The right to health and the sustainability of healthcare: why a new global health aid paradigm is needed

Abstract

The underlying question for this thesis is the discussion about paradigms for financing healthcare in developing countries, with the intention to achieve the Millenium Development Goals (MDGs). More specifically, can the health-related MDGs be achieved within the conventional health development paradigm? The experience of the introduction of AIDS treatment in Mozambique suggests that it cannot. Given an estimated decrease of average life expectancy from 42 years to 27 years, due to AIDS, the provision of basic AIDS treatment, extending life expectancy for five to 10 years, was crucial, not only to achieve the AIDS-related MDG target, but also the other MDGs. However, providing AIDS treatment did not fit within the conventional health development paradigm. In 2001, the government expenditure on health was US$6 per person per year in Mozambique. About 38% of that budget came from foreign assistance, and Mozambique was under pressure from the World Bank and the IMF to reduce its dependency on foreign assistance. The conventional health development paradigm, aiming for sustainability at the national level – i.e. current health expenditure must ultimately be financed with domestic resources – did not allow much space for increasing foreign assistance. There was no way to fit AIDS treatment at a cost of US$350 per person per year, for the medicines only, in this equation. Therefore the Government of Mozambique decided to introduce AIDS treatment as a medical relief operation, using a very different paradigm. This decision was the starting point of this thesis: to question the conventional health development approach to the sustainability of healthcare in developing countries. The general question was broken down into the following propositions: • The conventional health development paradigm is unable to achieve the health MDGs; • A human rights approach supports an alternative global health aid paradigm; • An alternative global health aid paradigm is feasible. To examine the first proposition, a theoretical scenario was elaborated for increasing the health expenditure level in Mozambique to US$38 per person per year in 2015 – the year in which most MDGs are supposed to be achieved – as recommended by the 300 Commission on Macroeconomics and Health. This ‘best case scenario’ that suggests that Mozambique could sustain this expenditure level with domestic resources by the year 2030 or 2040, was then tested on its most likely problems: 1. US$38 per person per year might not be sufficient; 2. The expected economic growth and mobilisation of domestic resources might not be realistic; 3. The expected foreign assistance might not be made available. If this ‘best case scenario’ passed the first test with some difficulties, it failed on the second and on the third test. A health expenditure level of US$38 per person per year might be sufficient. But the continued economic growth at the same pace is not realistic; growth is likely to be slower. Most importantly, donors declare that they are unable to make commitments for longer than four to five years, and even if they were, the IMF’s application of the ‘fiscal space’ concept as described in its working papers – which is based on the potential of future domestic resource mobilisation – does not allow the use of such levels of foreign assistance, because of the alleged unpredictability of foreign assistance. Although the IMF does not describe in detail how it applies fiscal space constraints, the building up of foreign exchange reserves with foreign assistance indicates a level of ‘excess’ foreign assistance: foreign assistance that remains unspent. These tests were then repeated, more roughly, for several other countries with high adult HIV prevalence. The gaps between the present health expenditure level and the needed health expenditure level are significant in most of these countries; economic growth is likely to slow down; and therefore, as long as the conventional health development paradigm aims for foreign assistance to be replaced with domestic resources within a foreseeable future, foreign assistance will not fill the gap. The second proposition was examined through a review of recent human rights law literature of the concept of ‘core content’ and the obligation to provide assistance. The core content of a human right is defined through a search of ‘the limits of the limits’: it defines the absolute minimum level, without which a human right no longer has a meaning. The core content of the right to health includes access to medicines and services for the most common diseases and health problems. In countries with high HIV prevalence, it includes AIDS treatment. Countries that are not able to achieve the Health MDGs are unable to realise the core content of the right to health. But one cannot oblige a state to realise the core content of a human right if it does not have sufficient resources. This is the point where the obligation to provide assistance reveals its essence: when ‘states in need of assistance’ need help from ‘states in a position to assist’ to realise the core content of human rights, foreign assistance is not discretionary expenditure, it is a matter of meeting legal obligations. This sheds a different light on the aim of sustainability. For several countries, donors should not expect domestic resources to replace foreign assistance; donors should provide foreign assistance as long as developing countries need it to realise the core content of human rights. Therefore, sustainability should be considered at an international level: sustained foreign assistance should support domestic resources as long as needed. The third proposition follows from the second proposition. If ‘states in a position to assist’ have a collective obligation or duty to respond to a collective entitlement or right of ‘states in need of assistance’, and if a new global health aid paradigm were based on those collective duties and collective entitlements, would it be feasible? Can it be organised? The examination of this proposition is based on the example of the Global Fund to fight AIDS, Tuberculosis and Malaria. This Global Fund has already abandoned the conventional approach to sustainability. If its mandate were broadened to support all interventions against the most common diseases or health problems – if its mandate were to lift health budgets of developing countries up to US$38 per person per year – it would require a lot more resources. This Global Health Fund would have to demand from developing countries to mobilise and allocate the equivalent of 3% of their Gross Domestic Product (GDP) to the health sector. It would have to demand from developed countries the equivalent of 1% of what they are currently spending on domestic health expenditure, or the equivalent of 0.07% of their GDP. This Global Health Fund would create a new global health aid paradigm. From the conventional health development paradigm, it would borrow the aim of technical sustainability at national level. From the medical relief paradigm, it would borrow the aim of financial sustainability at an international level, rather than at national level. The general conclusion is that an alternative global health aid paradigm is both needed and feasible. However, if the existing Global Fund were used to become a Global Health Fund, this shift would have to happen gradually, and broadening the mandate of the Global Fund would have to be accompanied with increased contributions to the Global Fund.