The need for equity in the health system was at the heart of the presentation of Davidson R. Gwatkin, Consultant with the World Bank, which asked the questions: "why is there a need for reform?" and "how can it be met?" Mr. Gwatkin, from the USA, revealed how household surveys and compilation of data for the World Bank's World Development Report in 2004 showed that health access is barely reaching the poor at either the national or international level. In order to deal with this problem of equity, Mr. Gwatkin described six approaches: the focus on poor geographic areas; the indirect measurement of the recipient's economic status; payments to poor service recipients; mass campaigns; contracting with NGOs and the active involvement of the poor. In answering critics of a fit-for-all approach, he identified five steps toward identifying a suitable pro-poor service delivery approach for a particular setting. These are: the study of other works; adaptation of already applied approaches; the need for field experimentation; the monitoring of results and the need to adjust whenever necessary. In sum, he said that not all needs might be reached, but with will it is possible to raise the percentage of needs being met.
Another issue was highlighted by Germán Velásquez, Department of Technical Cooperation for Essential Drugs and Traditional Medicine (HTP/TCM), WHO, Geneva, Switzerland, who discussed the access or lack of access to essential drugs. Illustrating the significance of this issue, figures show that more than one third of the world's population does not have enough access to vital drugs and consequently 10.3 million children under five years of age die each year. This problem is not only a 'Third World' concern since industrialized countries might face difficulties with sustainability where there is low economic growth and rising drug prices.
Mr. Velasquez presented a brief historical overview of World Health Organization (WHO) policy over the last decade, which led to four World Health Assembly (WHA) resolutions giving a mandate to the WHO. Overall, Mr. Velasquez emphasized the need to focus on essential drugs in primary health care and reliable health systems, and the need for technical tools to expand their access. The key challenge for the future is the legal trade debate, within which ethics and human rights are fundamental: the core issue of world access to health.
A third issue related to the scaling up of financing for global access to health was addressed by Mr. Marc Hofstetter from the Global Alliance for Vaccines and Immunization (GAVI), Geneva, Switzerland. He began by mentioning how the immunization gap identified a few years ago, which was projected to be closed by 2015, will not be eliminated by that date under the present circumstances. The international community is therefore not on track. One of the challenges to providing more vaccines is finance, which needs to be tackled urgently. The GAVI has come up with two innovative financing techniques:
1) International Finance Facility for Immunization (IFFI) which has the support of a number of donors whose commitments will be leveraged in the bond market. This substantial amount will be distributed to countries on a 50/50 basis for health systems and vaccines. The advantage of the technique is that it allows for long term planning and sustainability for countries in acquiring their vaccines. The financial cost is relatively low compared to the return.
2) Advanced Market Commitments (AMC's). Small unpredictable markets lead to under-investment in vaccines by manufacturers. AMC's are designed to provide adequate returns for manufacturers. A two stage pricing mechanism gives the manufacturer his production cost (paid for by the purchaser) plus a subsidy to cover his profit (provided by sponsors). After a period of time the manufacturers of the vaccine have committed to sell the vaccines at a very low price. The scheme will be proposed to the G7 Finance Ministers.
The final speaker, Didier Pittet, from the Infection Control Programme at the University Hospital of Geneva, Switzerland raised the issue of access to safe healthcare. Every year numerous people become infected with multi-resistant micro-organisms during their stay in hospital. Gaps in safety exist not only between countries but also within a country, both in developed and developing countries. Although different causes exist (such as blood safety; injection and immunization safety and safe surgical procedures) the most simple and avoidable cause is not tackled: insufficient hand washing. Hand hygiene is a primary measure to prevent health care associated diseases. One major reason for the absence of hygiene is time and system constraints. Hand-washing with soap and water takes time. In order to improve the situation he advised the use of alcohol rubbed into the hands at the point of service. Moreover, ongoing education and motivation of caregivers is necessary to keep standards at the necessary level.
The core message of this session was that global access to health still needs to overcome inequity. Inequity is not only due to social determinants. Stakeholders should take up their responsibilities in promoting equity and create conditions in which to achieve it.
Equity in health, which includes equity of access to essential drugs, can only be achieved through reformation of the health sector. This long-term goal can only be achieved by scaling up financing of health systems and changing government policies in developing countries.
