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SECTION 1 2 3 WHAT CAN BE DONE CASE STUDY FREE HEALTHCARE IN NEPAL A group of young mothers wait with their children for a check-up at a small rural public health clinic, Makwanpur, Nepal (2010). Photo: Mads Nissen/Berlingske Beginning in 2005, the Government of Nepal dramatically improved access to healthcare by removing fees for primary healthcare services (including essential medicines), and by providing cash incentives for women to give birth in a health facility. In Nepal’s poorest districts the proportion of women giving birth in a health centre more than tripled from six percent to 20 percent in just four years. 460 Before the reforms, the richest 20 percent of women were six times more likely to deliver in a health facility compared to the poorest 20 percent of women. This ratio halved when charges for deliveries were removed. 461 ‘I have been a health worker for 18 years. After free maternal health services were introduced the number of patients increased dramatically. We used to see just four or five women each month for deliveries and we now see more than twenty. It used to be very expensive to come to the clinic, but now women can deliver here safely for free and they do not have to wait for their husbands to give them the money.’ Nurse Midwife, Surkhet, Nepal There have even been victories over the pharmaceutical industry’s stubborn efforts to block access to affordable medicines. In 2013, the Indian Supreme Court rejected a patent on Glivec ® /Gleevec ® , a cancer treatment developed by Novartis. Patients suffering chronic myeloid leukaemia can now take generic versions of Glivec for only $175 per month – nearly 15 times less than the $2,600 charged by Novartis and a price that should make it possible for the government to afford to treat patients. 462 Promising progress in education Since the Education For All movement and the adoption of the MDGs in 2000, the world has seen impressive progress in the number of children gaining primary education. Through increased donor support, domestic spending and debt relief, a wave of countries have been able to eliminate school fees, accelerating access to education for the poorest children. For example, in Uganda, enrolment rose by 73 percent in just one year – from 3.1 million 98
SECTION 1 2 3 WHAT CAN BE DONE to 5.3 million – following the abolition of school fees. 463 Fee abolition is critical to tackling economic inequality, and boosting opportunities for the poorest. However, the quality of the education on offer has suffered in those countries which have failed to match the increase in enrolment with adequate investments in trained teachers, facilities and materials – a situation made more difficult by faltering donor commitments and falling government budgets due to the global economic crisis. This risks reinforcing inequalities in the quality of education between the public and private sectors, and between the poorest and wealthiest children. Beyond school fee abolition, additional targeted investments are needed to provide the most marginalized children with high-quality education. These include extra funding for schools in rural and under-served areas, policies to address other financial barriers to poor children’s access to education (such as uniforms, transportation and learning materials), and more accountability for education quality through active community involvement in school management. Some countries are leading the way. For example, Brazil has championed reforms that increase access to good quality education and allocate more spending to the education of poor children, often in indigenous and black communities. 464 These reforms have helped to reduce inequality of access since the mid-1990s: the average number of years spent in school by the poorest 20 percent of children has doubled – from four years to eight years. 465 Investment in education and healthcare played a key part in Brazil’s recent success in reducing inequality. A number of East Asian countries, including South Korea, Japan and Singapore, have implemented programmes specifically designed to promote equitable learning, including investing in high-quality teachers. Even the poorest students are now learning above the minimum threshold. 466 There is solid evidence that making equity an explicit goal of education policy can lead to improved educational outcomes across the board. Public investment in healthcare and education for all citizens is a powerful tool for addressing inequality, and these examples demonstrate that change is possible, even in the face of powerful special interests. Aid can tackle inequality and political capture Taxation and domestic resource mobilization are critical to boosting public spending. For some countries, harnessing aid and investing it well, for instance into good-quality public services that citizens need and demand, has also helped to reduce poverty and inequality through supporting national public service plans and boosting public spending. In 2004, just over a quarter of the aid received by Rwanda – a country that had spent 10 years rebuilding national institutions and economic stability following the 1994 genocide – was budget support: long-term aid that can support health and education systems, as well as institution strengthening. Steady growth in budget support up to 2004 allowed the government to eliminate fees for primary and lower-secondary school education, increase spending 99
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