Universal Health Coverage: a review
1. Ethical justifications for Universal Health Coverage
The World Health Organization (WHO) defines Universal Health Coverage (UHC) as a health policy with the main aim of providing the individuals of a country access to the full range of quality health services they need, when and where they need them, without financial hardship. Achieving UHC is one of the targets all countries in the world set when they adopted the 2030 United Nations Sustainable Development Goals (SDGs) in 2015 (1). I believe the main attraction of UHC is to achieve financial risk protection in health services, especially for vulnerable populations, to prevent them from making catastrophic payments that would lead to poverty because of unexpected illness that requires life savings, selling assets, or borrowing. When a country decides to achieve a UHC policy for its population, usually, it means getting all health actors and stakeholders on the same page, changing or adjusting their mechanisms used to generate funds for the financing system, creating tools to monitor indicators such as reduction of out-of-pocket expenditure and increase of healthcare coverage, all while making companion policies to make sure that UHC will achieve equity of healthcare access and quality of services for vulnerable populations. However, these tasks are done based on the ethical perspective of the particular society, which is one of the three pillars of the flagship approach. Understanding the more significant ethical perspectives behind justifying UHC policies can help policymakers judge health sector performance and improve their job (2).
The ethical justifications for universal health coverage largely depend on the perspective doctrine evaluating it. From the perspective of utilitarianism, UHC is the most logical policy to provide health services, as it should result in the most improvement in the sum of total well-being for the population. Margaret Chan, former WHO director, said in 2015 that “UHC is the ultimate expression of fairness,” implying an efficient and ethical justification for UHC. Priority setting is inevitable in the path towards UHC because all countries experience a gap between their population’s health needs and what is economically feasible for governments to provide (3). The difficulty lies in the different methods of rationing and creating explicit priority-setting for the provision of services. One method from the viewpoint of subjective utilitarianism is cost-benefit analysis. It assumes that markets are efficient and that consumers have complete knowledge when making purchasing decisions. Therefore, consumption patterns can let us know the willingness to pay for services, achieving a Pareto optimal due to market efficient allocation of resources. However, because healthcare markets are far from perfect, and individual choice is mostly distanced from social policy goals, ethicists have agreed on the following criteria for priority setting: cost-effectiveness, priority to the worse-off, and financial risk protection.
Another classic view to justify universal health coverage is from the liberalism perspective and the juxtaposition between libertarians and egalitarian liberals. Both have the starting point that society has to respect the set of individual rights and that individuals should choose their preferred way of living. Libertarians believe only in protecting negative rights from the State to guarantee personal freedom. In comparison, egalitarian liberals argue for the protection from the State of negative and positive rights––the right to a minimum level of income, shelter, education, and health, so that the liberty of choosing can be for everyone, including those that are most vulnerable. Therefore, a UHC policy would be most favourable and justified under an egalitarian liberal society that thinks there should be a minimum standard healthcare provision for all. However, some egalitarian liberals believe that the positive right perspective creates the responsibility to the State to guarantee a minimum health status (reasonable life expectancy, quality of life, etc.) in the population. I would argue that UHC is also ethically justified under this perspective because access to healthcare should be the first step towards obtaining better population health status.
2. Financing for Universal Health Coverage
The chosen financing method is essential to achieve UHC, as the way a country decides to collect funds for health care, pool funds (and therefore risks) across time and the population, and purchase health services could impact not only the timing of achieving UHC but also the equity of health provision. A health system financing method is critical as it determines the risk pooling arrangement and the distribution of the cost burden. It can also influence health outcomes and raise healthcare costs (4). Often, the traditional classification of financing schemes was done by individual blocks or dimensions, classifying countries by either having a “Beveridge,” “Bismark,” or “Market-based” financing scheme. However, focusing on a single mechanism used to generate funds for a country because it fails to reflect the shift towards mixed models of health financing that has occurred in many countries (5). For instance, most systems in LMICs have a mix of social health insurance contributions for the formal workers, usually related to income and shared between the employees and employers, and a government-subsidized and provided public healthcare scheme to the poor. Because of this shift, it is unrealistic to think that with only one dominant mechanism used to generate funds for healthcare, universal care will be achieved (5,6). Most effective systems use public and private sectors and frequently combine incentives, structures, and cost-cutting measures.
There is evidence that finance systems that are predominantly tax-based could achieve the goal of UHC faster than systems that are primarily financed under a social health insurance (SHI) scheme by defining a national essential benefits package to be publicly funded and provided to citizens free of charge(7). Further, taxed contribution mechanisms are based on income and detach payment from the risk of ill health. For instance, a review done by the Development Research Group at the World Bank found that of the OECD countries (excluding the United States, which has a predominantly market-based system), found that all tax-based countries have achieved UHC, some have yet to achieve (Mexico, Colombia, Turkey), and some achieved it only when switching from SHI to tax-based (Norway, Sweden, Iceland, Denmark). It is essential to recognize that while this way of financing is faster, it creates a trade-off between equity and sustainability that may require profound tax and health reforms down the road. Most of these successful countries are middle to high-income nations with established and, most of the time, reliable tax systems. Assuming that this is a country with the same income characteristics, I would be supportive of a largely tax-based system providing basic family health insurance for everyone and financed with direct and indirect taxes (value-added tax or applied to specific goods, such as an excise tax) that could be levied at the national, regional, or local levels. Further, I would support a mixed model with a publicly funded (free provided) insurance scheme for the low-income population and a two-tier system offering different health coverage options for those who want to pay out of pocket.
3. Access, quality, and financial risk protection and Companion Policies to adopt with UHC
UHC has been at the forefront of a global health policy agenda for many years. How a country funds and creates access to services on their way to UHC depends strongly on aspects of history, ethics, political leadership, the path dependency of their health systems, and the availability of domestic financial resources (8). Because there is not a holy grail to UHC, evidence on which approaches are most successful in achieving it is mixed (9). Although UHC does not guarantee improvements in all areas, ensuring access is often the main priority of countries when aiming to obtain UHC, leaving the financial risk protection and assurance of the good quality of services in a secondary position. For instance, in the 2021 Global Monitoring Report tracking UHC by the World Bank, the global incidence rate of catastrophic health spending defined as the population-weighted proportion of the population with household out-of-pocket health expenditure exceeding 10% of the household budget was 13.2% in 2017, 4 p.p. more than in 2000 (9%). The number of impoverished or further impoverished by out-of-pocket health spending increases before and after the pandemic (10). An example of a lack of translation of UHC to quality improvement is Kenya’s abolishment of user fees in public health care facilities, especially for maternal health care, in hopes of increasing utilization rates. While it increased utilization, outcomes of maternal and neonatal mortality remained the same (11), proving that the increase in access did not come with better medical care, human resources, and medical supplies, among other things, for quality assurance. This measure tried to gain more utilization of services by everyone. Still, removing fees might have burdened the financial system, worsening the quality of services even further. This is an example of how policies might exacerbate another in trying to improve one aspect. Furthermore, even measures in a UHC scheme that aims at gaining more healthcare coverage might only do so at the overall level but without considering the distribution of that access, which is an equity concern from the utilitarian ethical perspective. For instance, in a study of the utilization of services in the family health insurance of the contributory regime of the Dominican Republic, it was found that while more than 80% of the population was covered under UHC, the most affluent population by (9 and 10 income deciles) showed the highest percentage of people who utilize health services (46%) and the highest consumption (47%) of those services (12).
Each country must create its own path to UHC because it depends highly on the context (13). Nonetheless, some fundamental policy choices should be accounted for to have better performances. First, after considering the poor and formal sectors, how to cover the nonpoor informal sector is essential and sometimes forgotten in policy reforms. It could be either expanding the subsidized regime to everyone in the informal sector or requiring a percentage of contributions and the rest covered by public funds. Voluntary health insurance is sometimes criticized for its inability to provide UHC, but it might be helpful to include specific populations that are hard to reach in other ways.
Second, the pooling of resources is essential as we deal with multiple populations and funds from different organizations. The pooling will decide resource allocation and distribution of services and choose a payment method to provide incentives to providers (4). Third, and as we saw in class, understanding the healthcare delivery system of a country is critical so UHC can be achieved, as the effectiveness of a policy on a health system’s performance often depends on the meso and micro organization of the system. If, for instance, 80% of hospitals in our country are private, prioritizing services and patients with the highest profit margin, a UHC policy might conflict with the interest of for-profit hospital owners. A policy would first be to collect information on how the delivery system functions in the nation (inpatient/outpatient services, public/private hospitals, etc.), then coordinate with the Medical Association and the Hospital Association to align goals for the same objective of achieving UHC. Finally, UHC will require a lot of political and negotiation skills as every aspect and actor of the health sector needs to be aligned to achieve efficiency, access, quality, and financial risk protection. The health sector is known for having multiple actors with many interests in play (insurance companies, governments, pharmaceuticals, NGOs, private providers, etc.). UHC requires the active effort of rationing services, determining a benefit package with explicit prioritized services, targeting multiple populations, creating public programs, establishing new financing schemes, and creating accountability and monitoring measures, among many others. Therefore, it is a long path that will need the organization of the system, political negotiation, performance measurement, and alignment of interests.
References
1. Universal health coverage (UHC) [Internet]. [cited 2022 Dec 20]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
2. Roberts MJ, Hsiao W, Berman P, Reich MR. Judging Health-Sector Performance: Ethical Theory. In: Getting Health Reform Right [Internet]. 1st ed. Oxford University PressNew York; 2008 [cited 2022 Dec 20]. p. 40–60. Available from: https://academic.oup.com/book/7510/chapter/152444379
3. Norheim OF. Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services. BMC Med. 2016 May 11;14:75.
4. Hsiao WC. Why Is A Systemic View Of Health Financing Necessary? Health Aff (Millwood). 2007 Jul;26(4):950–61.
5. Thomson S, Foubister T, Mossialos E. Financing health care in the European Union: challenges and policy responses. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies; 2009. 200 p. (Observatory studies series).
6. Evans RG. Going for gold: the redistributive agenda behind market-based health care reform. London: Nuffield Trust; 1998.
7. Wagstaff A. Social Health Insurance Vs. Tax-Financed Health Systems - Evidence From The OECD [Internet]. The World Bank; 2009 [cited 2022 Nov 15]. (Policy Research Working Papers). Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-4821
8. Verguet S, Hailu A, Eregata GT, Memirie ST, Johansson KA, Norheim OF. Toward universal health coverage in the post-COVID-19 era. Nat Med. 2021 Mar;27(3):380–7.
9. National Academies of Sciences E, Division H and M, Services B on HC, Health B on G, Globally C on I the Q of HC. Embedding Quality Within Universal Health Coverage [Internet]. Crossing the Global Quality Chasm: Improving Health Care Worldwide. National Academies Press (US); 2018 [cited 2022 Dec 20]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535659/
10. World Health Organization, World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report [Internet]. Washington, DC: World Health Organization; 2017 [cited 2022 Dec 20]. Available from: http://hdl.handle.net/10986/29042
11. Gitobu CM, Gichangi PB, Mwanda WO. The effect of Kenya’s free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities. BMC Pregnancy Childbirth. 2018 Mar 27;18:77.
12. Rodríguez, J., Montas, M.; Martínez, M. y Ramírez, P. (2019). “Use Of Services In The Family Health Insurance Of The Contributory Regime, 2018” Technical Reports Series, SISALRIL, No. 2. Dominican Republic, 2019.
13. GOING UNIVERSAL "How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up" Daniel Cotlear, Somil Nagpal, Owen Smith, Ajay Tandon, and Rafael Cortez. World Bank
