Ten (Plus One) Things to Think About When Planning and Implementing Universal Health Coverage

Photo Credit: UN Foundation

This blog originally appeared on June 11, 2014 on The Rockefeller Foundation website.

In a previous post, I wrote about the Seven Things You Should Know About Universal Health Coverage (UHC). Here's another post digging deeper into the "how to" of making reforms happen, which list considerations critical to the planning, implementation, and measurement of UHC.

Essential Ingredients: Three necessary preconditions for UHC

1. Political commitment and will: Universal health coverage is about more equitable access to health services and financial protection. This is, historically, a profoundly political issue, as Jesse Bump notes. Sustained political commitment must precede health reforms aimed at moving towards universal coverage.
2. Fiscal space: For political will and commitment to translate into action toward UHC, governments require fiscal space. This can be achieved by some combination of efficiency gains, macro growth (with corresponding growth in health spending), and/or reallocating government budget to health spending. For more on this, see Di McIntyre and Filip Meheus' Chatham House working paper on Fiscal Space for Domestic Funding of Health and Other Social Services. See also Ajay Tandon et al's World Bank working paper on Reprioritizing Government Spending on Health.
3. Smart governance: Health systems reforms aimed at moving toward UHC require strong analytical capacity to design, implement, measure, and manage complex technical challenges. Many countries implement universal coverage through a mixed health system framework that incorporates both public and private insurers and providers. Sania Nishtar's article addresses the mixed health system syndrome and Sara Bennett and others' article shares how countries have approached developing stronger analytical capacity through health policy research institutes and think tanks.

Key Technical Challenges: Issues that must be tackled to implement UHC

1. Pooling: Creating risk pools—subgroups of the population among whom the costs and benefits of care are spread—is essential for moving toward UHC. From an equity standpoint, risk pooling enables cross subsidies from rich to poor, from lower to higher risk people, and from relatively younger to relatively older. It is a vehicle for ensuring adequate provision of health services across population groups. Pooling promotes improved health services purchasing arrangements and population health by enabling the poor and sick to access care affordably. For more information, see this primer on risk pooling from the World Bank, as well as this recent synthesis of lessons from eleven case studies of countries moving towards UHC.
2. Purchasing: Strategic purchasing of health services through provider payment mechanisms is critical for deciding how resources are allocated, and how services are delivered. Provider payment systems create incentives, and the way providers respond to these incentives influences how resources are allocated and used. This has implications for efficiency, depth, and quality of services. Read about the Joint Learning Network's work on provider payment mechanisms, and this manual on how to design and implement provider payment systems.
3. Enrollment: Enrolling informal workers, who account for 40-90 percent of the population in most low and middle income countries, is a huge challenge. Most health system stewards employ some mixture of three discrete approaches: a) using a tax-based system to offer health coverage to all people within a country; b) enrolling informal workers by "building out" from covering the formal sector through contributory schemes; or c) employing a combination of tax-based subsidies and contributions to enroll informal workers. See Ricardo Bitran's World Bank working paper on the challenge of informal employment and paper on Closing the Gap led by Annette Ozaltin and Jack Langenbrunner.
4. Service provision: Planners of UHC often place a great deal of focus on ensuring that service provision is geographically available, yet a bigger challenge is ensuring that required services are available. This is also known as effective coverage. Health professionals must be on duty, trained, and motivated, and adequate equipment and pharmaceuticals must be in stock and affordable. For an example of how service readiness impacts upon UHC, see this working paper from the World Bank in Indonesia.
5. Quality: Health services are of limited value if their quality is low. Even if health facilities are properly staffed and equipped, developing payment, regulatory, and/or support systems to incentivize and deliver consistently high quality care is an ongoing challenge. This depends as much upon staff knowledge, motivation, and adherence to protocols as it does having appropriate staffing and equipment available. Quality is often a "hidden" challenge for UHC (see examples from India and China), as it can be difficult to track facility-level quality. In addition, patient response to poor quality is often to "self-refer" to higher-level facilities, putting additional strain on the system.
6. Information technology: Health information systems are the backbone of a working universal coverage system: they support enrollment, provider payment systems, coordinate patient care across settings, assist providers in following care guidelines, and monitor patient- and population-level outcomes.
7. Priority setting: A crucial question is what to cover: what package of high-quality services and interventions will be guaranteed? Setting priorities and allocating resources appropriately can help achieve improved overall health outcomes, promote equity, and provide the most efficient use of scarce health resources within a country. This also needs to be regularly updated to reflect changes in epidemiology, technology, evidence and social demands. The Center for Global Development explains.

The Bottom Line: Ultimately, one of the biggest considerations for any country implementing UHC is tracking whether reforms are having the intended benefit.

Monitoring and evaluation: It is difficult to assess progress without a clear and transparent system to monitor and evaluate results. This both provides a mechanism for citizens and civil society to hold governments accountable, as well as provides government with the necessary information to build upon success and address problems in real time. The World Health Organization and World Bank recently released a joint framework for Monitoring Progress towards Universal Health Coverage at Country and Global Levels: Framework, Measures, and Targets.