Richard Smith: Working towards universal health coverage

Richard SmithSome one billion people have no access to health care, while each year 150 million experience financial catastrophe and 100 million are pushed into poverty because of having to pay for health care. Those are some of the reasons why the world needs universal health coverage, said David Evans from WHO at the 13th Annual Scientific Conference of ICDDR,B (International Centre for Diarrhoeal Disease, Bangladesh) in Dhaka.

Evans was the main author of the World Health Report 2010, which discusses how universal coverage might be achieved. Universal health coverage has been part of the constitution of WHO since it was founded in 1948, but, said Evans, we are “a long way off globally.”

Universal coverage is vital for progress in much else, including providing services, improving health systems, and hastening development, said David Ferranti, president of Results for Development in the US. Hence much is going on globally and locally, with Thailand having achieved universal coverage after a “long march of 27 years” and India debating how it can be achieved. But it is, said Ferranti, an “arduous task” and research is essential for achieving it.

Complete universal coverage would mean not only that everybody is covered but also that all services and all costs are covered. No system anywhere has 100% coverage of the population, 100% coverage of services, and 100% coverage of costs—without waiting. Usually some services are restricted, and patients must meet some of the costs.

To achieve universal coverage countries must raise sufficient funds, remove financial barriers, and minimise inefficiency and inequity. Just to achieve the Millennium Development Goals, which do not mention non-communicable disease and injuries and so do not mean universal coverage, WHO estimates that low and middle income countries need to spend $42 per head in 2011 increasing to $65 per head by 2015. Yet 31 of 49 countries are currently spending less than $35, and only eight have any chance of reacing $65 by 2015 from their own resources.

More money will have to come from governments, and yet government spending on health is less than 1% of GDP in Pakistan, India, and Bangladesh. African governments committed themselves in 2001 to spend 15% of their budgets on health, but “as many have gone backwards as forwards,” said Evans.

Shakil Ahmed from the National Institute for Global Health in Melbourne said that in countries that have achieved universal health coverage governments spend at least 5-6% of their GDP on health and out of pocket payments are less than 30%. He applied these criteria to six Asian countries, and showed that China, Mongolia, the Philippines, Cambodia, Laos, and Vietnam are a long way off with Mongolia being the closest.

Governments can also look for new sources of funds, and WHO report lists some 20 different ways, including a sales tax as in Ghana, a tax on currency exchange as in Gabon, “diaspora bonds” (sold to expatriates), and a “solidarity levy” as in Gabon. It’s for governments to decide, but WHO pushes hard for “sin taxes” on tobacco and alcohol.

The second essential for universal coverage is to remove financial barriers and ensure that people are not impoverished by the costs of health care. This means, said Evans, some sort of prepayment, either from taxes or insurance. Community insurance and microinsurance are both good things, but neither are large enough to adequately spread risk. Taxes have to be collected (and often are not in low and middle income countries as well as in Greece), and insurance has to be compulsory.

Throughout the conference people emphasised that systems that include only the poor will inevitably be second class. Srinath Reddy, president of the Public Health Foundation of India who is chairing an Indian government commision  to move towards universal coverage, made this point strongly in his keynote address.

Few people purchase insurance in low and middle income countries, so some 80% of payments are “out of pocket.”  Jahangir A M Khan from ICDDR,B showed that growth in economies in low and middle income countries has not led to a higher percentage of GDP being spent on health but has been associated with increased private expenditure. Tahmina Begum, a consultant from Dhaka, confirmed that the growth in expenditure on health in Bangladesh is private expenditure with out of pocket spending rising from 57% in 1998 to 64% in 2007. Drugs account for almost three quarters of the costs.

Syed Abdul Hamid from the Institute of Microfinance in Dhaka studied over 4000 housholds in 120 villages in Bangladesh and found that one in three of the households have experienced catastrophic health payments and have had to sell assets or go to money lenders.

A third task in achieving universal coverage is to minimize inefficiency and inequity. Many countries have highly inequitable health services with the small elite travelling abroad for treatment, the middle class accessing high quality care through private systems, and the poor, the large majority in most of these countries, left with low quality services or none at all.

WHO calculates that in most countries something like 20-40% of resources spent on health care are wasted. The World Health Report has a long list of ways to improve efficiency, including getting the most from technologies, reducing waste, error, and corruption, and critically assessing which services are needed.

“Every country can do something to move towards universal health coverage,” concluded Evans.
Reddy outlined the principles with which India is moving to universal coverage: universality, equity, comprehensiveness, financial protection, quality of care, protection of patient rights, choice, non-exclusion, and portability. Only government can make universal coverage happen, he said, and India has committed to spending 3% of its GDP on health by 2017 with 70-75% being ringfenced for primary care. The aim is for a single payer with private sector provision and most drugs available for free.

But finance will not be enough, said Reddy. Human resources are very important, and a doctor centric model will not be possible for primary care. There must be substantial “task shifting” with many more non-physician health providers.

RS tweeted throughout the three day conference, and if you would like to read the tweets follow him at Richard56 and go to the page that has only his tweets.

Competing interest: RS spoke at the ASCON conference and chaired two sessions. His expenses were paid by the UnitedHealth Chronic Disease Initiative, which he directs, but ICCDR,B gave him lots of good food and a ticket to the Bangladesh v South Africa World Cup cricket match.

  • David Dror

    Hello Richard,
    Your summary reads like a charm, as always, but on content seems to me to be far too skewed toward the voice of politicians and too far removed from the issues that impede universal coverage. Most (if not all) the impediments have for years been caused by conflicting interests at the political/governmental level and unimpeded greed and unaccountability at the private health sector. Yet, those same two “top-down” sectors are projected in this blog, in this conference and elsewhere as “the only solution”. I fail to understand how those that have been the main causes of the problem, with track record of “successful failures” over more than 50 years, can still be treated as credible providers of solutions (that even claim monopoly role). Dubbing what is done at the base of the pyramid as “micro”, implying that it is too small and too fragmented and too irrelevant to offer a solution, seems incredibly short-sighted and arrogant, considering the history of health financing: the prevailing contributory system that is today generalized in France, Germany, Netherlands, Switzerland, Belgium, and increasingly in Nordic countries, Italy, East European countries and elsewhere (i.e. not anything “micro”) was originally launched by Bismarck, with zero government financial contribution and limited only to regulation specifying that all people should organize local and mutual aid bodies to pay for health insurance and sickness compensation of a small group of members. It has taken the Bismarckian model 125 years to become the prevailing model in continental Europe. Each mutual aid society alone was “micro”, but the federated and generalized patterns have made it both affordable and credible models. Government re-distributive activities (mainly through subsidies that are funded from taxes) have followed only when the system was essentially in place already, and only after the governments had developed good abilities to collect taxes fairly. This has really been in place only since 50 years.

    Much can be learned from this success, and side-lining it (as is done by Reddy from India, or by WHO that does not represent the taxation or social security arms of any government) seems to me an act of self-complementary attribution of central role that can hardly be expected to work in the future than it has hitherto in in any low-income country. Most governments (Reddy's India included) do not even have a register of their population, where more than 70% are in the informal sector and outside any contact with government, let alone any taxation system. To say that those who do not know their population, and have been able to collect only about 3% of that taxable income are “the only solution”, seems preposterous, out of touch and patronizing. Go to any village in India any you will see that the government is viewed as the problem rather than the solution. Therefore, if we really want to advance toward universal coverage, we cannot and should not do it as a “top-down” thrust, and we are well advised to capitalize on solutions that people have already been elaborating on the ground today.

    While I would not expect everyone to agree with this view, in fairness I think the blog (and the dialog) should reflect all views, and report on actions to elaborate “microinsurance” solutions that actually do something at the base of the pyramid, side by side with the views of those (well quoted in the blog and elsewhere) who have kept quite aloof from understanding how people at the base of the pyramid elaborate solutions for themselves even in the face of failing governments, corrupt medical providers, huge supply of counterfeit medicines and many other failings of the formal health system.
    David Dror (Hon. Professor, Erasmus University Rotterdam. Winner, Asia Insurance Industry's “Personality of the Year” Award 2009-10. And Chairman & Managing Director, The Micro Insurance Academy (MIA). MIA won the Asia Insurance Industry's “Insurance Education Provider of the Year” Award 2010-11.
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