Universal Coverage and Equity in Integrated Health Systems David McCoy People’s Health Assembly, Cape Town

Public FinancePublic BudgetsPublic Provision Private FinancePrivate Insurance Private provision The National Health Service (NHS)

Public FinancePrivate 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 profits  A government that lied, bribed and threatened  Politicians (and doctors) with conflicts of interest  Neoliberal occupation of mainstream political parties  Neoliberal and managerialist occupation of the Department of Health  A servile and captive mainstream media  The lack of a social movement and consciousness to defend the public sector; demand accountability  Fear

So the point is....  We know what works; what ingredients are required  We have enough evidence  The goal of universal and equitable health systems is a political struggle  We need to be clear about what we are up against

{ Factors 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 institutions  Language and concepts: Public – Private Dichotomy  Public monitoring of health systems  Tax and Financing  Following the money Four thoughts

Not just a machine for the delivery of clinical services and public health programmes  They shape patterns of social and economic inequality  They shape the experience of poverty and exclusion  They can define the experience of being powerless and poor  Inequity in access to health care is one of the most potent expressions of social injustice  Medical impoverishment and medical insecurity 1. Health systems are social and political institutions

A vehicle /platform for community empowerment and participatory democracy  Active participants, not passive recipients of selective health care  Citizens, not consumers Shape 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 profit  where social solidarity is prioritised 1. Health systems are social and political institutions

 Commercialisation  Public-Public Partnerships  Communitisation 2. Language and concepts: Public-Private Dichotomy

3. Public monitoring of health systems Financing  Level of tax revenue to be at least 20% of GDP  Public sector health expenditure (government and donor finance) to be at least 5% of GDP  Public sector health expenditure (government and donor finance) to be at least 75% of Total Health Expenditure  Government expenditure on health to be at least 15% of total government 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) to be at least 50% of total public health expenditure, of which half on primary level health care  Ratio of total expenditure on district health services in the highest spending district to lowest spending district < 1.5

3. Public monitoring of health systems  Inequities in access and consumption  Denial of care  Incomes  Excessive profiteering  Conflicts of interest

4. Tax  Make it a key public health issue of the next ten years  for effective health systems  But linked to other struggles for health, development and equity

Thankyou