2007, representatives of hundreds of enterprises and organisations met with ministers, state secretaries, celebrities and members of the public on the former island of Schokland in the North East of the Netherlands. There, they signed the Millennium Agreements of Schokland, committing themselves to achieving the MDGs.
They did so in the conviction that the MDGs can only be achieved by entering into new partnerships, between government, the business community, NGOs and individual citizens, and by making a joint effort.
Under the Pact, more than a thousand individual agreements have been signed, and another 36 have been concluded between enterprises, knowledge institutes, trade unions and other organisations. HIF, PharmAccess International and the Investment Fund for Health in Africa signed one of these agreements. They committed themselves to improving healthcare services in Africa. I am convinced that new players like the HIF can bring great added value to healthcare systems.
innovative
The HIF targets private institutions to meet a public objective. I think it is an innovative concept, that has quite rightly received considerable attention, in the media and among experts. I am proud of that, because our ministry was involved in designing the fund and had the honour to work with inspiring people.
Fortunately, the HIF does not stand entirely alone. It was set up in response to increasingly louder calls at international level for a new approach. Various reports, conferences and evaluations point out that change is needed. The WB/IFC report on the business of health in Africa is one example. It focuses on identifying new and additional avenues through cooperation with the private sector, including the introduction of private insurance systems. During a conference at Wilton Park in April this year, which was mainly attended by the private sector, various examples were given of higher effectiveness when the private sector delivered public services. The results were sometimes incredible. Lesotho’s central public hospital, which is now run by a private party, can now handle five times more patients.
As you probably know, the HIF grew from a desire to develop a healthcare system to which, ultimately, everyone would contribute what they could afford. Setting up such a system is a long-term process. It is not going to happen overnight. In the Netherlands we also built our health system slowly – starting in the 18th and 19th centuries when the guilds set up a sort of insurance system of their own. In Africa there are insurance companies, but they are practically all geared to the higher income groups, and to the formal sector. In many countries, a national insurance system has emerged that is mainly intended for civil servants. People working in the informal sector are excluded, but they are often the most vulnerable.
Insurance is a way of making people less vulnerable, by making their costs predictable and manageable. In this way, you can prevent them falling into the poverty trap. Studies show that 150 million people a year are caught in the poverty trap through illness and medical bills. It is even worse if people don't see a doctor when they need to, because they are afraid the bill will be too high.
better health care = economic development
Better health care, with an insurance that guarantees it, doesn’t only save lives, but also ensures that people can continue working and caring for their children and families. So good health contributes to economic development. Investing in health pays dividends, or as Kees Storm just pointed out, health is wealth.
Health is wealth: with these words, Professor Elebute, Chairman of Hygeia Nigeria, hit the nail on the head. I am delighted that Professor Elebute could be here today at this conference to share his experiences with us. We can benefit from these lessons learned from practice in Nigeria in launching new HIF projects.
the future
In Nigeria, the HIF is up and running. The HIF is soon to be launched in Tanzania, where we hope it will contribute to the further development of the insurance sector.
Pharm Access is involved as the main technical adviser in a number of other insurance programmes. Namibia, for example, has now developed its own model, a pool for insurers through which high-risk individuals, such as people living with HIV, can take out insurance. Pharm Access is also involved as technical adviser in Ghana's national system. Not long ago, HIF and Pharm Access representatives went to Liberia at the request of the World Bank to see how the health system could be rehabilitated with the assistance of insurances. And in Rwanda, Heineken and Pharm Access International have set up a small HIF for farmers producing for Heineken. Contact has been established with other countries and programmes with the aim of sharing knowledge and experience and developing an effective model.
criticism of HIF
Of course, the HIF has its critics. One frequently heard comment is that the HIF only benefits the better-off. Granted, it doesn’t target only the poorest of the poor, but people with just enough money to make a contribution. But many of these people are working in the informal sector, and would have had few opportunities to insure themselves before the HIF was set up. They would generally have found themselves in financial difficulties after a hospital visit, or they would simply have gone untreated, with all the attendant consequences. Thanks to the insurance, illness does not automatically lead to poverty. Resources from the fund can also be used for investments that lead to more capacity – more doctors, more hospital beds and more efficient healthcare services – to the benefit of the poor.
We need to ensure that the pilot project is sustainable. It is crucial that other parties, like government authorities and donors, help subsidise the premiums, so that larger groups of people can be insured, including the poorest of the poor. In Nigeria, this is going better than we had expected. Participation of companies and other employers from the formal sector is also essential. As far as I am concerned, the HIF should not only be of relevance to the people who benefit directly from it. It could also contribute to the development of the insurance sector in the broader sense. I call on the HIF to take on this challenge.
Another risk is that people will be cautious about taking out insurance, because they are not used to paying premiums for services they might not actually need, and which, in the past, were not always available. That is why it is essential not only to set up an insurance system, but to work on quality and quantity at the same time. Experience in Nigeria has shown that this process takes time, but that prospects are good.
I am aware that the HIF’s innovative approach is also a source of criticism, from donors, within governments and also in my own parliament. Innovation is seldom greeted with immediate consensus, so that it is no easy task to slot it into the donor harmonisation agenda. It is an important challenge indeed to combine harmonisation with innovation. Within governments in developing countries themselves, the interests of the various ministries are not always the same. However, involving the private sector in providing care also presents opportunities for a new approach, and an appropriate division of roles between the private and public sectors. Adequate regulation, quality standards and oversight are government tasks. I should like to call for more attention to be paid to these factors, including in our support for the health sector.
role of Dutch private sector
I am very pleased that the top people from the Dutch insurance sector are making such an effort to make this pilot a success. This should be continued. Without your support we will not advance. It is crucial that, additional to the HIF, money should be invested by the private sector in improving the quality of both care providers and the distribution of medicines. And that is happening through the Investment Fund for Health in Africa. The strength of the HIF is in combining insurance with care providers. Here too, Dutch parties have had the courage to invest in this new sector.
For the future, I see opportunities to strengthen private sector involvement through knowledge exchanges and training courses for, for example, staff of Dutch insurance companies and local counterparts. I know that you are working on this. It would be wonderful to see whether Dutch parties would be willing to invest on a larger scale in insurers in developing countries, together with FMO, for instance. Rabobank is an inspiring example. These are the broad coalitions I mentioned at the start of my speech. They really make a difference.
role of national governments and donors
As I pointed out earlier, it takes time to bring about improvements. It costs a lot of time and money, government and tax money. This is the first time that the Dutch government, as a donor, has invested money – a total of 100 million euros up to 2012 – in such a large-scale pilot project as the HIF, providing support for private insurance. This amount of money has to lead to success.
But the Dutch government and the HIF cannot do it alone. Cooperation and a support base are needed. The governments of developing countries have an important role to play. Governments also need leadership and courage to involve the private for-profit sector in service provision.
The HIF has already loosened tongues – and much of what is said is positive. I am pleased to hear that in putting the business of health in Africa into operation the IFC and the World Bank are planning to set up a unit to advise ministries of finance and health on integrating the private sector and private insurances into their long-term policies. As I said, the Netherlands welcomes initiatives like this involving the private sector and private insurance.
At the same time, we have to acknowledge that experience with alternative healthcare funding systems, such as insurance systems, in low-income countries is still very new. What is more, the situation varies from country to country. I would therefore call for a more open debate on funding health care in these countries, with more room for different positions and for experiment. It is important for a practice to develop with evidence of various alternatives at its core, and for us to embark on a joint learning process. I hope that we can take the first steps within the EU framework. I applaud the French Presidency's initiative to give priority to health financing and social protection.
I come back to Nampula, Mozambique. While Mozambique is making considerable investments in health care at macro-level, the hospitals in Nampula province, for example, lack the most basic facilities, such as mosquito nets to protect people from malaria.
This doesn’t mean that there has been no progress, but that investments are not trickling down fast enough to the level where the poorest people living in rural areas would benefit directly from them.
Ladies and gentlemen,
I dream of good, affordable, health care for everyone. Health care that ensures that maternal and infant mortality rates drop radically. Health care that guarantees that people – wherever in the world they were born – can get the medicines and vaccinations they need.
I am convinced that insurance is a good, transparent means of getting people the care they need. With their insurance passes, they have the right to decent care, and can hold their care providers, insurers, and governments responsible for that. I hope that this initiative will spread, and that in the future, people living in many countries in Africa will get the care to which they are entitled.
Thank you.