As the U.N. General Assembly gets started this month, one cause in particular seems to be under the spotlight; staggering global maternal mortality rates that have gone seemingly unnoticed, until now.Since the WHO’s Commission of Social Determinants of Health presented their results on the social factors of global healthcare inequity in August, a growing number of voices have brought maternal mortality rates to the center of attention. Both the UN’s funds for children, UNICEF, and women, UNIFEM, have released reports on maternal healthcare and mortality barely a week before the General Assembly is set to have a special meeting regarding U.N. Millennium Development Goals. Others have also called for greater support of the goals including Oxfam and various political figures, with one European Member of Parliament calling for more “political will” to deal with the problem.
Just in case you’re wondering, Millennium Development Goal (MDG) number 5 is to improve maternal health by 2015, aiming to reduce the maternal mortality ratio by three quarters and to make universal access to reproductive care possible. One would think this quite a lofty goal, everything considered, or is it?
Alongside the reports’ and news stories’ depictions of broken systems, horror stories and exhortations to action, there was also a measured amount of good news, and some of it coming from completely unexpected places. Africa and Southeast Asia, unsurprisingly, still labor under some of the worse mortality rates and accessibility to reproductive care, but, there are vast disparities between countries in the two areas.
Take Sri Lanka, where the maternal mortality rate has dropped from 155 deaths per 1,000 live births to only 1.4 per 1,000 in the last 60 years or so. Due to the government’s determination to achieve the MDGs, they now have a strong healthcare system where any individual Sri Lankan has access to primary care within 5 km and 97% of all births in the country are attended by a skilled professional, typically one of the Public Health Midwives. This stands in stark contrast with other nations in the vicinity. For example, in India only 41% of births are delivered by a professional and in 2005 an estimated 117,000 maternal deaths in India made up around 22% of the world wide total.
Africa is much the same story, some countries like the 6 nations in the Gulf Cooperation Council, Syria and Jordan which have professional care during birth at least 90% of the time (100% in Jordan according to the figures), while, on the flip side, Sudan and Yemen have maternal mortality ratios that at least double the regional average of 210, triple that in Djibouti, and an astounding rate of 2,037 deaths per 100,000 births in Southern Sudan where maternal healthcare is almost non-existent due to ongoing conflict.
One of the oddest things about the stories in recent articles is that it seems that the maternal health situation of the country has little or nothing to do with the economic prosperity of the nation. Case in point, despite being from a much richer country, South African women are 3 times more likely to die giving birth than Cuban women.
So if it isn’t an issue of economic inequity between countries (if you needed more proof of this, the United States of America has a higher infant mortality rate than Cuba) what is it?
Judging by the relative success stories of Sri Lanka, Cuba and the like, accessibility of care and trained professionals are the ground work for a sturdy system. Oxfam, which has recently been training midwives in Northern Africa, has made some recommendations based upon their work experiences and WHO data. It pretty much mirrors the advice given in the Commission of Social Determinants of Health study, in that you need to need to have trained professionals who are readily accessible and affordable if you really want to bring down maternal mortality rates, or any other mortality rates really. Considering that most people across the world go through public health systems for child birth, and that national governments would be in the best position to assess, roll out, and fund such a reformative healthcare system, it really only makes sense to pour our efforts and funding into public systems.
So what repercussions does this snowballing notion of affordable, basic healthcare have for the insurance world? Short-term, barring a critical mass of governments deciding to pick up this challenge, there is probably not going to be any change in your insurance premiums, and healthcare in various parts of the world will probably cost the same. However, long-term, I hope this has far reaching implications. If every mother in Southeast Asia or Africa had access to cheap professional maternal care, pregnancy would become a time for celebration instead of worry, both infant and maternal mortality rates would drop and communities would be richer for it. A world in which quality basic healthcare is available to just about anyone at affordable prices, regardless of location, would be a fundamentally different one. For one, if the affordability and accessibility of healthcare was a primary focus, for-profit healthcare systems may be difficult to maintain, which, in itself would have enormous ramifications for the insurance industry.
Either way, unless governments can find enough backbone to drastically alter the current global healthcare situation, poorly organized, under-funded, inaccessible and unaffordable healthcare will continue to be the death of people all over the world.
AIG: The letters on Manchester United’s football shirts, on buildings dominating skylines in major cities worldwide, and in the past week, on the front covers of the business pages, if not the entire paper.
A company with a long and storied history, AIG had posted total losses of $18.5 billion over the last three quarters, before being bailed out last Tuesday (Sep. 17th) with a loan of up to $85 billion dollars from the Federal Reserve. This was designed to effectively secure the company’s important economic position worldwide, and in exchange the Fed would get around an 80% stake in the company as a kind of security, and 12% interest on the loan.
What happened? Why did AIG suddenly need so much cash to avoid going under? Should they have been lent it?
This was not the start of the story, and it is far from being the end of it. It began, like so many of today’s economic worries, with the sub-prime mortgage crisis. To enable them to continue making yet more bad loans, banks in the US and Europe insured some of the loans with insurers such as AIG. As the largest insurance company in the US, AIG also insured many other deals made by banks or large companies, so as the economy went into recession, it lost a great deal of money, resulting in a situation where the company was very illiquid and could therefore fail. This would have had a huge knock-on effect on banks and companies not just in the US but worldwide, meaning that the Fed felt justified in bailing out AIG (whereas it left Lehman Brothers Holdings Inc., who announced last week that they would file for chapter 11 bankruptcy protection, to their own devices).
The government was fresh from shoring up Freddie Mac and Fannie Mae, (the Federal Home Loan Mortgage Corporation and the Federal National Mortgage Association) with guarantees and the prospect of a ‘conservatorship’, and back in March, the Fed backed the purchase of the stricken Bear Stearns by JP Morgan. The Federal Reserve has as a result been rather seriously depleted.
The US is not the only country that is having to take action of this kind. The UK government ‘nationalized’ the Northern Rock bank, another victim of the sub-prime crisis in the US, back in February. Some slack is taken up by companies taking over other companies, e.g. Bank of America buying Merrill Lynch, Lloyds TSB merging with HBOS, or Barclays buying up some of Lehman Brothers’ core assets- which many would argue is how the market should work. At present, however, the US looks likely to spend yet more money to try and solve a problem that, although originating in the country, affects the world’s economy as a whole. It is unlikely that other countries will be able to continue to sit back and watch the US deal with the problem alone for very long.
The AIG bail-out looks to be only the start of an almost unprecedented level of government spending to assist private business. Lawmakers are still hashing out the details of a plan to use taxpayers’ money to buy the bad debts of financial institutions with significant operations in the US. The plan would put about $700 billion dollars spending money into the hands of Treasury Secretary Henry M. Paulson Jr. who would theoretically decide how to spend it in a way that balances the interests of the taxpayer – minimizing immediate costs but ensuring liquidity in the financial markets in the long term. This is a very controversial plan, and has even been called a kind of undemocratic socialism. Paulson in fact used to be head of Goldman Sachs, which along with Morgan Stanley just announced a change of legal status to enable it to take advantage of the proposal. Many politicians, including McCain and Obama, have expressed concern and are demanding greater oversight, but as it is hard even for financial experts to put a value on bad loans of the type that caused the crisis, it is unclear how this would work.
How does this affect my insurance?
Essentially, it shouldn’t. AIG has been more or less guaranteed by the US government. In any case, most private policies are with subsidiaries of AIG that are separately regulated and financially sound. Also, in the US, policies are usually guaranteed to some extent by state run associations should an insurer fail.
However, as anyone who has seen Mary Poppins should know, customers are not necessarily rational beings, as has been demonstrated in the past week, particularly in Asia. The offices of AIG subsidiaries in Singapore, Taiwan and Hong Kong have been mobbed by people wanting to either enquire about the safety of their policies or cancel them altogether. In Hong Kong some 1,700 people surrendered their policies with AIA on Tuesday. This was despite assurances, including from the monetary authority of Singapore, that the subsidiaries of AIG are still sound. AIA in Singapore has announced a policy conservation program to enable those who surrendered their policies in panic last week to reinstate them. While some unscrupous agents might be tempted to advise people to switch insurers to get a new commission, the best course of action is probably to wait and see.
Effects on the presidential election race, and the candidates’ healthcare proposals:
Both candidates are going to have to make significant changes to their policy proposals in the face of the economic realities which will likely face the next administration. They also both have to come up with a stance on this new proposal. So far their responses have been fairly similar, with both calling for more oversight. Both McCain and Joe Biden were supporters of the deregulation in the late 90s that arguably made the sub-prime crisis possible, which may mean Obama has the edge in not having to backtrack too much. What is certain is that there is going to be a lot less money available for expensive programs such as Medicare or Medicaid, and any candidate promising tax-cuts will have serious credibility issues. The future of health insurance and healthcare financing in America is now very unclear.
The World Health Organization (WHO) was recently presented with the results of a 3 year study by an advisory body named the Commission of Social Determinants of Health (CSDH). The commission was comprised of policy makers, academics, heads of state and health ministers from around the world including two former directors of the U.S. Center for Disease Control, a former president of Chile, an economics Nobel laureate and a former prime minister of Mozambique. The study focused on what, outside of medical knowledge and technology, affects our health in the largest ways and what we can reasonably hope to do about it.
Health data from across the world was gathered and studied by the advisory body to afford us a more thorough knowledge of global health inequities, described by the WHO as “unfair, unjust and avoidable causes of ill health”. The study confirmed prior reports which highlighted inequities between countries but also showed that even within a country’s own borders there is a gradient of health. Those living in abject poverty were more likely to live shorter, sicklier lives than poor segments of the population, while the poor were, in turn, worse off than those of average incomes and so on.
The social determinants looked at by the commission covered almost every aspect about a person’s situation which could be changed by altering political or economic resources. Topics included education, the environment, availability of basic amenities, economic circumstances, and gender equality, as well as political and cultural factors.
The report is replete with factoids and statistics relating to the difference in life expectancy and mortality rates of diverse sectors of the population both between and within countries. For instance, not only will a girl born in Japan live on average, 42 years longer than a girl born in the country of Lesotho, Africa, but an indigenous Australian man will live, on average, 17 years shorter than their non-indigenous counterparts. However, the commissioners stress that the wealth of a country is not a determining factor in the level of health inequity. Countries such as Cuba, Costa Rica, China, Sri Lanka and others have done a surprisingly good job of maintaining good levels of health in their populations despite their relatively low per-capita income. The U.S. leads the charge in the other direction with a larger gap in health equity than many other wealthy nations. A former U.S. Surgeon General says this may be due to both to the high level of diversity in the American population and the fact that the U.S. does not invest much into improving the social gradient in terms of trying to ensure that the entire population has access to a basic level of healthcare.
The general conclusions and broad recommendations that the commission drew from their data and research had precious little to do with improving medical care and technology. In fact, the advice was to not rely on medical advances as these would most likely further increase social health inequity. Instead, we should focus on improving the day to day conditions of where people are born, live, work and age. Clean drinking water needs to be provided and substantial investments need to be made in education, public transport, working environments and housing. The panel of experts also says that the problem of inequitable distribution of wealth, power and resources needs to be tackled on every level; global, national and local.
The commission strongly advises that further study and data gathering needs to be done on health inequity and its social determinants so we may further understand the problems and that any move forward needs to be fully examined and assessed to determine what impact it will have on social health inequity. Focus needs to be on managing health resources more efficiently, with the commissioners in fairly unanimous agreement that reallocating health investments to focus on social determinants will save money and peoples lives over time. This of course means that policy makers and many workers both inside and outside of the health industry will need to be trained to asses these impacts.
The question is will this bring about a brave new world of healthcare? Will other countries reorient their healthcare systems to promote socially equitable healthcare, let’s take the U.S. for instance. With staggering numbers of uninsured, underinsured and people in medical debt in the U.S., will the growing movement for a government-backed single-payer system come to pass? Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the UK have already drawn inspiration from the WHO commission’s findings, declaring that they are already developing policies which are committed to improving the social factors of health equity. With a growing public concern in the U.S. over the cost of healthcare and many Americans being nigh uninsurable under the current for-profit system, does America have the political wherewithal to enact such broad sweeping changes or will they continue to run with what they have? Maybe we’ll get a sign of the future in November.