By Karl Hofmann and Simon Cooke
World Health Organization Director-General Dr. Margaret Chan calls universal health coverage (UHC) “the single most powerful concept that public health has to offer.”
But what is UHC? Officially, UHC means that every person, everywhere, has access to health care without suffering financial hardship.
Indeed the World Bank, once a staunch advocate of out-of-pocket fees for users of health care, has conceded that UHC can deliver better health to populations, with President Jim Kim describing the bank’s previous stance as “ideological” and contrary to overwhelming evidence.
Today it is no longer a question of whether UHC will be implemented, but when and where next. Ghana and Indonesia are out in front, with many other developed and developing countries committed to eventually replacing out-of-pocket fees and voluntary private insurance with full public financing.
The barriers to success are obvious and systemic, and the widening gap between rich and poor hinders access to health.
In many parts of the world today, those with money can protect their health by paying for private insurance and health care as needed. Poor people are often left unprepared. When they do need care, making out-of-pocket payments may mean making choices between food, schooling or other basic necessities. In the worst cases, the cost of health expenses can push a poor family to financial ruin.
Here’s where details matter. For UHC to shift from noble to possible, to probable, three things need to happen:
1. Start with financing reforms for poor people. UHC planning must address groups who need care the most — the poor, women and children. Financing reforms have often started with coverage just for the employed, and have been too slow to expand coverage to those at greatest risk and in greatest need of subsidy from richer and healthier groups. An example is Tanzania, a leader in extending health insurance initiatives. The Tanzanian government rolled out the National Health Insurance Fund 15 years ago, followed by other health insurance expansion initiatives, but to date only 16 percent of the population is covered.
2. Better balance treatment and prevention. Reforms that focus too narrowly on treatment alone won’t deliver value-for-money in the long run. The best way to avoid poor health, and the financial hardship that can follow, is to prevent it. In particular, we need to do a better job of making reproductive health services widely available. Increased access to contraception can save governments up to $6 for every dollar invested. But in too many countries — like Ghana or Vietnam — contraception has been largely left out of the benefits package of UHC. The savings to poor households — by preventing a mother’s death and allowing families to space their children — are immense. It’s a fact: when women can decide when and if to have a child, girls can finish school, go onto further education and join the workforce, and so promote economic development and gender equality.
3. Include the private sector. Around the world, governments are recognizing that public financing for health must be dramatically scaled up. At the same time, a majority of poor families rely on private health providers to meet their needs. In countries like India and Nigeria, we won’t see an end to inefficient and often inequitable out-of-pocket payments if we don’t also tackle the way private health services are financed. Bringing private sector providers into the mix also allows for increased choice and competition — both important market forces. National insurance is just one promising example that can make it easier for people to access both public and private health providers.
It goes without saying, that partnership is critical to success. Population Services International and Marie Stopes International, at times competitors, are working more closely than ever to make UHC a reality. Under the Africa Health Markets for Equity program, we’re linking our vast franchised provider networks with publicly financed insurance schemes in Kenya, Nigeria and Ghana, and similarly collaborating on the U.S. government’s Strengthening International Family Planning Organizations project to link family planning with national health financing across the globe.
So on the first-ever UHC Day, let’s not celebrate. Instead, let’s address the tough questions and acknowledge that the devil is in the detail.
For UHC to become a reality we must make provision for the health of the most vulnerable, tilt our efforts towards prevention, and push for fair financing strategies that consider the realities of a world where private and public providers can exist side by side to deliver health care to all.
Karl Hofmann is president and CEO of PSI. Simon Cooke is CEO of Marie Stopes International.
Photo: A hospital in Bamyan, Afghanistan provides primary health care services. How can universal health coverage make the shift from noble to possible, to probable? (Credit: Sandra Calligaro / Aga Khan Foundation / Canada in Afghanistan / CC BY-NC-ND)
