Under JPG Teaching Fellowship

Permission from JPGSPH

CoE-UHC

Concepts and Principles of Universal Health Coverage

Tim Evans, Dean, James P. Grant School of Public

Health June 6, 2013,

Outline

• What is Universal Health Coverage?

• Why focus on Universal Health Coverage ?

• Moving towards Universal Health Coverage

What is Universal Health Coverage (UHC) ?

• A widely shared objective across all health systems

– World Health Assembly Resolutions 2005, 2012

• A “consensus value”:

– a universal right or entitlement to health

– justice, fairness and equity in health

– an intolerance of inequities in health

“Without health nothing is of any use, not money nor anything else” Democrit, 5th Century B.C.

“The preservation of health is … without doubt the first good and the foundation of all other goods of this life” Descartes,1637

"The health of the people is really the foundation upon which all their happiness and all their powers as a state depend" Disraeli,1877

Health as a Special Good

WHO Constitution 1946

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition (...)”

The right to health

Health Equity

The absence of unfair and avoidable or

remediable health differences between more or

less disadvantaged groups defined socially,

economically, demographically, or

geographically (Evans et al. 2001; Braveman & Gusman 2002)

Based on principles of social justice, it implies

that everyone should have a fair opportunity to

attain their full health potential (Whitehead 1990, Sen 2002)

Inequities in health

" there is no good biological reason why someone living in Sierra Leone's life expectancy should be a full 50 years lower than someone living in Japan".

Sir Michael Marmot, the Chair of the Commission on Social

Determinants of Health

"spectacular progress, spectacular inequities".

– Bill Foege, looking back on progress in health in the 20th century,

What is Universal Health Coverage (UHC) ?

• WHO definition –

– Access for all to a full spectrum of services of good quality ranging from prevention through to rehabilitation according to need

– Affordable cost to consumers

ThreeDimensionsofCoverageExpansion

WHO,WorldHealthReport,201016

Why focus on Universal Health Coverage?

• Worrisome Shortfalls in Coverage

–Extremely Low levels

–Endemic Inequities

–Evidence of harm

Why focus on Universal Health Coverage?

• Extremely Low levels of Coverage

– Single interventions

– Packages of interventions

– Key health systems inputs

• health workforce

• essential drugs

• health facilities

1/21/2014 Information, Evidence and Research

Only between 2-15%

African children

are sleeping under

bednets (2001)

3 m estimated

annual deaths

from malaria

Equity and survey data

Dipping-in-and-out of the health system: Nepal 2006

0

20

40

60

80

100

120

Poorest234Richest

Coverage patterns: a blueprint for saving lives

Of these 18, only the 4

vaccination interventions are reaching 80 per cent

of the children who could benefit from them. The

empty space in the chart represents millions of

•

deaths each year that could be prevented if all

interventions were universally available.

Median coverage estimates vary widely across

different interventions. Such variations can

reflect the different characteristics of interventions,

such as how each is delivered, how long it has

been available, if it is accessible and affordable in

developing countries, and the training required to

deliver it adequately and with effective management

and monitoring. Other reasons for coverage

variations include differences between services that

can be scheduled in advance (for example, through

campaigns that reach children of a particular age

during recommended immunisation periods) and

services that must be more regularly available (such

as delivery, postnatal care, family planning services

or nutritional counselling). The characteristics of

interventions, and their relationship to achieving high

and sustained coverage, are priority areas for the

Countdown’s continuing technical work.

Coverage levels for all interventions show large

intercountry differences. The ‘Range’ columns in

table 3.5 show wide variations in coverage for each

intervention across the 68 priority countries. Though

a full explanation of these gaps is beyond the scope

of this report, it should be a priority research topic

for Countdown conference participants.

Of 18 life-saving interventions, only

vaccinations are reaching 80% coverage

Trends in coverage since 1990 follow similar

patterns

Interventions able to be scheduled routinely (®)

have higher coverage than those needing

functional health systems and 24-hour availability

(24H)

®

®

®

® ®

®

® ®

24H

24H

24H

24H

World Health Report 2006

Critical shortage of health workers in 57 countries;

4.3 million more health workers needed to provide essential interventions.

17

Poor coverage of vital events

World Health Report 2003

Why focus on Universal Health Coverage?

• Endemic Inequities

–“Poorer” less likely to be covered

– widespread evidence of “inverse care”

the “inverse care laws”

• Rich consume more hospital and public health care than the poor (Tudor Hart, 1971)

• Immunization coverage strongly correlated with socioeconomic status (Gwatkin et al., 1999)

• Poor with illness don’t access care: 2x more likely to self treat; 10x more likely to do nothing (Uganda, HH Survey, 1994/5).

• Poor that access health care risk medical impoverishment (Voices of the Poor, 2000)

1/21/2014 Information, Evidence and Research

Trends in skilled birth attendance by income quintile Egy[t

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

1995

2000

1992

Indonesia

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

1994

1997

1991

Zimbabwe

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

1994

1999

1988

Bolivia

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

1994

1998

1989

2x more likely to have TB?

3x less likely to access TB

care?

4x less likely to complete TB

treatment?

5x more likely to suffer

impoverishment due to the

costs of TB care?

Why are poorer populations…

Why focus on Universal Health Coverage?

• Evidence of harm

–Unsafe care

• Selection of super-bugs e.g. XDR TB

–Lack of financial protection

The Lancet 2006; 368:964 DOI:10.1016/S0140-6736(06)69391-4 XDR-TB—a global threat See Comment See Articles Following an emergency consultation in Johannesburg on Sept 7 and 8, global health agencies have developed a seven-point plan to combat extensively (or extremely) drug-resistant tuberculosis (XDR-TB). Representatives from several southern African countries have agreed to implement the plan within 3 months. Multidrug-resistant TB (MDR-TB), defined as resistance to at least isoniazid and rifampicin, requires the use of second-line drugs that are less effective, more expensive, and more toxic than first-line regimens based on isoniazid and rifampicin. Recognised earlier this year, XDR-TB is MDR-TB that is also resistant to three or more of the six classes of second-line drugs. Of 17 690 TB isolates taken between 2000 and 2004, 20% were MDR and 2% were XDR. XDR-TB has now been identified in all regions of the world but is most prevalent in Asia and in eastern Europe. Since WHO guidelines recommend the use of at least four drugs for those with MDR-TB, XDR-TB is untreatable to international standards. Data presented at the XVI International AIDS Conference in Toronto last month indicate the high mortality associated with XDR-TB—of 536 patients with TB in a rural district in KwaZulu Natal, South Africa, 221 had MDR-TB, and 53 of these were defined as XDR-TB, most of whom were coinfected with HIV; 52 of these 53 patients have died. The South African Medical Research Council, WHO, and the US Centers for Disease Control and Prevention plan calls for: rapid surveys to assess the current prevalence of XDR-TB globally; enhanced local laboratory capacity to carry out culture and drug-resistance testing; increased training for public-health staff to identify, investigate, and treat XDR-TB outbreaks; implementation of infection control precautions; increased research support for drugs to treat XDR-TB and for development of rapid diagnostic tests for TB; and access to antiretroviral drugs. Failure to act now to contain the threat posed by XDR-TB will have devastating consequences for patients with TB, particularly those co-infected with HIV/AIDS. Prompt enacting of the seven-point plan agreed in Johannesburg is crucial for the future of TB and HIV/AIDS control efforts and for the prevention of XDR-TB related deaths. The Lancet

"poor TB services" deemed the

underlying reason for emergence of

XDR-TB.

•Insufficient vehicles •Inadequate supervision of patients beyond hospital •Interruption in supply chains

•Unacceptable rates of "first line" treatment failure

•No response to evidence of "first line" failure

•Sloppy "second line" treatment practices

•Poor infection control in hospitals (over-crowding)

•Missing laboratory support structures (resistance monitoring)

Number of People Suffering Financial Catastrophe and Impoverishment Due to Health

Spending

- 30 60 90

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (million)

impoverishment

catastrophic

Inequitable and Inefficient Financing of Health

• Out of pocket expenditure (OOP) >65% of total health expenditure (THE)

– Major cause of household impoverishment (Sen 2003)

– 4 to 5 million impoverished annually (Van Doorslaer 2007)

– 22% of all shocks in the lives of the poor (World Bank 2008)

– Discourages accessing health care when needed

– Most important cause of micro-credit default

• Out of pocket expenditure as share of THE is increasing over time (NHA 2007).

• All evidence, everywhere indicates OOP is most inefficient and inequitable way to finance health care (WHR 2010).

Source: Van doorslaer et al. 2007

Catastrophic health expenditure

A major deficit on fair financing

• Government health expenditure:

– Vastly insufficient at $4/capita relative to need of $24/capita

– decreasing as share of total health expenditure

– regressive – rich benefit more than the poor

– demand side financing – innovative but not clear that is “scalable” to whole country or beyond MNH

A major deficit on fair financing

• NGOs efforts – While micro-credit has mushroomed, micro-

health insurance has failed to grow!

– Coverage is very shallow – no clear evidence of financial protection

• Private sector health insurance – Insurance industry show little activity in health

(<!% of total health expenditure).

– Employers only just beginning to provide health insurance benefit

Why Focus on Universal Health Coverage?

• Policy relevance:

– strongly linked to MDGs attainment

– a widely agreed policy objective

• World Health Assembly Resolutions 2005, 2011

• World Health Report 2008: Primary Health Care

• Commission Social Determinants of Health 2008

• First World Social Security Report 2010, International Labour Organization

• World Health Report 2010: Health financing

HEALTH SYSTEMS FINANCING The path to universal coverage

The World Health Report 2010

The path forward:

Universal Health Coverage (UHC)

Are we missing the big picture?

.

Changes in Global Landscape

Urbanization

Chronic

diseases

BRICs

Innovative

Developing

Countries

Emerging

Market

Economies

Footprint

Countries

Emerging

Donor

Nations

Aging

Env. issues

Health concerns

Megacity

Migration

Youth bulge

1

2

3

4

5

6

Environmental degradation will increase in countries that have already experienced some of the world’s worst environmental problems

Europe and Japan will face the most immediate impact of aging

The infectious disease burden will aggravate other demographic problems in the developing world

Global migration could be a partial solution to other demographic imbalances

Some of the world’s poorest and most politically unstable countries will have the largest populations

Urban growth and stresses will be particularly great in developing countries, especially in Asia

1

2

3

4

5

6

1/21/2014 Information, Evidence and Research

Tanahashi Framework for Service Delivery Coverage

The Imperative of Political Commitment

“As the movement for UHC intensifies in other parts of the world, there is an imperative to prepare Bangladesh for it!”

Honourable Prime Minister Sheikh Hasina. Inaugural address at the 64th World Health Assembly,

Geneva May 2011 (http://www.who.int/mediacentre/events/2011/

ha64/sheikh_hasina_speech_20110517 /en/index.html )

The need to begin now

• Opportunities:

– Increased UHC activity in the region and globally

– New 5 year health sector plan - HPNSDP 2012-2016

– Sustained economic growth, middle income country status in next 10-15 years likely

– Rapid growth in the health sector

• >10% per annum in total health expenditure

– Better than expected performance in MDG achievement….can build on some strengths

ThreeDimensionsofCoverageExpansion

WHO,WorldHealthReport,201016

Three dimensions of coverage expansion for

universal health coverage

Strengthening supply of services

• Comprehensive package of quality services

– Responsive to users

• Respect for persons (dignity, autonomy, confidentiality)

• Client orientation (health needs, basic amenities)

• Skilled workers – right place, right time

• Infrastructure – sturdy, clean, functioning

• Drugs, diagnostics – in stock, minimal co-pays

• Info Tech facilitated –

– Cashless transactions with single “smart card”

– Electronic medical records, m-health

MOVE-IT Bangladesh

CONTEXT:

• New health strategy

“Scale-up” maternal child health services

“Results focus” investment in information

• “Digital Bangladesh” Innovative use of digital

technologies such as

E-health and M-health

MOVE-IT Bangladesh

Aims: 1. Universal registration of all pregnant mothers

and their newborns;

2. Unified electronic information system that: - tracks vital events (births, deaths, and cause of

death),

- non-fatal health events;

- coverage of priority services

Mothers – Ante-natal care; delivery; post-natal care Newborns – neo-natal, infant and child care.

Fix the financing system I

• Mobilize more resources – – taxes – direct and indirect i.e. sin taxes

• Improve allocation – – According to need –essential interventions – Can demand-side financing be scaled up? – Set up separate purchaser agency e.g. National

Health Security Office as in Thailand • Better payment systems

– Needs-adjusted capitated systems – Remove incentives for “over” and “under”

coverage

Fix the financing system II

• Regulatory framework to promote health insurance in private sector:

• Subsidies to private insurers for coverage of below poverty line populations

• Incentives for larger pools to avoid the micro-insurance trap

• Long-term plans for “federation” of private insurance plans to minimize duplication and promote efficiencies

Communicate the health and economic benefits of

insurance

Engaged in designing benefit package to meet needs and expectations

Make Premium payment simple and sustainable

Everyone experiences “benefits” through health promotion and wellness

checkups

Expedite claims adjudication process

with prospective reimbursement

Based on ability to pay

Part of a compulsory, group membership

Part of a larger financial transaction

1

2

3

a)

4

5

b)

c)

Educate and empower beneficiaries

Learning by doing

• No one size fits all

• All ambitious policies require course corrections

• Set time-bound targets for performance i.e. decrease in OOP below 30% THE

• Generate evidence to inform, implement and evaluate UHC efforts

• Investing in individual and institutional capacities to make reforms work

Experiences from other countries

• Thailand: A long but successful road to UHC

• Ghana: UHC through community-based Health Insurance schemes

• India: Health Insurance for the ‘below poverty line’ population

• Rwanda: Community-based health insurance schemes in a low income country

Thank you all !