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Universal Health Coverage and the post-2015 development goal agenda. And Mrs Gauri

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In a recent blogpost I asked whether Universal Health Coverage (UHC) is old wine in a new bottle, and if so whether that’s so bad.

I argued that UHC is ultimately about making sure that “everyone – whether rich or poor – gets the care they need without suffering undue financial hardship as a result.” I suggested UHC embraces three important concepts:

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

These concepts aren’t new, and they don’t jump out at you from the name "UHC". But as an overarching label “UHC” isn’t bad. So, yes, old wine in a new bottle. But as I said, if by slapping a new label on the bottle, we get people more interested in the wine – even if the label is a bit misleading – that's ok, given the wine’s a good one.

Which brings me to a question that's on a lot of people’s lips right now: Could UHC be the right health goal for the post-2015 development goal agenda?
Can we “sell” UHC to Varun Gauri’s mom?

My colleague Varun Gauri wrote a nice paper recently – and a blogpost to accompany it – called “MDGs that Nudge”. His idea is that if international goals have any impact, they do so by inspiring people. For people to find them inspiring, goals should be framed in a way they’re “psychologically, morally, and politically salient”. This sounds quite complicated, but it’s not. What Varun is saying is that they should resonate with people. They should be goals people feel are important to pursue. And they should be expressed in a way people can relate to.

For people like me who struggle with words like “salient”, Varun has a simple rule of thumb: “If you can’t sell a goal to my mom, don’t bother with it.”

Everyone should receive the health services they need!

UHC essentially has two dimensions. The first is the idea that everyone – rich and poor alike – should get the health services they need. We could put this into a nice slogan that ought to rally Varun’s mom and her friends very nicely: Everyone should receive the health services they need!

I don’t know Mrs Gauri, but I think she’d probably agree this is morally salient. Allocating health services according to medical needs is an idea that people find intuitively fair – seeing a rich person get the care they need while a poor person goes without offends our basic sense of fairness.

Knowing Varun, I suspect his mom is pretty smart. She’ll want to know how we're going to operationalize this idea. This is where we have to ask Mrs Gauri to bear with us a bit.

We obviously can’t see whether everyone in a given country receives all the health services they need in a given year. We will need to work with samples – just some people, and just some health needs.

The people we sample should be a nationally representative sample. We can’t randomly sample health needs, but we can try to come up with some ‘tracers’ we all agree on. We should make sure they span all types of health service – prevention, treatment, rehabilitation, and palliative care. After all, people have needs for all these types of care. And we should make sure our tracers span all stages of the lifecycle – the prenatal period, infancy and early childhood, later childhood, adolescence, and the various phases of adulthood. The MDGs focused very firmly on some phases of the lifecycle. In the process, they probably lost some appeal. The next health development goals should probably be more inclusive.

So much for the principles – how do we proceed in practice? We actually already have some tracers and data for them, not just for populations as a whole but also for subpopulations such as the poorest 40%. We have data on childhood immunization: we know, for example, what fraction of young children are fully immunized in many countries, and what the fraction is among the poorest 40%. We have data for many countries on whether women aged 40-69 have received a mammogram. There are lots more indicators for preventive services that we have data for, and there are probably lots more we could get through surveys and make sense of if we continue to collect more and more biomarker data in household surveys.

Getting data on medical treatment will be harder. We want to know – for different types of health needs – whether a person sought treatment, whether they were correctly diagnosed by the provider they visited, and whether the provider gave them the correct treatment. A household survey won’t be much help on any of these. We need to see what happens during the consultation – if the consultation happens. We might need to use fake or “standardized” patients along the lines I wrote about in my “Shocking facts about primary health care in India” blogpost.

It’s a time-consuming exercise but it’s easy to explain. We’re simply asking whether a patient with, say, unstable angina will get diagnosed correctly and come out of the clinic with the right treatment. And we want to see whether this happens to the poorest 40% of people, not just those living in affluent neighborhoods in the capital city.

When we have our tracer indicators, we can come up with targets. They could be set either in terms of levels or annual changes. In both cases, we want to set targets for specific subpopulations as well, such as the poorest 40% of the population. So, for example, we could say that we want to see a 2% increase every year in the fraction of women aged 40-69 who receive a mammogram; and among the poorest 40% we want to see this fraction grow at 4% a year. Or  – and this is probably easier to get across: by 2030 all women aged 40-69 will be regularly receiving a mammogram.   

End impoverishment caused by health spending!

I’m worried Mrs Gauri might be thinking she just got a whole lot more information than she really wanted. So let’s quickly turn to the other aspect of UHC.

What we’re after here is that when people use health services, they don’t put their family at financial risk. I suspect most of us would agree that, at the very minimum, people ought to be able to get the health services they need without impoverishing their family. This also makes for a nice slogan that should appeal to Mrs Gauri and her friends: Payments for health services should never push a family into poverty! Or how about this one: End impoverishment associated with health spending!

I think Mrs Gauri would probably agree that this too is morally salient. People don't choose to fall ill. It's not much fun being ill, and being ill tends to limit one's ability to do things and enjoy life. The idea that people may fall into poverty by having to paying for something that will simply make them better offends our basic sense of fairness. We don't feel the same way when people fall into poverty when they run into problems with their mortgage becauase they've bought a home that's larger or more luxurious than they can afford. Or when they vacation more often or more expensively than they can afford. Health spending is mostly involuntary or non-discretionary – this sets it apart  from most other items of household expenditure.     
We can get at the impoverishment issue using household survey data. We can see how much households spend out-of-pocket on health care, and how much they spend on everything else – food, clothing, housing, etc. Money spent on health care is money that can’t be spent on these things. We're looking to count instances of when out-of-pocket payments make the difference between a family being above the poverty line and being below it.

Our goal and target here are straightforward: to reduce – and ultimately eliminate – impoverishment due to health spending.

Look sharp, Mrs Gauri is coming!

And now, if you’ll excuse me, there's a lady coming towards my office who bears a strong family resemblance to Varun.

I must remember to concede when I talk to her that even if I can explain UHC in a way that resonates with her, it doesn’t clinch the argument – there could be other health goals that might also resonate with her. As it happens, I happen to think UHC will likely do quite well when compared to other contenders.

But let’s see first whether Mrs Gauri “buys” UHC. 


Adam Wagstaff

Research Manager, Development Research Group, World Bank

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