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Health policies must focus on the needs of individuals
by Dr Mercedes Tatay
Médecins Sans Frontières
Dec. 2017
Between 12 and 15 December, the Universal Health Coverage Forum 2017 will take place in Tokyo, Japan. This major gathering, co-hosted by the Government of Japan, the World Bank, the World Health Organisation (WHO) and others, aims to “stimulate global and country level progress towards Universal Health Coverage (UHC)”, which the world has committed to reach by 2030 as part of the Sustainable Development Goals (SDGs). Dr Mercedes Tatay, MSF’s International Medical Secretary, will attend the forum and provide a critical reality check based on Médecins Sans Frontières’ experience on the ground. On her way to the forum, Dr Tatay answered a few questions.
Why is MSF attending this meeting?
Through the direct provision of free medical assistance to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare in more than 60 countries, MSF teams see first-hand the barriers that some of the poorest and most discriminated communities face to access healthcare. We want to bring this direct experience to inform international policymakers of their dreadful consequences on people’s health and lives and to advocate for non-discrimination and unhindered access to healthcare for all.
As doctors and health professionals, we want to remind delegates at the forum that all their discussions should be about people. Making sure individuals have access to basic healthcare should come before any considerations for return on investment, security or national interest. It’s about saving lives and reducing the impact of diseases.
In MSF we are convinced that universal health coverage can only be achieved by removing persistent barriers like unaffordable drugs and charges for healthcare (known as ‘user fees’).
For many people it seems normal to pay for medical care: why is MSF fighting against that?
Vulnerable groups, such as pregnant women, those forced from their homes, patients with HIV, tuberculosis, malaria and non-communicable diseases in places like the Central African Republic, Democratic Republic of Congo and Guinea, still need to pay for care. So do refugees in Jordan. This is extremely damaging; evidence proves that making people pay for medical care prevents them from receiving it. Making people pay also reduces the quality of health services, increases financial distress and delays the detection of epidemics and outbreaks; instead of coming to health centres, people get ill or die unreported in their communities.
In these places, MSF doctors and nurses see terrible stories of people who went without basic treatment because of the cost, or were told to buy their own drugs because hospitals had run out. We’ve also documented stories of patients being held captive in health facilities until they can pay for medical care they have received.
This situation persists, despite progress made in the last decade to expand healthcare for specific groups such as pregnant women, children and people with certaindiseases. Worryingly, the situation could worsen further still as policies to improve access to healthcare are being reversed in many countries, including Afghanistan, Mozambique, and Malawi.
International health funding is being reduced and there is mounting pressure on countries to start paying for their own health services, often at an unrealistic pace, regardless of their actual capacity to do so. This leaves an inevitable funding gap, which some countries look to patients to fill, even though charging these ‘user fees’ is something that institutions and organisations involved in global health have committed to eliminating.
International health funding cuts now also threaten Sierra Leone’s Free Health Care Initiative for women and children. This is quite cynical for a country that lost 10 per cent of its health workforce to Ebola during the 2014-15 outbreak and where access to quality health care remains a major issue.
These examples and others are developed in a new report released by MSF: “Taxing the ill: How user fees are blocking Universal Health Coverage”
Is free care an affordable option?
We realise that providing quality care comes at a cost. But when exclusion of care is so clearly linked to patient fees, it is unfair and detrimental to ask them to foot the bill. MSF has had a policy of providing care without charging patients since 2004 (before this date, there were certain places where we charged patients a nominal fee) and this has led to significant increases in the number of people using the services we offer, increasing access and having a positive impact on people’s health.
We also know that revenue generated from asking patients to pay is marginal, so people are kept away from healthcare with no real added value for the system. The end result is an increased lack of trust towards health practitioners and a high number of diseases and deaths that could have been prevented. This is obviously counterproductive and unacceptable on so many levels.
‘User fees’ also create or reinforce inefficiencies; they keep patients away from health workers, who are left sitting idle, and leave drugs to expire when they should be used to treat patients.
Affordable solutions do exist. After introducing free care to a district hospital in Lesotho in 2014, the number of women coming to deliver their baby safely increased by 49 per cent in just 18 months. We calculated that making delivery care free across the country would add just 1 USD per inhabitant per year to the country’s health budget. This would include not only free delivery care but also provide women with transport and accommodation prior to giving birth.
Although we agree that countries with health access problems need to do all they can to respond to the health needs of their own people, what is expected from them in terms of financing is often unrealistic. They need to be able to fund health infrastructure and provide decent and regular salaries to their health staff, allowing them to do their critical work. This will also help to avoid underpaid health workers charging patients for drugs and consultations to compensate for their low wages.
To put it simply, there’s a need for financial resources to remove financial barriers for patients. To make that possible, we also ask donor and policy-making agencies like the World Bank, WHO and other global health initiatives to uphold their commitments to support free health care with funding and technical advice. We want them to leave no doubt about the detrimental effects of asking patients to pay. We don’t expect them to tolerate the growth of ‘user fees’, as we see looming in several countries.
The globally agreed goal of Universal Health Coverage (UHC) by 2030 will remain a distant dream if people are deprived from even the most basic care because they cannot afford it.
Beyond the issue of patients paying for healthcare, are there other issues that MSF will bring to the forum?
Health system strengthening is high on the UHC agenda. We want to see a prioritisation of decent pay for frontline workers and guarantees that patients will not face stock outs of essential drugs. These are essential conditions for the provision of quality health services and which will ultimately make a difference to people who are ill or vulnerable.
We will also express our concerns about the lack of readiness to respond to large-scale epidemics. This is particularly true in places where health systems are weak and where access to health care is already an issue.
Such countries are hesitant to declare epidemics as it may lead to trade or tourism restrictions and create additional economic strains. Without guarantees that the declaration of an epidemic will come with decisive support to respond, lives will continue to be lost unnecessarily. In addition, proper emergency response and surveillance capacity needs to be built within health systems.
We are also concerned that the Global Health Security narrative – which relates to the prevention and management of major infectious disease outbreaks – is too often based on fear, relegating affected populations into a threat, rather than people in acute need. Making all of us healthier depends on making each of us healthier – it’s not one group at the expense of the other. The health sector should maintain leadership and muster the political power to respond to epidemics.
Looking back at the Ebola outbreak of 2014-2015, one could wonder if certain countries put more efforts into protecting themselves over providing meaningful support to the people of West Africa who were facing the real medical emergency.
As MSF works in many conflict settings, we will also carry a specific message on the protection of the medical mission in these places. In today’s conflicts such as Afghanistan, South Sudan, Syria and Yemen, health structures are increasingly considered as commodities that can be looted or attacked as part of military strategies with impunity. They also escape strong condemnation.
We desperately need all parties involved in conflicts to unambiguously commit to respecting health structures, allowing and supporting the delivery of care to all sick and wounded people, including combatants and those designated as enemies or terrorists.

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20 years after the historic treaty on landmines, we cannot afford to lose momentum
by Peter Maurer
International Committee of the Red Cross
21 Dec. 2017
220,000 children threatened by mines and other explosive weapons in eastern Ukraine - UNICEF
Eastern Ukraine is now one of the most mine-contaminated places on earth, endangering 220,000 children who live, play and go to and from school in areas littered with landmines, unexploded ordnance and other deadly explosive remnants of war, UNICEF warned today.
"It is unacceptable that places where children could safely play less than four years ago are now riddled with deadly explosives," said UNICEF Ukraine Representative Giovanna Barberis. "All parties to the conflict must immediately end the use of these gruesome weapons that have contaminated communities and put children in constant danger of injury and death."
Available data from January to November this year show on average one conflict-related child casualty a week along eastern Ukraine''s contact line - a 500 kilometre strip of land that divides government and non-government controlled areas and where fighting is most severe.
Landmines, explosive remnants of war (ERW) and unexploded ordnance (UXO) were the leading cause of these child casualties, accounting for approximately two-thirds of all recorded injuries and deaths during the period. Leaving many children with lifelong disabilities.
In most cases, the child casualties occurred when children picked up explosives such as hand grenades and fuses. One child, a 14-year-old boy named Aleksey, recently told UNICEF, "I picked it up and I think I pressed something, and it just exploded. There was a lot of blood and the fingers were hanging. I was so scared that I started shaking. I almost collapsed."
Landmines and other explosive weapons also put vital infrastructure such as water, electricity and gas facilities at risk. Earlier this month, a UXO was found at the Donetsk Filter Station which provides water to nearly 350,000 people. Demining groups have been called to the filter station 13 times this year.
UNICEF and partners have reached more than half a million children in eastern Ukraine with Mine Risk Education sessions since 2015. These sessions teach children how to protect themselves from mines, UXO and ERW. UNICEF has also provided psychosocial support to 270,000 children affected by the ongoing conflict.
In 2017, only 46 per cent of UNICEF''s emergency appeal to support children and their families in eastern Ukraine was funded. Child protection activities including mine risk education and providing psychosocial support for children had an even larger funding gap of 73 per cent.
UNICEF is calling for all sides of the conflict to recommit to the ceasefire signed in Minsk and allow mine clearance activities and recovery efforts to begin.
Dec. 2017
ICRC President''s address to the Meeting of States Parties, Anti-Personnel Mine Ban Convention.
Twenty years ago anti-personnel mines were a regular and lethal feature of armed conflicts across the world. Combatant or civilian: these weapons struck indiscriminately.
At that time a staggering 20,000 people, the vast majority civilians, were killed or mutilated by anti-personnel mines every year.
Amid a swell of global condemnation, one of my predecessors was incensed by the impact of these weapons, which he described as ''abominable and... a destructive technology out of control''.
He called on the international community to uphold a ''moral, political and legal obligation and to put an end to the mass destruction in slow motion'' caused by mines.
The global crisis of human suffering required a global solution: the Anti-Personnel Mine Ban Convention. It was the result of a remarkable partnership between States, civil society and international organisations, including the ICRC and the broader International Red Cross Red Crescent Movement. And importantly, the treaty would not have been possible without the determined advocacy of landmine survivors themselves.
The treaty brought unprecedented attention to the plight of the people and communities affected by landmines and other unexploded ordnance. And it was extraordinary in its approach:
It was the first time that a weapon in widespread use had been prohibited due to its appalling human, economic and social costs;
It was the first treaty of international humanitarian law to prohibit not only the use of a weapon, but also its production, stockpiling and transfer... and to require its elimination; and - It also demanded that States provide assistance for victims, and mobilize resources to clear contaminated land.
And let us not forget that this progress was possible also, because of the support of many members of armed forces who understood early on the political and moral unacceptability of a continued use of these weapons.
Today, the goal of a world-free of antipersonnel mines is within reach. Broad adherence to the treaty has seen: The use of anti-personnel mines diminish; More than 53 million anti-personnel mines destroyed; Thousands of square kilometres of mined lands cleared; and - The legal trade virtually disappear. And as a result, countless numbers of lives have been saved.
However, on this anniversary, I fear that we have reached a dangerous crossroads.
Landmine victims may not be on the front pages of the newspapers as they were in the 1980s and 1990s but today mine casualties are rising sharply in some countries. Anti-personnel mines, in particular improvised mines, are taking a heavy toll on civilians in places including in Afghanistan, Iraq, Myanmar, Nigeria, Syria, Ukraine and Yemen. Shockingly children account for 42% of all civilian casualties.
Today, 35 States remain outside of the Convention, and many of these have huge stockpiles, totalling an estimated 45 million units. I do not wish to think of the casualties if these weapons were ever used.
I encourage all States, who are not yet part of the Convention, to continuously reassess the military need for anti-personnel mines in light of their severe human costs. Those who have joined in the last 20 years wait impatiently for the Mine Ban Convention to become truly global treaty.
The ICRC sees all too often in our hospitals and rehabilitation centres the injuries caused by mine blasts. We work to fit victims of explosions with prostheses for missing limbs and to help them live a full life. We help where we can, but frankly no one should have to have to suffer the lifelong trauma, pain, social and economic disadvantage that mine victims face. And we engage and will continue to do so in Mine Risk Education to prevent accidents and to bring the number of victims down even before all the mines are cleared.
In 2014, States Parties expressed a determination to meet key goals of the Convention by 2025, that is, in just seven short years. There must be greater urgency and determination to ensure that these goals become a reality. Focused effort must be directed to make certain that by 2025:
All stockpiles still held by States Parties are destroyed; Contaminated land is cleared within the Convention''s deadlines and the 2025 commitments; and - Victims can access the care, rehabilitation and socio-economic services they need to participate in their societies on an equal basis to others.
Of critical importance is the commitment of funds to achieve these actions. I urge all State Parties able to do so to provide resources and exert influence where necessary. By 2025 the ICRC is advocating that affected States Parties are landmine free and with no new victims on their territories.
No affected State Party should be left behind in this process. The international community must again use its collective determination, harness this remarkable partnership to overcome these challenges. As the 2025 deadline approaches, there is not a moment to waste.
The Anti-Personnel Mine Ban Convention is a shining example of how the international community can collectively respond to widespread suffering caused by the use of indiscriminate weapons.
Since its adoption, new treaties have followed to protect civilians from explosive remnants of war and to prohibit cluster munitions. Short of developing new law, ensuring respect for existing IHL rules is critical to protect civilians from the indiscriminate effects of weapons.
In conflicts around the world the ICRC sees what happens when weapons are used without regard for civilian life, when the internationally agreed constraints of distinction, proportionality and precaution are disregarded.
As we are witnessing in the ongoing armed conflicts in Syria, Yemen, Iraq, Libya, Somalia and Ukraine for example, the use of heavy explosive weapons in densely populated areas is having disastrous consequences for civilians.
For example when a city is shelled the consequences are not limited to death, physical injury, but also include damage to critical infrastructure such as water and electrical facilities, hospitals and health services.
Given the enormous costs for civilians, the ICRC calls on all parties to avoid the use of explosive weapons with wide-area effect in populated areas, due to the significant likelihood of indiscriminate effects. All States should be in a position to apply this as a matter of good practice, to ensure better protection for civilians in urban warfare.
Today I call on the international community to harness the goodwill and common action that led to the adoption of the Anti-personnel Mine Ban Convention. I call on you to maintain vigilance against all weapons that cruelly and indifferently attack the innocent and for humanitarian law and the wisdom of humanity to prevail.
* ICRC President Peter Maurer''s address:

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