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Universal health coverage: Old wine in a new bottle? If so, is that so bad?

Adam Wagstaff's picture

It's easy to see how the concept of universal health coverage (UHC) became so elusive.

At the start, the idea must have seemed straightforward enough. Lots of countries "covered" only part of their population, and several were making efforts to expand coverage to "uncovered" populations. China, for example, started out on this process in 2003, trying to expand coverage to the rural population that lost coverage when the old rural cooperative medical scheme collapsed following the de-collectivization of agriculture in 1978.

It didn't take long, however, for someone to point out that in a sense everyone already has coverage. China's rural health facilities continued to receive subsidies even after 1978. Thailand already had a network of government facilities even before it launched its UC scheme. Mexican families without a social security member already had access to the network of government facilities run by the ministry of health even before the Seguro Popular scheme was launched.

Coverage was already universal. That wasn't the issue. Rather the issue was that not everyone enjoyed the same depth of coverage: people outside a "scheme" (often the less well off) were liable for higher out-of-pocket payments than those inside a "scheme" (often the better off). So what was needed was not universal coverage (which existed already) but rather "deep coverage for everyone" (or DCFE). The argument was accepted, but the acronym DCFE was horrible. Adding a D to make UDHC didn't get any support either so it was decided to stick with UHC but add a second dimension to coverage—depth.   

Soon there was another complaint. We were focusing on the financial side of coverage and ignoring the issue of what health benefits countries would get by expanding and deepening coverage. If the focus was on reducing out-of-pocket payments, might not coverage expansion initiatives be skewed against low-cost but highly effective interventions in favor of costly inpatient and pharmaceutical-based interventions with limited effectiveness? In short, shouldn't we be thinking about what is covered and not just who is covered and how deeply. There was of course some debate. There were those who accepted that publicly-financed coverage expansion initiatives needed to have an eye to the health impacts, but that wasn't the only goal of public policy: financial protection mattered too. But it was conceded that there needed to be a third dimension to UHC reflecting what is covered.

A cube is born

And so the famous WHO UHC cube was born. This helped for sure. But since the adjective "universal" captures only one of the three dimensions, and since all countries afford some coverage to everyone, the concept underlying UHC would always be hard to get across: "Well yes actually it's not so much who has coverage we're talking about so the 'universal' bit is indeed a bit misleading; it's more about the depth of people's (financial) coverage and what (services) they're covered for."

It didn't take long after the cube's birth before people started asking awkward questions about the three dimensions.

Are we talking about coverage on paper on paper (de jure) or coverage in practice (de facto). What if a country promises but doesn't actually deliver coverage? After all one of the complaints with government facilities has been that people don't always get the services they think they're entitled to. There's plenty of evidence on health worker absenteeism, drugs being unavailable, and so on.

And what of providers failing to deliver the correct care? We know many fail to make the correct diagnosis, and even when they get the correct diagnosis often fail to prescribe the right treatment. This isn't always due to ignorance. Often providers make the wrong diagnosis because they fail to do everything they know they should do.

It soon became clear that when thinking about the "service coverage" dimension of UHC, we need to look beyond what services people are entitled to. Service coverage is about people getting the care they need. We can't get at this by looking at the number of contacts with a provider.We need to look at what happens during the contact, comparing the services the person gets (or doesn't get) to what's needed. In some cases, this is straightforward. A child of a certain age requires a specific set of vaccinations, and one can verify whether they've been received. In most cases, though, establishing what's needed and what's received during the contact is much harder—if not impossible beyond a detailed case study. But if we don't try, and instead focus on what services people are entitled to or the number of contacts, we could go badly wrong.

The de jure and de facto distinction matters too for the financial coverage dimension. We need to look beyond the payments people should make on paper. Financial coverage is about what people pay in practice, and how affordable these payments are. Patients may end up paying considerably more out-of-pocket than they expect to on the basis of what's written on paper. Providers may deliberately overprescribe to make money. They may do this even more when they know a patient is in a "scheme". Or providers may deliberately switch to a more resource-intensive style of care. Paradoxically we may find that expanding coverage may lead to larger out-of-pocket payments and hence shallower coverage.

So what exactly is UHC? 

As each layer of argument has been added, UHC has thus morphed from a straightforward notion of making sure everyone has coverage to something much more complex and useful.

Yes universalism is still there. But UHC isn't about getting everyone coverage, since everyone already has it.

So what exactly is UHC? I think it means that that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result.

UHC is about equity: linking care to need, not to ability pay. UHC is also about financial protection: making sure that people's use of needed care doesn't leave their family in poverty. And UHC is about quality of care: making sure providers make the right diagnosis, and prescribe a treatment that is appropriate and affordable.

New labels aren't always bad

Are these new ideas? No. They've been around for a long time. Countries have been pursuing these goals for ages, and scholars have been studying these issues for ages. It's just that it hasn't been called UHC. UHC is indeed old wine in a new bottle. We've all been working on UHC all along; we just didn't know it!

And yes the term UHC doesn't capture the richness of the agenda we've been working on very well. There is indeed a risk that it draws people's attention toward the rather empty question of who has coverage—the dimension of UHC that gave its name, but the one that turned out to the least useful.

But if we can manage this risk, UHC may yet serve as a useful rallying cry for the goals of equity, financial protection, and quality of care. We just have to downplay the original concept and explain that despite its name UHC isn't just about giving everyone coverage. It's about ensuring that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result.

If by slapping the UHC label on the bottle, we get people more interested in the wine—even if the label is a bit misleading—that's surely a good thing. After all the wine's not a bad one. Far from it. 
 
 

Comments

Submitted by Patricio V Marquez on
Adam--Excellent blog!. Your comments are right on the mark! Indeed, we have been working all along for a long time in different regions and countries pursiuing the three dimensions of UHC as you noted: expansion of coverage, standarizing the content of services and minimizing risks associated with out-of-pocket payments, and on the elusive quality dimentsion (structure, yes it matters, processes, the new battlegroung, and outcomes, still in the future) in service provision. A little institutional memory or a simple review of the literature will confirm the above. And as you suggested, UHC can be a "rallying cry for the goals of equity, financial protection, and quality of care." So let's move on remembering the past! Well done. Patricio

Submitted by Gyorgy Fritsche on
This is a very nice blog Adam. We have indeed known for ages the problem: inequitable health systems that deliver low quality inaccessible health care to the poorest. The question for us - implementers and practitioners - is as follows. How do we move from what we know (for ages) to solutions that work in the most difficult of circumstances. Let us say: how we can we get the Nigeria’s and the DRCs to work better - soon. Can we use all we know so far to deliver in moving such health systems to deliver better? The money is there. The knowledge is there. But how can we move with our knowledge to delivering solutions that work? Solutions are available, and such solutions also are in need of being branded differently, to move into a world where UHC has become the new slogan. It is indeed old wine in a new bottle. We need people like you to help us frame this better and to help us explain to others why we do what we do.

Submitted by Paul Shaw on
While the UHC agenda may be somewhat akin to ‘old wine in a new bottle’, I think it’s also a more refined, complex wine with sharper operational prompts and more satisfying, intellectual ‘ah-ha’s’. The ultimate goal of UHC, as I see it, is to improve both health status outcomes and financial risk protection. If you want to say, ‘reduce inequalities’ in these joint goals, I can work with that too. Accordingly, UHC is not an ‘end’ but a ‘means to an end’. And progress will surely be incremental. A problem, however, is that without greater clarity on the ‘engines’ of UHC, almost anything could be construed as fitting within the UHC envelope. For example, one could argue that a politically motivated tertiary hospital offering free services in a remote rural area contributes to UHC because at least someone is likely to benefit from improved health status and/or financial risk protection. But such broad inclusiveness – and watering down – surely isn’t what the UHC agenda wants to imply. So what are the ‘engines’ of UHC, and what kinds of ‘sharper operational prompts’ do they facilitate? I submit there are two, (i) prepayment and risk pooling, and (ii) public health goods and services. As the latter ‘engine’ has been in the headlines for ages, I focus on the former, ‘prepayment and risk pooling’. My take is that getting this core engine of UHC to function (better than in the past) demands clear thinking on four sets of enabling/disabling conditions. The first set of conditions has a lot to do with fiscal space. Expanding prepayment and risk pooling requires some combination of (i) improved general tax efforts, (ii) increased share of government budget devoted to health, (iii) reducing interest payments on national debt, (iv) mobilization of SHI, CHI, PHI premiums, and (v)attracting donor subsidies to pay for the poor. This puts health financing squarely on the map as a policy lever to incrementally expand UHC. In response to this challenge, domestic governments are working hard to accomplish (i) through (iv), whereas donors have merely been fringe contributors to (v). The second set of conditions has to do with making purchasers or providers – reimbursed by prepayment and pooled funds -- perform better. They include (i) more efficient purchasing and contracting, (ii) designing cost-effective benefit packages, (iii) incentivizing providers through payments, and (iv) better targeting to poor households and the informal sector. These aim to improve capacity of both public and private providers on the supply-side to honor demand-side entitlements to benefits under the UHC banner. Donors have been quite active in this area, though their funding has been marginal, usually for pilots, M&E and research. The third set of conditions has to do with WHO-type building block inputs for health system functioning – drugs, HR, infrastructure, quality enhancement, behavior change, regulation. This category of conditions typically includes supply-side financing of inputs (not outputs) that are a necessary but not sufficient condition for achievement of UHC. Donors have been most active here with the lion’s share of domestic and donor investments unclearly aligned with strategies to scale up prepayment and risk pooling. The fourth set of conditions pertains to interventions in health systems that cannot be explicitly aligned with strategies to expand prepayment and risk pooling and, indeed, could be at odds with them. It’s anybody’s guess. Off-budget funding by donors that is not recorded in national health accounts is one example, NGO funding of scattered and fragmented micro-pilots may be another. The other ‘engine’ of UHC, ‘public health goods and services’ is critical as well. No matter how well ‘prepayment and risk pooling’ advance UHC, public expenditures on ‘pure public’ goods and services will always be important because (i) they benefit everyone, (ii) no one can be excluded, and (iii) they aren’t likely to be financed by the private sector. Perhaps the most interesting question -- for both government and donors -- is to re-examine the allocation of current public funding in LICs to assure it gets best value for money via (i) the ‘public health goods and services’ engine, or (ii) the ‘prepayment and risk pooling engine’. Increasingly, households will receive the lion’s share of preventive and PHC services via entitlements to an effectively available package of health care services funded by prepayment and risk pooling. This could provide a much-desired ‘exit strategy’ for vertical donor programs in LICs.

On the concept of UHC, I think I’m saying something different from what you’re saying I’m saying. Yes, UHC is ultimately about better health and improved living standards through stronger financial protection. But it’s more than that. UHC is about making sure that everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result. The word universal isn’t optional: UHC is about making the health system work for everyone. Reducing inequalities isn’t an optional add-on; it’s a core element of UHC. That’s not new wine to me, but I guess to some it will be. The second twist is that it’s getting us to think harder about relating use of services to need: UHC is partly about making sure people get the right care at the right time. Conceptually this isn’t new to me at least, but I think we’re learning that a lot of things we took for granted about what happens in practice can’t be taken for granted. We can’t continue to count doctor visits and hospital admissions and treat them all alike—we have to start looking to see what care is actually delivered during the contact, whether it’s what’s needed, and whether it’s delivered in a timely fashion. You ask whether the concept of UHC points toward a specific set of policy approaches or ‘operational prompts’. It’s a great question. You highlight prepayment and risk-pooling, and public health programs. I think prepayment and risk-pooling are indeed likely to be key. But UHC pushes you much further, it seems to me. You could have multiple risk-pooling schemes stretching across the income distribution without any risk-equalizing transfers. Such fragmentation—with coverage varying systematically with income—wouldn’t be consistent with UHC. I think you’re losing sight of the universal bit of UHC: the commitment to equity. And sure public health has an important place, but UHC is much more than ensuring the government delivers programs with public goods characteristics. It’s about ensuring that everyone gets the personal health services they need irrespective of their ability to pay. That means UHC needs to get into the demand for and delivery of personal health services. I’m starting to think I might have misspoken; perhaps the wine is new after all!

Submitted by Rob Yates on
Excellent piece Adam - your definition of UHC and emphasis on ensuring that coverage is effective are spot-on. However I wouldn’t dismiss the importance of the “who is covered” dimension. This in effect is the political dimension of UHC [one could argue that the other axes represent the economic and medical dimensions]. As you rightly point out it is “the who is covered” issue that interests political leaders because more covered people can mean more votes and/or political stability. But it is this political self-interest that can create the elusive political will needed to catalyse radical UHC reforms. As Savedoff et al show in their excellent transitions in health financing paper http://t.co/zNdm5VdX it is political negotiation that often leads to greater levels of pooled financing and better coverage. Now I fully admit there has been a tendency for some political leaders to forget the other crucial dimensions of UHC and make hollow claims about extending coverage and just increase entitlements to non-existent services. For many years I worked in one of these countries. These stunts have done the UHC cause no good at all. But thankfully electorates are beginning to wise up to this and are increasingly complaining about inadequate and shallow coverage and are telling politicians they must do better. The demand for effective coverage is particularly noticeable in middle income countries which are adjusting their benefit packages and contribution policies in response to mounting political pressures. Some of the BRICS are good examples of this. So rather than dismiss the political dimension we should be aware that this can be an extremely powerful driving force for UHC. However we need to make sure that the politicians construct a substantial UHC box and not just knock-up a two dimensional facade that only lasts until the votes are counted.

Thanks, Rob. I didn’t mean to write off the “who’s covered” dimension, but rather to say that it’s hard to make much sense of without the other two, since it can always be claimed everyone has some coverage and is therefore “covered”. The key is asking whether—at each point in the income distribution (or ethnic group distribution or gender distribution…)—people are getting the care they need without suffering undue financial hardship as a result.

Submitted by Georgina Planters on
I do not want to spoil the party with all this wine and universality, but I am really missing something. What you did not say when defining the U and the H and the C: UHC is a way to guarantee stable and rising incomes for the medical industrial complex. How better to get paid than to make sure that the fiscal powers of the government step in and create a parafiscal fund when the consumer cannot pay up out of pocket? No other service industry has such a great deal. Even farmers who sell food do not benefit from Universal Food Coverage. Yet most people need food more than they need doctors. How many people malnourished? Medical doctors and other health staff , and administrators of hospitals and similar facilities, generally make the best incomes in any country and have the highest status. In some countries this is extreme, like in the USA where a doctor makes about 20x what a teacher makes. Go figure. The former has a government guarantee for payment for his services, which is now more secure because of UHC. Similarly for medications. What's not to like if you are in the medical business. So I am missing some mention in your excellent long expose about the cost of these health services and their actual usefullness for the poor patients. Or is cost containment and quality "out" when UHC is "in". Make sure doctors get paid first and then later worry about quality and unit costs. What does the World Bank recommend? One more thing seems very wrong with your approach. This is very serious. You are not talking at all about improving health. Only about mobilizing and organizing payments to providers for ill people's care. Maybe the patients get better, maybe they die but in any case coverage will cover the providers. No risk. What about prevention? Most people who are getting sick now from NCDs did not have to get sick if prevention was in place. We missed that boat. But what about the people who need not get sick in 2020 and 2030? Does UHC do anything for preventing future growth of illnesses? Does UHC prevent contagious diseases? Or is cholera going to keep breaking out in Haiti and elsewhere every couple of years -- this will surely bankrupt any UHC scheme in those countries. Does UHC prevent another AIDS-like epidemic? Or does the need to pay the doctor today override all such possible concerns about opportunities for future savings? While the program you set out guarantees employment for more that a hundred World Bankers for many years, how many World Bankers are actually working on prevention? From what I see on this blog it's 20:1. Prove me wrong, please. Is somebody fixing the factors behind preventable diseases so that UHC funds will not have to pay up for more and more medical services for illnesses that can be prevented at minimal cost? Have you calculated the impact of the coming pandemic of antibiotical resistance? Finally, you write that "everyone already has coverage." I suggest you visit one of about 30 African countries, Haiti, etc, and see how many people that "already have coverage" you find. Not many. Maybe it's a priority for everyone here on these blogs, where UHC seems to be the most written-about theme the last few years. When does the World Bank expect, e.g., Nigeria having UHC - before 2050 or after 2050?

Thanks for these great comments, Georgina. I certainly don’t see UHC as about enriching the medical profession. UHC is about making sure that everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result. That includes the various types of preventive care. UHC is also about making sure people get the care they need—in a lot of places, that’s mostly about ensuring people don’t go without the care they need; but in many places (including some middle income countries) it’s also about making sure people don’t end up getting and paying for care they don’t need and can’t afford. As I said in my post “Where in the world is a hospitalization least affordable?” http://bit.ly/W0yQFT, “UHC reforms also need to devote a lot of attention to putting downward pressure on the overall cost of hospital care.” And as for the point “everyone has coverage” my point was simply that everyone has some coverage, and that the issue is more about some groups having minimal coverage and/or coverage for just a few things. My whole point was that the “universal” bit of UHC doesn’t actually get at the real coverage issues.

Submitted by Emre Ozaltin on
An excellent distillation of key UHC components. To me, this reinforces the case for continued work by the Bank and global actors on this topic, to make expertise, studies and tools such as UNICO and UNICAT available to countries trying to expand coverage, to help them think through key issues such as costing, provider payment, benefit packages, financial protection, harmonizing existing schemes and so on. A more pertinent question is whether UHC should be part of the post-MDG agenda. I submit that any candidate for inclusion should satisfy two minimum criteria: (1) be concrete and easy to explainable to policy makers; and (2) have clear, readily measurable targets. At present, UHC comes up short on both counts. For the first, while I think this post does an excellent job of reframing UHC, we are still left with a concept that is soft, diffuse and difficult to explain without several parentheses. With its subtleties, misnomers, qualifications and cubes UHC, as currently conceptualized, is not easily understood by a non-technical audience, which will limit its usefulness in inflaming passions and serving as a rallying cry. Second, and more important, the components outlined – particularly coverage and clinical quality – do not lend to straightforward quantification. As discussed in the post, all populations are covered by some health care, whether it be public, private, non-medical or of low accessibility. The issue of what is covered is even more elusive; how do we quantify or rank different packages (depth) in different setting? The concept of “effective coverage” – the proportion of the population in need of an intervention who receives an effective intervention – best gets at the both. But, while at a macro level the intersection between burden and service mix may serve a useful indicator, getting at effective coverage at the individual level if difficult. In addition to clinical quality, responsiveness is another dimension not mentioned but that should be part of UHC. Quantifying gaps between theoretical coverage and utilization, and the barriers thereto is challenging. While catastrophic spending is an excellent indicator, out-of-pocket expenditure is regressive and it is unclear if zero OOP is the right target in every context. This is not to say that these conceptualizations and quantifications cannot be done, but that important work remains. Finally, as has been often pointed out, UHC is a means rather than an end. As such, it may lead to a focus on process rather than the outcomes we ultimately care about. The effectiveness of expanding the depth and breadth of effective coverage on improving health outcomes remains an incomplete area of research. Moreover we have been moving, in the right direction in my opinion, towards multisectoral interventions – UHC, perhaps unwittingly, reinforces the outdated notion that the solutions to improving population health lie exclusively in the health sector.

Thanks, Emre, for these excellent points. I’m pretty optimistic about us being able to come up with indicators to track progress toward UHC. I’ll go live with some ideas soon. And at its core UHC is pretty easy to understand—it’s about ensuring everyone gets the health services they need, and ensuring nobody has to put their family at financial risk to get the health services they need. The more difficult bit to monitor is the “service coverage” part—ensuring everyone gets the care services they need (the financial coverage bit is easier to measure.) Some aspects of service coverage—e.g. prevention—are fairly easy to track. Tracking coverage of appropriate treatment is much harder, since it requires seeing what goes on during a consultation. But we’ve made a lot of progress in this area (see my post on my colleague Jishnu Das’s work http://bit.ly/QCF0Nl) although it does suggest that getting at quality through structure indicators isn’t going to be the answer. While I think UHC has a lot to commend it as a unifying theme for the health system, it’s only that. Ultimately we’re concerned about health outcomes and living standards, and we clearly shouldn’t stop tracking those. I think there’s a consensus growing on that—see my post on the WHO-World Bank ministerial meeting on UHC at http://bit.ly/YFJ9Cn.

Submitted by Jennifer Hennig on
Thanks for the great food for thought in this blog. Everyone seems to agree on the broad concept of UHC: Everyone should have access to quality health services without suffering financial hardship. But the actions to be taken after we have reached this general agreement seem to be less clear. I agree that the question whether the concept of UHC points toward a specific set of policy approaches is a great one. I think the UHC concept does not lead us directly to a specific set of policy approaches. And it does not tell us how we know whether we are moving into the right direction. For this, we need clear and measurable targets (and having these targets would also make it more concrete and easier explainable to policy makers). The UHC debate has shifted the attention to equity and universalism (and might through this have added some new flavors to the wine shifting discussions towards possible effects of fragmented risk pools etc.). So the “equity dimension” of the cube got a lot of attention. And there was also a question attached to it which sounded like leading us to a clear target that would easily be measurable: “Who is covered?” --> “Everyone is covered”. And this question – and especially the word “covered” - might be misleading. The word “covered” can easily be understood as “people holding an insurance card in their hand” and some then used this as a proxy of whether we are moving towards UHC. But the question does not make any sense of course without a link to the other dimensions. So maybe we should rename the dimension and call it “equity” rather than “coverage” dimension and attach a different question to it: Who has access to quality health services without suffering financial hardship? This again makes it more complex and less easy to measure of course...

Thanks, Jennifer. I think we’re stuck with the name and acronym, but I think we can live with that. To me UHC is all about ensuring everyone—whether rich or poor—gets the health services they need, and don’t put their family at financial risk in paying for it. There’s equity here, there’s financial protection, and there’s the idea that the health services that people should end up getting should depend on what they need—not what they can afford, and not what suits the doctor. You can’t get at all that by looking at whether someone has an insurance card.

Submitted by Por Ir on
Hi Adam, Thank you very much for sharing this very concise post on UHC and its historical development. I have no doubt to agree with your analysis and description. I would just like to share a few ideas which you on this topic. As UHC can mean many things, it is crucial to make sure that individual country adopts a right UHC policy ("quality" wine), which "increases access and financial protection without deteriorating equity." Some countries may tend to shift from implicit coverage (government subsidized service provision) to explicit coverage (insurance-like schemes), which may not necessarily yield better results, but worse if the current state subsidized primary health care system is functioning reasonably well, e.g. Cambodian people seem to enjoy access to subsidized (mostly free) preventive services (RMCH services) provided by large coverage of health centers, and efforts to increase explicit coverage may undermine this core function of the Cambodian health system. We all agree that for all countries the bottle is not empty and competing the bottle is not an overnight action. For any country adopting/readopting UHC, a sound and clear pathway (road map) toward the ultimate goal of full coverage is necessary. Three points should be considered for this: (1) Depending on the country context and where the country is on the pathway, the UHC models currently implemented in countries already achieved UHC may not be relevant to a country being still on the way to UHC. For the latter, the past historical development in full UHC countries can be more useful; (2) Although all country health systems aim to improving health (as reflected by core health indicators) and financial protection (as reflected by health expenditures, mainly out-of-pocket payments, their level of achievement for these two health system objectives may be quite different, e.g. Vietnam has relatively good health indicators, but still high out-of-pocket payments. Particular emphasis on one of these two objectives, may requires different approaches to UHC. This is even more challenging if the countries take equity objective into consideration; (3) How to measure the progress toward UHC is also necessary (how the bottle is properly filled in over time). As a researcher, this is crucial for building a right path toward UHC. So far, we do not have clear consensus on how to measure the three dimensions of the cube yet. For breadth of coverage, it is rather straightforward for the insurance-like model, but not for state-subsidized service provision, which relies on physical coverage rather membership. It is even more challenging for measuring depth of coverage. Benefit package or package of services provided can only tell one part of it The quality of the services is another critical one. How about height of coverage, is out-of-pocket payment as a proxy enough? For all the three dimensions, the average is not enough, but also poor-rich, urban-rural, and gender difference (equity analysis) needs to be looked at carefully. Please let me know if I am going off track...

Thanks, Por, for these great comments. I touched on the measurement issue above, but will say more on this soon. I think we all agree there’s no right or wrong path to UHC. I don’t the equity dimension is an optional add-on—it’s central to UHC.

Submitted by Monica Mutesa on
In principal it seems ALL key actors are agreed on UHC. Tying down the who seems to be almost done.... the what is a little way down the road ..... the HOW seems to be the one thing that is farthest down the road could result in derailing the extremely popular UHC train. There are many divergent views on how this will be actualised. One line of thought is that to achieve UHC the Social Health Insurance way is the best. Many policy makers are hailing the Ghanaian SHI experiment as showing the way to go. Evidence from Ghana reveals that their social health insurance scheme is paid for by everyone through taxation, but doesn't offer everyone coverage. It is letting people fall through the cracks .Thanks to CSO activism/alertness they got authorities to downgrade their claims on the 'fantastic' numbers they claimed they were reaching. Enter Zambia where SHI is hurtling headlong to be the vehicle that the authorities will use to achieve UHC. The removal of user fees was one of the issues which was addressed by the newly elected PF government. But alas not long afterwards a new SHI scheme is on its way which could put this life-saving free healthcare initiative at risk. Good old tax financing has for all intents and purposes been relegated to the back seat! And with the phasing, in the roll out of SHI (first to formally employed) there is a risk that it will create a two tier system within the health sector and flies in the face of equity. The recently released report on Tax avoidance of a British Food company by Action Aid, seem to have crystalised my argument for the fact that there aren't enough taxes being raised to fund the social sector. The excuse that tax funded systems cannot provide quality care seems to be premised on weak analysis. The Ghana example again shows that despite the fact that premiums for the SHI are collected, the system is still supported by the use of tax funds. A joke taking the rounds in the CSO community is that it will cost more to collect premiums than the money that the schemes will collect and the schemes will still resort to taxes. Taxes should be the route to take. I end with a statistic and a question. 48,000 children could have been sent to school if the British Food company had paid their taxes! How many other culprits are out there evading/avoiding tax who if brought to book would contribute to ensuring UHC through fair taxation fairly spent? thanks

Thanks, Monica. I suspect that like UHC itself some of the labels attached to policies and programs aimed at achieving UHC are often misleading. But, yes, SHI is traditionally associated with collecting mandatory contributions through the payroll from formal-sector workers, and yes it has lots of drawbacks—see my Social Health Insurance Reexamined piece http://bit.ly/Y3cu5r. That said tax-financed budget-cum-salary systems haven’t worked well in most developing countries; they’ve mostly disproportionately benefitted the better off, and haven’t usually delivered decent quality care. The good news is that we’re starting to see some fresh new approaches emerge as countries use UHC as an opportunity to experiment—see the case studies at http://bit.ly/14Vgivy.

Submitted by Jim Campbell on
Adam - a great piece, and a lot of synergy with other work that is looking at quality of care. One of those pieces, in development with the Global Health Workforce Alliance, looks at "UHC: the Grand Challenge of HRH". A technical paper was shared with Ministers and participants at this week's World Bank / WHO Ministerial-level meeting on Universal Health Coverage (18-19 Feb). I hope you got chance to read it? Out of this work a new cube is born. One that sets out a conceptual framework for looking at effective coverage (i.e. quality) The HRH/UHC cube is an adaptation of the Universal Health Coverage cube (WHO, 2010) and the Availability, Accessibility, Acceptability, utilisation and Quality (AAAQ) dimensions that are included in both a) the right to health (General Comment No.14, 2000) and b) the Tanahashi framework (1978). The figure is to prompt discussion on the ‘Effective Coverage’ i.e. the differences between the theoretical coverage implied by the Availability of the workforce versus the actual coverage resulting from the Quality of the workforce. New data from Afghanistan, using this approach, will be available soon, but the results identify that effective coverage of MNH services is a fraction of the proxy indicator of 'Skilled Birth Attendants'. The debate must turn to quality, not quantity, and this is an HRH discussion that is applicable to ALL countries, not only those with a lower density of health workers per 1,000 population. Thanks, Jim Campbell

Submitted by Maria Suzuki on
We should aim for better health outcomes in the entire population. I think the emphasis on financial protection is just wrong. It's the health outcomes, stupid , as BillClinton would say. UHC is just making money to pay the health workers and pharmaceuticals, regardless of service quality. If the patients are not cured, the doctors will still get paid. The best way to health population-wide is prevention, prevention, and prevention. Is this in the "C"? It should be. But it's never stated and never measured, so it will not occur enough. More prevention reduces the cost of health care and improves health outcomes. Without prevention, UHC is a pipedream!!! UHC is one input, neither necessary nor sufficient , for better population health outcomes. I really wonder : why is it the only goal here?

Thanks, Maria. Prevention is an integral part of UHC—it’s part of people getting the care they need, and it’s vital to promoting financial protection. It’s doubly important!

Thanks, Jim. I think quality is a central element to UHC, not an add-on. It’s implied by the requirement that people get the care they need. It’s not about whether people visit a facility. It’s about whether when they do there’s actually someone there to treat them, whether they get diagnosed correctly, and whether they get the correct treatment. As my colleague Nazmul Chaudhury and others have shown in their Journal of Economic Perspectives paper http://bit.ly/Xpi3Om, the first of these often fails to happen—health providers often simply aren’t at their post when the patient shows up. And as my colleague Jishnu Das has shown, the second and third often fail to happen as well—providers do much less than they know, and many know very little. Jishnu’s work (see my post at http://bit.ly/QCF0Nl) poses something of a challenge, as it shows the limited informational value of structural indicators of quality and provider knowledge. Look forward to seeing the MNH study, and how it gets round these challenges.

Submitted by Georgina Planters on
Two years ago the World Bank came out with a big message on NCDs. The looming threat to economy everywhere. Very costly. A disaster in the making. It would use up all of the health dollars that are to be had. Therefore there should be a lot of prevention of these "lifestyle" diseases. The year after the World Bank ditched prevention as a focus and started working on UHC. Whatever happened to prevention on population-wide scale? It simply does not exist at the World Bank. Yet it helps the poor especially. So UHC will be a really uphill battle now that the World BAnk does not even say that prevention is important. Would somebody from the World Bank, please, explain why the bank emphasis shifted this way, in this sequence? It appears irresponsible or worse.

Submitted by Anonymous on
Very interesting piece. I particularly enjoyed your call to try hard to establish what is needed health care and compare it to what is actually being delivered, 'cause "if we don't try", "we could go badly wrong". And as you pointed out, establishing what's needed in health is hard. I am particularly concerned with one of the many difficulties for doing so: dealing with people’s expectations. What UHC movement has to say about that? I’ll try to explain myself. Ok, so UHC is an old wine in a new bottle, right? After reading the blog I wanted to taste the wine in one of those older bottles, so I went to the wine cellar and took one of my favorites (this one, not so old though, the World Health Report 2000). Of course, a lot of ideas in the report are common to the UHC movement, so I will focus on the objectives where I think there may be a key variation. The report proposes three goals that are intrinsically valuable: i) responsiveness to people’s non-medical expectations, ii) fair financial contribution and iii) health as the primary and defining goal of any health system. UHC on the other hand propose three dimensions that, despite being sometimes misleading, encapsulate a concept that means “that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result”, which implies other goals such as equity or quality of care. And all that is a means to end: better health for all (with equity) and improved living standards. Now I wonder: How does the responsiveness goal fit into the UHC concept? What is the interplay between health needs and people’s expectations? Are people’s expectations partly defining what is needed?, or the need should be ‘objectively’ determined?, is it possible? I really do not know which countries have achieved the goal of UHC, but let’s assume a country achieves UHC when its health system provides coverage to all the population for the costs of accessing health care within a reasonable set of services, with reasonable quality of care, given the resources the society have allocated to health, and also, the functioning of the system succeeds in guaranteeing that everyone receives the care, as stipulated in the paper. What if the average waiting time to visit a specialist in a country that has achieved UHC is, say, 5 days (assume 5 days is medically appropriate), but the people find such time unacceptable and they want same-day appointments for specialist care? What if the system provides effective coverage for most services, but excludes aesthetical care and the population or a group of people, think that such treatments should be covered as well? Or, what if a country achieves UHC, but people dislike the service because it’s perceived as rude and unfriendly? The above are probably extreme examples, but I think several countries may be in similar situations; many countries have taken huge steps towards UHC, both on paper and in practice, but the health system is still perceived by the population as administratively cumbersome, ineffective or inhumane. As they put it in the World Health Report 2000 (p. 24): "The three goals are separable, as is often shown by people’s unhappiness with a system even when the health outcomes are satisfactory". This is something in which the new bottle is somehow obscuring rather than illuminating. I agree that getting more people interested in the wine is a good thing, but if the concept is not clear enough and do not appropriately address real concerns for many countries, it may become useless if not harmful. You started the blog entry saying that the concept of UHC has become so elusive, and although you make a huge contribution in clarifying the concept, it is still a long way to go!

Thanks. Very fair point. I don’t think UHC is inconsistent with making sure the health systems is responsive to people’s non-medical expectations, but I don’t think it requires it either. I suspect there will be differences of view as to whether it should be put as a side-condition or set as a goal in its own right that can be traded off against the elements of the UHC goal. And that view may change over time as well.

Submitted by David Dror on
Adam, thanks for enlarging the debate. There are many points I concur with, which have been ably put so no need to repeat. There are a few that have been stated, which I think should be challenged, and have not yet been raised by others in this exchange. For one, you say that universal coverage exists already, to some measure, everywhere. Really? The reality that every person working at grassroots level at low income countries (and in some middle income ones as well) will confirm is that most people cannot get any service whatsoever under the existing schemes without some payment out-of-pocket. Payments may be for goods that are missing (e.g. drugs or perishables),or for services (e.g. tests and imaging) or for bribes that are de facto demanded for every access to any type of care, as well as indirect costs (e.g. interest on borrowed money to pay for the care, transportation, loss of income of care-giver etc). To describe this as a situation that universal coverage exists seems either an error or terribly cynical. I know you are not a cynic, and you rarely err. So, maybe a clarification on this very fundamental statement of facts is called for. The issue of funding precedes that of quality of care, or that of macroeconomic policy. Not that the other topics are unimportant - they are very important. However, the naked truth is that nobody wants to pay everything for everybody forever, and therefore everybody, even very poor, must pay something sometimes. At present, the very poor pay exorbitant prices for every kind of "protection" or "care". The case about "the unaffordability of free care" has already been made more than once. I would add that there is also the case that in most places in low-income settings, there is no market for health insurance, and a very dysfunctional market of health services. Governments most often bear the full responsibility for both, and expecting them to right the wrongs is perhaps naive, considering the huge flows of funds and the political interests involved. The main voices in this debate (WHO, WB) being governmental organizations sound to me too shy in pointing out those aspects. Painfully, the experience of more than 50 years suggests, indeed points, that governments are part of the problem rather than part of the solution, in all but very few exceptions. Would it not seem plausible that if governments cannot fix the basics (in part because the majority will not willingly transact with government-led schemes unless they must) and for/profit providers have not been keen to reach out to the large mass of poor in the informal sectors, maybe the time has come to look at other players that can provide at least some solution out of the box (both the UHC box and the conventional top-down thinking that prevails in this debate? I found no mention in your blog of the role of non/governmental and civil society players. Hopefully this comment might offer the opportunity to flag these basic points as well. Best and thanks

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