(This CRI post is not a reflection of our editorial position but published as part of our continued commitment to provide intellectually diverse opinion to our readers)
In health policy circles, the acronym with the buzz is UHC. It is used interchangeably for both Universal Health Coverage and Universal Health Care, although the accepted expansion is Universal Health Coverage.
Universal Healthcare, as the term suggests, is defined as the universal guarantee of healthcare to all citizens. It implicitly affirms healthcare as a right. The colossal scope of UHC necessitates government involvement to ensure its success. Governments do this either through legislation, mandate, or regulation. Achieving Universal Health Care is dependent on balancing two critical factors – coverage and cost. The details of delivery and access are addressed under the broad umbrella of coverage while health economics wrestles with the tough problem of the cost and funding of the details. For the present, coverage has precedence. Globally, healthcare delivery systems are somewhat in place even if, in many cases, rudimentary. Yet many millions around the world go without access because they can’t afford it. UHC models were developed internationally, to plug the gap that kept people out of the healthcare system and to satisfy the moral, ethical and economic need of progressive societies. No one model fits all groups. Member countries are working in close collaboration with the WHO to develop indigenous versions that incorporate the local culture and better serve the local community.
UHC is a globally recognized public health concept, goal and aspiration that varies in its details according to the population it aims to serve. Therefore, the term does not seek to define standards but expresses within it the components and characteristics of an affordable health system accessible by all. These include: people, services and needs; where people should get free and affordable medical services according to their needs1.
A concise yet comprehensive definition has been articulated by the HLEG (High Level Expert Group) report2, commissioned by the Indian Government to develop a blue print for health reform. Here, UHC is defined as: “Ensuring equitable access for all Indian citizens regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality as well as public health services addressing the wider determinants of health, with the government being the guarantor and enabler, although not necessarily the only provider of health and related services.”
At the level of the consumer, UHC aims to provide the 4As (affordable, accessible, assured quality and appropriate health); whilst simultaneously guaranteeing the 3Es at the delivery platform (efficiency, effectiveness and equitable health with accountability)
Making the case for UHC:
The argument for UHC can be neatly summed under three headings: 1. Moral/ethical, 2. Economic and 3. Financial hardship
The moral/ethical question: The political and economic dialogue has spilled over into health with the oft touted question; is health a responsibility or a right; a duty or an entitlement? For those that work in the health sector and for the people who have a personal experience with illness, this question is moot. Their experience attests to the common knowledge that while responsible health behavior leads to better outcomes; that alone, in and of itself, cannot guarantee freedom from debilitating disease. Linking better health to responsible behavior is mistaking the correlative for the causative. Our bodies are biological machines. Despite the adoption of the best possible practices; there are times (the simple process of aging is itself an example) when the balance tilts to infirmity and/or disease. At that point, can a society dissociate itself from the obligation to provide the benefit of available treatment and knowhow to a large swath of its people simply because of financial considerations? Health is a right to be enjoyed by all; not a privilege to be enjoyed by a few. This is also asserted as such, by Article 25 of the UN’s Universal Declaration of Human Rights3.
Economic inequity: We live in a large heterogeneous structure called society, within which actions are enmeshed and interrelated with outcomes. Health is a complex system within this framework. A healthy population is a determinant of economic and social development. Contrarily, a society wherein large numbers of people are ill or do not have access to treatment languishes from a marked waste of human potential, man-hours and productivity. The chasm in health metrics is an ever widening one, between rich and poor nations; between the haves and the have-nots. A recent WHO report4 describes the socio-economic disparity in stark numbers: A citizen of a wealthy nation can live up to 40 years longer than someone in a poor country. Of the 136 million women who give birth annually, about 58 million (43 %) receive no medical assistance during childbirth or the postpartum period. Per capita health care spending statistics reveal more of the same, ranging from around 6000 USD in wealthy nations to 20 USD in the poorest. Traditionally, countries that have large gaps in economic equality have more difficulty transitioning from private systems to a public funded UHC. Health and economic inequity make the system lopsided and promote unstable growth with the ultimate consequence of social unrest, chaos and collapse.
Financial Hardship: In the context of health, the WHO4 defines financial catastrophe as spending that exceeds 40% of household income on health after basic costs have been met. Even for those that can afford health to some moderate extent; the potent combination of rising costs and inadequate coverage can lead to financial catastrophe in a health crisis. This is true across the spectrum of nations from the very rich to the very poor. Medical expenses are the commonest cause of bankruptcy in the US (almost 60 % of personal bankruptcy). At the other end of the scale, more than 100 million people around the world are pushed below the poverty line, annually, because of medical bills and another 150 million suffer financial hardship.
A cursory look at the graph of health care costs worldwide shows movement in only one direction – upward. Countries that have a more homogeneous, less fragmented system of paying for health are able to better contain costs. At the same time, they also provide an equitable standard of services. More than 3 billion people around the world rely on direct payment (out of pocket) to pay for medical care. High out of pocket costs invariably result in people choosing to not take treatment at all and often, women and children are the first to fall through the money gap. Health economics research has consistently proven that wherever direct payment is the dominant reimbursement method; fewer people can afford to purchase health; people with precarious financial situations teeter into poverty and/or medical bankruptcy and those that can afford to pay at the time of need, face rising costs and unaffordability at a later time. The solution to keep costs down is to increase coverage, pool funds, pool financial risk, standardize reimbursement, make it accountable and reduce direct payment to lower than 15% of total cost.
|WHY IS UHC AN IMPERATIVE AND URGENT NEED:
- More than 11% suffer severe financial hardship every year, stemming from a health related cause
- More than 5% are pushed into poverty and health bankruptcy every year. The economic and social costs of this to a society are a looming crisis
- As populations age, and as medical advance leapfrogs us into the era of tissue engineering; people will live longer and disease will get more chronic. Chronic illness threatens the financial stability of an individual, a family and a society and is expected to absorb 70% of all healthcare
(Figures from the WHO 2010 Health Report on Health Systems Financing4)
EVOLUTION AND CRITERIA
International accreditation of the right to health was first achieved in the Universal Human Rights charter in 1948. This position was ratified again in 1966 by the International Covenant on Economic and socio-cultural rights. These were followed by the Alma Ata Conference in 1978 that defined health, for the first time in a positive context, as ‘a state of wellbeing and not merely the absence of infirmity’. Alma Ata also captured the public health goal for nations in a Declaration, “Health for All”. It brought Comprehensive Primary Health Care (CPHC) to the center of health reform and stressed a holistic approach that integrated social development with health.
Hardly was the agenda set at Alma Ata, when a movement that shifted focus from CPHC to Selective Primary Health (SPH) took shape; first in a conference in Bellagio in 1970 and later endorsed by both the UNICEF and the World Bank. SPH rejected the holistic approach of CPHC and launched instead the GOBI program that focused on four vertical and distinct child interventions – Growth monitoring, Oral Rehydration, Breastfeeding and Immunization. In 1982; this was expanded into the GOBI-FFF to include food Supplementation, Family planning and Female literacy.
Many nations followed the lead established by the international organizations and shifted priorities accordingly. Two decades on, the consequences were visible. While there was definite improvement in these predetermined areas of interest; overall public health metrics had deteriorated and the move towards ensuring the universal right to health for populations was severely derailed. SPH had translational difficulties too. By standardizing implementation models; it ignored local sociocultural determinants of health which are important to policy success and thus, struggled to translate its goals into positive outcomes.
By 2000, many lessons had been learnt and the UN once again included the central role of the universal right to health and CPHC in the millennium development goals. In the past decade; the WHO has taken the lead in setting the public health agenda of nations with two major statements. In 2005, it passed the UHC resolution – defining UHC as the international standard for progressive reform and development in health, and in 2008, the WHO annual health report brought CPHC back to the core of its global health program. Despite these laudatory efforts, international organizations like the WHO and the UN have normative functions of setting agendas and directing efforts. On the ground, both UHC and CPHC are political processes and require political and governmental will for success.
Apart from and alongside these institutional efforts, individual nations have charted their own course towards fulfilling their responsibilities to the health of their peoples. The country experience with UHC is long and varied.
National aspirations for UHC preceded the international impetus. Nationwide health insurance was set in motion by Germany in the late nineteenth century. The UK followed this example by instituting NHS in 1911. Today, both these robustly far thinking systems continue to thrive and sustain their populations. Further, all of the OECD (save the USA) nations have followed suit and provide near total health insurance coverage, of some sort, for their populations. At the present time; 58 countries around the world have achieved and delivered on UHC and 23 more have legally mandated it.
Criteria of coverage
What comprises the criteria of coverage? How is a country determined to have achieved UHC?
Since coverage cannot include 100% of the people for 100% of services; UHC is accepted as achieved when: 1) more than 90% of the population has insurance coverage and 2) more than 90% of the population has access to maternal skilled health workers.
UHC broadly encompasses two themes: population coverage with access to an affordable package of healthcare services and the infrastructure for delivery with an adherence to a minimum quality standard. Simple coverage of a population does not mean much unless it comes with the guarantee of quality and services. It is easier to define what constitutes population coverage than to agree on the package of services that insurance will cover and the quality of delivery. At this level; the decisions become intensely political and local and no one blanket model or system can be laid down across cultures and continents. The most that international organizations can do is lay down the norms for practice and work with national ministries to develop a health system that best suits their needs and sets them firmly on the UHC road.
Can governments of poor countries afford UHC? The general consensus and the empirical evidence say, yes. Poverty, per se, is not seen as a deterrent; contrariwise, inaccessibility to health is one of the factors contributing to poverty. A more-true deterrent to the implementation of UHC is the lack of functioning systems and/or the infrastructure that will ensure delivery and convert the program into a success. Much of the success of UHC is therefore in the domain of the political will and muscle of the government to implement true reform in infrastructure and reform. Mexico, Thailand and Chile are shining examples of success.
Health has thus moved into the purview of universal fundamental rights. The dramatic progress in treatment options (drugs, devices and procedures) has increased the potential for cure, extended lifespans and enhanced quality of life despite disability. Every individual has the right to expect to avail of the benefits of these advances in science. Health is a need, not an entitlement. Not an avoidable item in a consumer’s budget. It is fundamental to living and ranks high amongst people’s priorities for a good life and for a measure of happiness.
(This is the first article in a series. The next will focus on Thailand’s experience with UHC and compare it with existing systems in Malaysia)
1. The long road to Universal Health Coverage, The Rockefeller Foundation: http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf
2. HLEG report on UHC for India: http://uhc-india.org/
3. Universal Declaration of Human Rights: http://www.un.org/en/documents/udhr/
4. The world health report 2010 on Health Systems Financing. http://www.who.int/whr/2010/en/index.html
(Image Courtesy – http://www.businessreviewindia.in/)