Going Universal”: 24 Countries and the “How” of Universal Health Coverage Dec 28, 2015

Going Universal”: 24 Countries and the “How” of Universal Health Coverage

In recent years, the UHC movement has gained a lot of traction. September 2015 saw the passage of Sustainable Development Goal 3, target 8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines, and vaccines for all.

On December 12, 2015, the world celebrated the second annual Universal Health Coverage Day to commemorate the anniversary of the unanimous United Nations resolution calling for countries to provide affordable, quality health care to every person, everywhere. More than 100 countries and 500 partners participated in UHC Day this year, proving yet again that #healthforall is on everyone’s mind.

In the spirit of UHC Day, the Results for Development Institute (R4D) and the DC Health Systems Board, in collaboration with the World Bank and the Joint Learning Network for Universal Health Coverage (JLN), held a robust discussion on key takeaways from the newly-released ‘Going Universal: How 24 developing countries are implementing UHC from the bottom up’ series, including various perspectives on how policymakers can tackle common challenges such as: expanding coverage, expanding benefits, domestic resource mobilization, improving service delivery, and strengthening accountability.

The discussion, which took place on December 16 at the R4D headquarters in Washington D.C., featured an exciting lineup of speakers, including:

  • David de Ferranti, President and CEO of R4D – Moderator
  • Daniel Cotlear, Lead Economist and Task Manager of the Universal Health Coverage Studies Series (UNICO) at the World Bank – Presenter
  • Karen Cavanaugh, Director of USAID’s Office of Health Systems – Panelist
  • Davidson Gwatkin, Senior Fellow at R4D – Panelist
  • Amanda Folsom, Program Director at R4D – Panelist

Daniel Cotlear, a Lead Economist at the World Bank, believes the publication brings further good news to supporters of UHC. The book shows how 24 developing countries are hard at work to achieve bottom-up UHC through programs that are new (<10 years old); large-scale (cover 1/3 of the world’s population); and transformational (change the way health systems work).

Expanding coverage starts with the poor

Many countries have realized that poor people should not pay for healthcare, and have therefore adopted a “bottom-up” approach that begins by targeting the poor before reaching other groups. This approach calls for countries to make a concerted effort to identify (through citizen identification systems), target, and enroll the poorest and most vulnerable populations onto their UHC schemes.

Expanding benefits means being explicit

Most countries, as part of the new UHC reform, are going beyond providing the basic MDG packages. They are now making the benefits that they provide clear and explicit--there's no longer the general promise that "all your needs will be covered." Rather, most of the countries are explicitly stating what is being covered, or at least, what is not being covered.

Managing Money through collaboration, not competition

In terms of managing money, the authors found that most countries are leveraging—not replacing—the Ministries of Health. This shows an attempt, on the part of countries, to reform and improve their existing health systems. The study found that UHC programs are designed to leverage public spending already used to finance public providers under the Ministry of Health—making these programs collaborators, not competitors with the Ministries of Health.

Improving Supply requires being flexible

The study found that all countries have demonstrated greater flexibility in public hiring and in the management of public providers. Another important finding was that half of the UHC programs studied utilize private providers—much higher than was previously the case, though certainly not 100 percent. Finally, Cotlear spoke of the fact that accreditation systems are everywhere. However, these systems are ubiquitous and there is little evidence to show them improving quality.

Strengthening Accountability

Many countries are using arms-length delegation along with output-based financing. In some countries, this means a split between purchasers and providers. In other countries, this means a new way of establishing inter-fiscal relations. There is also a stronger effort from most countries to collect data.

Going forward, countries face several policy decisions. For example:

  • Should they adopt a bottom-up or trickle down approach? Should they pick supply-side programs or demand-side programs involving purchasers?
  • Should there be a greater focus on expanding coverage to non-poor informal sector? Which path should they take: contributory or non-contributory?
  • What additional benefits should programs include next: Inpatient, specialist outpatient, expensive drugs, etc.?

USAID’s interest in UHC echoes many of the points addressed in the “Going Universal” series, said Karen Cavanaugh.

The book was especially helpful in guiding some of Cavanaugh’s work on promoting UHC in Bangladesh. The chapters on strengthening accountability and identifying target populations were, in particular, very relevant for Cavanaugh and her team when they traveled to Bangladesh.

“What we discovered in Bangladesh is that the move towards UHC is going to require an understanding between the population and the government about what the relationship between the two is,” she explained, “We tried to figure this out by using a lot of the very helpful content from the book. Something that we discovered is that you have to be able to identify your target population. You have to be able to identify the poor.”

In addition to identifying and enrolling the poor, Cavanaugh believes that countries need strong accountability systems in place. In Bangladesh, for example, any major health reform that gets passed will need to take into account the relative power of the different parties (national and local political leaders, private and public providers, the general population, etc.).

Globally, USAID wants to build a strong evidence base of what countries are currently doing to achieve UHC. On a country level, USAID wants to work with countries to improve their quality and cost of services, distribute essential medicines to people, build capacity of health workers, and improve electronic databases to capture information.

Amanda Folsom, who works extensively with the Joint Learning Network for Universal Health Coverage (JLN), discussed how countries can make population coverage the foundation of UHC.

"There are so many big and tough choices at the policy level. [Should countries cover] more services or more people? Do [countries] start at the formal sector or informal sector?”

Through her work with the JLN, Folsom mentioned that financial sustainability is huge. In order to expand population coverage, countries need fiscal space to cover the population, political commitment at the highest level, and a greater focus on the purchasing side.

“What we're finding is that a lot of countries have focused more on the revenue side but not on the purchasing side, which needs more attention going forward. We need to look at ways to increase efficiency, value for money, and open up fiscal space to expand population coverage,” Folsom said.

In many ways, the book’s focus on covering the poor is a major conceptual advance, said Dave Gwatkin. In the past, many countries believed in a trickle-down approach, where they would target the rich first and the poor last. However, this system would take years to cover the poor. The book’s approach, on the other hand, urges countries to really be cognizant of the populations that need access to healthcare the most. 

Though tough policy questions and tradeoffs continue to plague the minds of policymakers everywhere, Cavanaugh closed the discussion on a bright note.

“I see a future where countries have grown economically. People have moved out of poverty…I think we are going to be seeing that health systems strengthening, with a primary health care focus, is going to be key to achieving UHC and global security.” 

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