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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.