[This opinion piece was originally published on Devex.com. In this op-ed, JLN Convener Rozita Halina Tun Hussein, World Bank Health Specialist Somil Nagpal, and JLN Network Coordinator Lead Amanda Folsom share five key insights that JLN member countries have learned about making universal health coverage a reality in their respective countries.]
The inclusion of health for all and financial protection in the Sustainable Development Goals was a watershed moment for the movement to advance universal health coverage.
Global support has spurred remarkable progress, with more countries than ever pursuing UHC. However, it is no easy feat to design and implement the reforms needed to make UHC possible, and it’s a formidable goal for a country at any income level.
But, for 27 predominantly low- and middle-income countries across Africa, Asia, Europe, and Latin America working toward or improving UHC, full access to essential health services may soon become a reality for their citizens — nearly 3 billion people.
To that end, the Joint Learning Network for Universal Health Coverage brings together practitioners from government agencies to accelerate this momentum — working to translate country experiences and expertise into actionable policies and practices. This community of practitioners from national health and finance agencies meets regularly to tackle common technical barriers to UHC in service delivery — especially primary health care — health financing and provider payment, data and information systems, and quality of care.
We’ve learned a lot through practitioner-to-practitioner learning, and here are five key insights we’ve gained along our journey.
1. Align health financing and primary health care goals.
As countries progress toward UHC, they grapple with dual challenges of how to provide universal access to essential health services and ensure financial sustainability. Recognizing the tension between these two goals, practitioners from eight countries produced a self-assessment tool to help fellow LMICs identify gaps in the alignment between their health financing and primary health care, or PHC, goals.
In Ghana, health ministry representatives discovered that the government was failing to reimburse a successful PHC program, which relocated health workers into communities to deliver preventive services in its Upper East Region, due to the lack of provision for community-based care reimbursement in Ghana’s national insurance agency.
Engaging in an inclusive assessment process resulted in consensus among stakeholders that primary health care must serve as a foundation for Ghana’s UHC goals, paving the way for planned reforms to strengthen its primary care and payment system, with a focus on introducing a PHC-oriented benefits package, provider payment mechanisms that incentivize preventive and promotive care, and automatic enrollment for patients in primary care programs.
2. Engage the private sector in the provision of primary care.
Most health systems need to engage both the public and private sectors to provide quality PHC services, but too often, the stewards of government health schemes lack essential information to engage effectively with private providers. Practitioners collaborating in the JLN’s working group on private sector engagement documented the importance of mapping out private providers to reveal where the public and private sector can work in tandem to deliver care.
Aiming to better integrate the two sectors, Malaysia’s Ministry of Health discovered through a two-year provider mapping exercise that private clinics tended to cluster in urban areas, whereas public clinics were dispersed throughout the country, exposing a need to better integrate and incentivize the private sector into service delivery across the country’s diverse geographic regions.
In Kerala, India, a public health insurance program increased the quantity of both public and private sector providers. The public health sector responded to the surge of private sector competition and growing patient choice of providers by reinvesting their insurance earnings to improve facilities, address the behavior of providers to attract more patients, and enhance the quality of patient experiences.
3. Leverage medical audits to improve quality of care and system efficiency.
Countries often struggle with the complexities of designing a strong medical audit system, but the results of medical audits provide crucial data to improving quality of care, increasing the efficiency of health systems, and reducing the cost of services.
With their medical audit system recognized as a gold standard, South Korea has regularly convened with eight JLN countries to both address gaps in practical knowledge and provide guidance on setting up medical audits and using the results, from identifying providers prone to fraud or poor quality of care, to conducting investigations. The result? A step-by-step, comprehensive toolkit for designing and improving medical audit systems using countries’ combined expertise.
Applying best practices learned from South Korea, the Philippines’ national insurance agency provided staff training on improving data quality and standardization in its newly established provider assessment system and is currently working toward defining trigger thresholds for fraud identification.
4. Use costing studies to inform evidence-based provider payment policy.
In discussions across our network, countries have identified costing to set evidence-based provider payment rates as the greatest technical challenge to developing payment schemes that incentivize providers to improve efficiency, deliver a higher quality of care, increase responsiveness to patients, and enhance the system’s sustainability.
Nine countries came together to co-produce the first guide that puts forward practical steps to designing a costing exercise that practitioners can employ in data-constrained environments. Even when compromises must be made, imperfect cost information to inform provider payment policy is better than having no cost information at all and is essential to informing how and at what rate health providers are paid.
To inform its provider payment policy, the Ministry of Health in Vietnam applied this approach to determine the cost per service in its fee schedule. Government hospitals estimated the cost of more than 700 services, ranging from a simple urine pH test to heart surgery. The cost data, along with consumption norms, were used to establish a standard fee schedule to effectively pay and incentivize providers to deliver high-quality care.
Policy analysts and costing practitioners can now reference the costing toolkit in an interactive online course based on the costing module, with support from the World Bank’s Open Learning Campus, that features focused lessons on the process of designing a costing exercise and analyzing the results.
5. Employ data analytics to monitor provider payment systems and quality of care.
Given the powerful effects that financial incentives have on providers for resource allocation and UHC outcomes, monitoring indicators that measure the quality and effectiveness of health services — and detect unintended consequences — are vital data points for payment systems.
Indonesia took a major step toward UHC in 2014 by unifying its public insurance schemes to provide health insurance to all Indonesians and strengthening its provider payment system to improve the quality of health services, bolster system efficiency, and contain rising costs.
Practitioners in the country’s national insurance agency used data analytics to monitor unintended outcomes of its new payment methods, such as providers selecting less complicated and more profitable patients, upcoding diagnoses or underutilizing primary care services.
The experiences of Indonesia and 10 other countries in monitoring data analytics within payment systems are documented in a toolkit developed specifically for fellow practitioners to design effective and routine monitoring for UHC-focused provider payment systems.
While considerable academic research and guidance are already available for countries on the journey toward UHC, the practical knowledge to address common constraints and support the tough and strategic decisions on policies touching health care systems remains an area with limited insights within the global body of UHC resources. Ultimately, countries need practical solutions to drive measurable progress toward UHC — and the JLN community believes that there’s no better place to find these solutions than from countries themselves.
The JLN serves as a country-owned and country-led hub to meet the demand from countries on their key UHC challenges as they explore solutions from the experience of other countries.
Photo credit: A pregnant woman gets a checkup at a health center in Ethiopia. Photo by: ©UNICEF Ethiopia/2017/Mulugeta Ayene / CC BY-NC-ND