Published on Let's Talk Development

Saturday, December 12 was UHC Day. What have we learned in the last 12 months about Universal Health Coverage?

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It turns out lots of interesting things happened on December 12. Beethoven had his first lesson in music composition with Franz Joseph Haydn (1792), Washington, D.C. became the capital of the US (1800), Guglielmo Marconi sent the first transatlantic radio signal (1901), Kenya declared independence from the UK (1963), The Beatles played their last UK concert (1965), and  Ed Sheeran announced he was “taking a break” from social media (2015). Oh yes, and the UN endorsed a resolution calling for countries to “provide affordable, quality health care to every person, everywhere” (2012). Which makes December 12 UHC Day.

Here’s a personal look at what we’ve learnt about UHC in the last 12 months or so.

What are countries doing in the pursuit of UHC?

September 2015 saw the publication of a must-read for everyone working on UHC and health systems: a World Bank book called Going Universal that contains 24 country case studies explaining in a systematic way what countries are doing to achieve UHC. Most countries are taking a bottom-up approach, giving special attention to the poor and vulnerable. They’re tackling both the “financing gap” (lower per capita spending on the poor), by spending additional resources in a pro-poor way, and a “provision gap” (underperformance of service delivery for the poor), by expanding supply and changing incentives in a variety of ways. Countries have decided, it seems, that pursuing UHC is going to require not just more money – also needed are changes in the “rules of the game,” so that money is spent more effectively and in a more pro-poor way.

What exactly is UHC?

Here’s a multiple choice question:
  1. UHC is about giving everyone the legal right to health through, say, a constitutional guarantee.
  2. UHC is about getting everyone into a health insurance or ‘financial protection’ scheme.
  3. UHC is about ensuring that everyone – the poor and the rich – get the health services they need without suffering financial hardship.
If we’ve learnt one thing about UHC in 2015, it’s that (1) and (2) are wrong answers – even though lots of people still talk and write as if they were right.

If you’re not convinced they’re wrong, take a look at two 2015 studies, an article in Health Affairs looking at the 20 Latin American countries, and another World Bank book looking at a selection of countries in Latin America and the Caribbean. Most countries are busily engaged in reforms in the name of UHC. Yet most have legal – often constitutional – rights to health, and have had for some time. They also have extensive networks of government-run clinics and hospitals that are available to everyone and charge either nothing or a highly subsidized user fee. They’ve had these for a long time too.

Countries are pursuing reforms in the name of UHC because, despite legal guarantees, and despite free government-run health facilities available to everyone, many people – especially the poor – don’t get the care they need. And if they do, they often pay so much out-of-pocket that they end up pushing their families into poverty or close to it. Changing that is ultimately what UHC is all about. So (3) is the definition of UHC that WHO and the World Bank have agreed on. As I argued in another blogpost, it’s not a particularly new idea; it’s what many countries – especially egalitarian ones – have been working towards for decades. The old ideas are often the best!

What do the data tell us about UHC attainment?

2014 and 2015 saw a lot of studies comparing countries in terms of how well they get services to everyone. These studies mostly focus on basic services, such as key maternal and child interventions and other interventions that were part of the MDG goals. A 2014 paper in the World Bank Research Observer and a 2015 paper in The Lancet both found that the poor have seen larger percentage improvements in key MDG interventions, but coverage rates fall short of 100% and are still systematically lower among the poor. The first WHO-World Bank UHC global monitoring report also highlighted the low levels of (effective) coverage of some NCD interventions, such as hypertension treatment, especially among the poor. The article in Health Affairs on Latin America found increases in rates of cancer screening, but rates are still a long way from 100% and there has been much less progress among the poor than among the better off.

2014 and 2015 also saw the publication of multi-country evidence on financial protection in health – the second dimension of UHC. These included the first WHO-World Bank UHC global monitoring report, the article in Health Affairs on Latin America, and a forthcoming paper in the Oxford Review of Economic Policy. All painted a rather worrisome picture – out-of-pocket spending reaches catastrophic if not impoverishing levels in many countries, and it’s not clear that things are getting better.

Have programs and policies helped move countries towards UHC

With the move to definition (3), a whole new research agenda has opened up. Do policies and programs implemented in the name of UHC actually get countries to – or at least towards – UHC? And, for that matter, do policies and programs not implemented in the name of UHC help (or hinder) a country in its   pursuit of UHC?

2014 and 2015 saw lots of new work in this area. For example, expansion of health insurance to the poor in in Indonesia and Thailand increased service utilization, at least among some groups. In China, more generous insurance coverage among rural households led to higher utilization. In Cambodia health equity funds reduced out-of-pocket spending by 26% (by even more among the poor), and in Thailand the so-called universal coverage scheme reduced out-of-pocket spending on average by one-third and large out-of-pocket expenditures (expenditures at the 95th percentile) by a half. By contrast, in Indonesia, there was no evidence of any negative impact on out-of-pocket spending; in fact, among urban residents just the opposite. And in China, the new research confirmed the finding of some of the previous studies on the topic, namely that China’s rural health insurance scheme has not improved financial protection.

We’ve also seen studies of the effects on UHC of programs and policies that are not usually thought of as UHC initiatives. New studies of performance-based financing (PBF) in Burundi and Cambodia find that PBF has had positive effects on some MCH indicators though not all, and not always among the poor, while a recent study finds that PBF in Rwanda encouraged HIV testing. Recent studies of demand-side programs, like earlier demand-side studies, tend to find strong effects, especially among the poor. For example, recent studies found that use of antenatal care and facility deliveries increased in Cambodia and India among poor women who were given vouchers to cover the cost of maternal care.

One common theme throughout these studies is that even where programs have helped a country raise service coverage or improve financial protection, there’s still work to be done – we still see people going without the care they need, or incurring catastrophic or impoverishing out-of-pocket spending, even after the program.

Can we measure progress towards UHC in one number?

We know now what UHC is, and we have lots of data on indicators that should be a part of UHC measurement efforts. Wouldn’t it be great if we could bundle lots of different indicators – of service coverage and financial protection – together, in a logical and transparent way, to capture, in a single number, where a country is on UHC? The article in Health Affairs on Latin America, and the forthcoming paper in the Oxford Review of Economic Policy do just that. The UHC index captures not just how well countries do at the population level, but how well they do in getting services to everyone, and in ensuring out-of-pocket payments don’t become becoming catastrophic and impoverishing for anyone.

A version 1.0 of the UHC index has been computed for 30+ countries at different points in time. The good news is that the index is going up in most countries. There are two pieces of bad news. First, the service coverage sub-index is going up faster than the financial protection index. Second, the best-performing countries are at around 80 out of 100, not 100.

@UHC_Day needs to stay busy

All of which reinforces the point I made above – UHC isn’t simply about giving people legal rights and getting them in a financial protection scheme. We’re not as far down the road to UHC as many people seem to believe. We need UHC Day to stay around for some time yet. Ed Sheeran may be able to afford to take a break from social media. @UHC_Day can’t – it needs to stay busy. 


Adam Wagstaff

Research Manager, Development Research Group, World Bank

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