Time to put “health” into universal health coverage


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photo by: Patricio Marquez

While on a walk with my younger son over the holidays, we got into a good discussion about the future of health care.  After taking a class on health economics this past semester, he wanted to share his perspective about the need to “do something” to deal with the high cost of medical services that are pricing people out of health care in many countries.

Contrary to arguments used to justify the need for expanding access to services without putting patients at risk of impoverishment when they have to pay out-of-pocket for services rendered, even when they have health insurance, I was pleasantly surprised by his prescription.  He said:  we need to focus on “keeping people well” rather than only “treating the sick.”

As a public health professional, I could not agree more. 

In 2015, we saw significant movement toward the goal of universal health coverage, culminating in a high-level meeting last month in Tokyo at which global leaders highlighted the need to accelerate progress toward affordability of care and access to basic services.

To achieve these objectives, and to ensure the financial sustainability of health systems, which can be severely undermined by the uncontrolled rise of health care costs, it is important that the push toward UHC include efforts to change lifestyle choices that contribute to chronic disease.

To be clear:  this is not only a predicament affecting developed countries.  Given the growing relative importance of non-communicable diseases and injuries across the world, developing countries are also starting to face this unavoidable dilemma but without the resource base, health systems or coverage levels of developed countries.

Are disease and injury prevention then the “cure” for this global challenge?  In large measure this may be the case.  However, this course of action requires a fundamental rethinking of how to best keep people healthy and out of the hospital. 

For starters, there has to be a widespread realization among policymakers, employers, health insurers, service providers, and the population at large, that the lion’s share of health care expenditures goes for treating diseases and injuries that could be “prevented”.  This, however, would require priority attention for supporting population-wide efforts to tackle social and behavioral determinants of ill health and premature mortality, such as policy measures to curb tobacco use, second hand smoke, alcohol and substance abuse, obesity and Type-2 diabetes, road traffic injuries, and in some countries, gun violence.

Besides regular collection and dissemination of data on the nature and characteristics of health risks and associated conditions needed to guide policy formulation and implementation, including funding allocations, active involvement of different stakeholders is required to advance this public health agenda.  

Taxation and regulatory measures, as well as “institutional nudges” such as offering healthier lunch options in the staff cafeteria, can help influence behavior change and reduce the social acceptability of health risks. High taxes on tobacco that make cigarettes unaffordable, for example, coupled with smoke-free public spaces and bans on advertising, have been shown to reduce consumption and prevent addiction among youth. Community-based nutrition and physical activity programs have also proved to be effective in helping control obesity and the onset of diabetes.  Strict enforcement of laws against drunk driving has contributed to significant reduction of road fatalities across the world. 

Insurance arrangements and health care organization and payment innovations are increasingly used in different countries to advance this public health agenda as well.  For example, insurance companies, by charging lower premiums for those who quit smoking, lose weight, and pass screening tests for artery-clogging cholesterol, high blood pressure, and high sugar levels, provide an incentive for individuals and families to assume responsibility for their health.   

Health care reforms that promote care coordination among hospitals, physicians, nurses, therapists and home care providers in accordance with evidence-based care protocols and that reimburse services using annual or capitated fees for members of an assigned population, are used to promote collaborative structures centered on ambulatory, community-based, primary care services.  These arrangements have the potential to reduce costly emergency room visits and inpatient services through early detection and treatment of chronic diseases and by keeping people healthy and out of the hospital. 

There are also generic drugs to treat most of these conditions as a secondary prevention measure.  Statins, for example, are prescribed to reduce cholesterol and lower the risk of heart attacks and strokes.  But measures to keep people on medication adherence need to be adopted to reduce the risk of disease progression or the development of multi-drug resistant conditions, including facilitating access to low-cost generic drugs, since the high cost of drugs that control chronic diseases may be a disincentive to use them.

The use of smartphones and specialized apps can help keep people healthy, via text message reminders about medication schedules; keep track of lab results and vital signs; and monitor progress in achieving personal health goals.   

Many employers are offering on-site clinics as part of workplace health or wellness programs to help workers access health promotion counseling to  encourage exercise and diet regimens, and to provide secondary prevention services such as flu vaccination, screening for high blood pressure and blood sugar levels, and psychosocial support for anxiety and depressive disorders and alcohol and substance abuse.  In the United States, for example, it is estimated that one-third of firms that have 5,000 or more employees now have such clinics.

As we start the New Year, it is time to make the case for giving more attention to health promotion and disease prevention as part of scaling up of universal health coverage.  Let’s make our goal healthy people and not simply more health services.  The realization of this goal, however, has to be a shared social responsibility!

Follow the World Bank health team on Twitter: @WBG_Health

Dallas Morning News series on US health care spending: 
The Dallas Morning News: Editor’s Note: Series explores the high cost of health care
Cost of Care: The U.S. health care system is bleeding green
Cost of Care: High Dallas-area hospital prices spur revolutionary ideas
Patient Responses to Incentives in Consumer-directed Health Plans: Evidence from Pharmaceuticals

Making the public health case for tobacco taxation

Stopping the Carnage on the Roads: a Multisectoral Challenge

Diabetes and Overweight: A Growing Global Burden

Healthier Workplaces = Healthy Profits



Patricio V. Marquez

Senior Associate, Johns Hopkins University Bloomberg School of Public Health

Abdulsalami Nasidi
January 14, 2016

A wonderful write up and I absolutely agree with your Son. What is the need of having the best that is not accessible or not affordable. In the circumstances we are finding ourselves, and from the experience we are having from emergence of disease outbreaks that come to shock the fragile health systems, such as we saw with ebola experience, keeping people safe and healthy is the way forward.
For developing pcountries in particular, building a resilient health system and empowering the public to access health is the answer.

January 15, 2016

...insurance companies, by charging lower premiums for those who quit smoking, lose weight, and pass screening tests for artery-clogging cholesterol, high blood pressure, and high sugar levels, provide an incentive for individuals and families to assume responsibility for their health.
We used to have that here in America, but the ACA did away with it by insisting on (and making part of the law) that all persons regardless of level of health, are to be accepted into the system. Now that near-universal coverage is here, to tell people they cannot access affordable coverage unless they meet a certain set of criteria is akin to health-ism (if there IS such a thing).
I myself made a similar proposition on my blog many years ago (the blog is long dead), only WITHOUT the discounts, thinking this would help weed out the people who aren't really interested in their health, and don't care to do anything to help themselves. But what would the people who DON'T meet those stringent requirement do for healthcare? How would they get tested to see if they qualify or not--wouldn't you have to have coverage already just to find out? Paying cash for lab work is pretty pricey, and out of the reach of most low-income people.
I also suggested the government subsidize basic gym memberships. But then, what are the disabled to do when their disability prevents them from using gyms (such as wheelchair-bound or missing limbs)?
We cannot exclude here, because the method of exclusion would lead to other exclusions. I commend your child for thinking ahead--I wish others would do the same thing. I hope you told him all he can do is his own part by eating right, exercising, and doing his darndest to avoid the risks of accidents (including health accidents, like HIV, unwanted pregnancies, addiction, etc.). He needs to live his life in such a way as to NOT need insurance!
If more of us lived our lives this way, "insurance" would be quaint old term lost in the annals of history (along with the chronic diseases that made the health crisis we currently live with today).

January 15, 2016

Many thanks for bringing to the table a debate concerning wellness programs that is currently being played out in the US. See today's story by Rebecca Greenfield on Bloomberg Business that clearly describes different dimensions of this debate. Bottom line, as the title of the article in the BB suggests, "Employee Wellness Programs (are) Not So Voluntary Anymore." The article notes that "wellness programs, an umbrella term for employer-supported initiatives to improve and promote employee health, were one of the most popular "benefits" last year, with three quarters of organizations surveyed by the Society for Human Resource Management offering some sort of program..... And successes have been claimed. Companies that require health care surcharges for smokers, for example, say employees subsequently cut tobacco use, a recent SHRM survey found." More on this story see:

Robin T. Kelley
January 15, 2016

Well said! It is interesting that for some, wellness is more a matter of economics. This not only means that some times, particularly in the developed world, we find "healthy" produce and goods more costly than non healthy items,but also, even for those who have a financial choice, the motivation is not there. A piece on NPR today, Jan. 15th, discussed how economic value and not just reductions in insurance premiums or savings on gym membership, but really having tangible real finances along with emotional support lead to more healthy behaviors or changes. Interesting.

Ulysses Dorotheo
January 19, 2016

Your son has a good head on his shoulders. If only more people, young and old, thought and did more to prevent diseases than curing them.