Published on Let's Talk Development

What’s the “universal health coverage” push really about?

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L. Garrett, A. Chowdhury, A. Pablos-Méndez. “All for universal health coverage”, The Lancet, 2009, 374(9697), pp. 1294-1299

Maps, like pictures, are often worth a thousand words. The map above comes from an article in the medical journal The Lancet. The article is part of a campaign to make 2010 the year of a big push toward universal health coverage. Over the course of the next three days, over a thousand health systems researchers are gathering in Switzerland for the First Global Symposium on Health Systems Research; the theme of the symposium is “science to accelerate universal health coverage”. Next week, health ministers from around the world will gather at an international ministerial conference on “Health Systems Financing – Key to Universal Coverage” hosted by the German government. At the conference, the World Health Organization will launch its 2010 World Health Report entitled “Health Systems Financing: The Path to Universal Coverage”.

The Lancet’s map—ostensibly showing the fraction of the population currently with health insurance coverage—is a neat tool for the participants in these exercises to see where they’re starting from. Or it would be if it were accurate. Unfortunately, it’s not. According to the map, the US already has universal health coverage! In which case, what was President Obama doing risking his political capital by trying to expand insurance coverage? And according to the map, Brazil has incomplete coverage despite the fact that in 1988 the government amended the constitution to guarantee all citizens access to health care and introduced a tax-financed universal health system. In fact, all Latin Americans would probably be rather confused by the map, since they all live in a country whose ministry of health (MOH) operates facilities that are open to everyone. The same is true of African countries too. And India. And Indonesia. And the Philippines. In fact, come to think of it, it’s true of most countries.

Unfortunately, then, the map is completely misleading. The problem with the map—and indeed with much if not most of the debate on universal coverage—is that it portrays the universal health coverage challenge as an either-or problem. People either have coverage or they don’t. In actual fact, everyone everywhere has some coverage. The stark reality, though, is that in many—if not most—countries there are large inequalities in coverage, typically mirroring pretty closely the income distribution.

The challenge, it seems to me, is not to cover everyone (already achieved). Or even to give everyone the same cover (desirable but equality of effective coverage is best seen as a long-term goal). Rather, the coverage challenge to my mind is really about narrowing inequalities in coverage.

Many countries have segmented health systems. Government facilities often charge for services, so while people have access to them, they have to pay for them. And in some countries, when people arrive at government facilities for treatment, they find no staff, no drugs, and no equipment. So, people have access to services that don’t actually exist!

By contrast, more privileged sections of the population—civil servants and formal-sector employees—are often covered by one or more social health insurance (SHI) schemes. These either reduce out-of-pocket payments in government facilities or give enrollees access to an altogether separate network of (public or private) providers. These providers may or may not charge a lower price, but at least when patients arrive, they find doctors, nurses, drugs and equipment.

It is this segmentation that countries are trying to reduce. They’re doing so in different ways.

Some—like the Philippines and Vietnam—have tried to bring informal-sector workers and their families into the SHI scheme, often offering partial or complete subsidies for the poor. Other countries have set up insurance schemes that operate in parallel to the SHI schemes. Sometimes, as in China and Mexico, these are located in the health ministry. In others, like India, the labor ministry operates the parallel scheme.

Irrespective of who runs it, voluntary schemes have proved vulnerable to adverse selection, and to low enrollment rates and/or low revenues from contributions (on paper some governments apply means-testing but in practice haven’t done so rigorously). And enforcing mandatory enrollment has proved hard.

An alternative model is the Thai model. Thailand set up what is in effect a parallel insurance scheme within its health ministry for those outside of the SHI programs; however, everyone is covered, and the costs are covered through additional taxes.

All these parallel schemes—however financed and wherever located—leave open the possibility of narrowing gaps in coverage but not eliminating them, a useful strategy for a government with limited revenues to play with.

But they all raise the question of what enrollees gain from the ‘insurance’ process, especially when the health ministry operates the scheme. What’s different from the original MOH model that was seen as the cause of poor quality care and high out-of-pocket spending in the first place?

One answer seems to be that the schemes give their enrollees a card that explicitly entitles them to a specified set of services—a type of patients’ charter. Providers have to deliver.

Another advantage seems to be that it provides governments with an opportunity to change the way providers are paid. They can shift from salaries and budgets (that do nothing to incentivize providers to turn up to work and make sure drugs and equipment are in stock), to higher-powered payment methods like fee-for-service or payments per case (which encourage doctors to show up for work and to make sure they have drugs and equipment).

So, what should the Lancet’s map have shown?

It wouldn’t be straightforward to calculate but one possibility would be the amount of spending needed to bring everyone up to the de facto coverage enjoyed by the group with the most generous benefit package. Does anyone have any other ideas?

And am I right that the coverage challenge is not actually about achieving universal coverage, but rather about reducing inequalities in coverage? If so, where do we go wrong in policy discussions—if at all—by misleadingly talking of reaching “universal coverage” when everyone already has some coverage?


Adam Wagstaff

Research Manager, Development Research Group, World Bank

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