At least half the world’s population still do not have full coverage of essential health services.
Every year, over 100 million people are pushed into extreme poverty because they have to pay for their healthcare out-of-pocket.
All UN Member States have agreed to work on achieving universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals.
This year’s World Health Day is dedicated to UHC, which means that all individuals and communities receive essential, quality health services – from health promotion and prevention, to treatment, rehabilitation and palliative care – without enduring financial hardship.
UHC is an investment in the human capital of countries. Access to essential quality care and financial protection for health not only improves people’s health and life expectancy, it also protects countries and businesses from epidemics, reduces poverty, creates jobs, increases productivity, and ultimately drives economic growth.
But it does not mean free coverage for all, and for every possible health intervention. What it does do is allow everyone to access services that address the most important causes of disease and death, and ensures that the quality of those services is good enough to improve people’s health, while providing financial risk protection.
The Director General of WHO calls UHC a “question of values”, as it ensures that millions of families have access to care without being impoverished due to catastrophic health expenditure. It is certainly a question of increasing equity and developing more inclusive societies.
Equity: UHC is about protecting people from the financial consequences of paying for health services out of their own pockets, and we know that nearly 800 million people spend at least 10% of their household budget on healthcare. In a country with a fully functioning UHC system, the breadwinner of a family who is diagnosed with lung cancer, for example, would not have to pay to pay out-of-pocket for their full treatment because they have no insurance; this would, in many cases, force a family to spend most of its disposable income, all its savings and often any valuable assets.
Inclusion: While UHC is about accessing treatments for the most common morbidity and mortality causes for all citizens, and ensuring these are provided according to quality standards, it also allows for the progressive expansion of services as more experience and resources become available.
Many view UHC as a health financing tool. However, for it to work, it has to integrate all aspects of the health system: the health workforce, delivery systems, medical devices and products, governance, legislation, and more. It is not surprising that the former Director General of WHO describes universal health coverage as “the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way.”
Yet, to accomplish all this, societies will require four main shifts towards a new mind-set:
1) From international aid to sustainable domestic revenue collection: sustainable UHC will increasingly come from countries’ own resources, and less from philanthropic or international aid. Governments have a critical leadership role to play in this shift.
Whether UHC is financed through general taxation, earmarked tax for health, or a flat-rate premium, the money has to come from the people themselves. For that to happen, governments need to improve their health systems as described above, so that people see value in the services, and so willingly contribute the necessary taxes. There are many cases in which countries have UHC legislation, and tax-based financing, as well as institutions to provide care, yet people still have to pay as much as 50% of their health costs out of pocket because of inefficiencies in the delivery system, corruption or other failures.
Thus, when governments don’t play their part, citizens may lack motivation.
Another aspect of domestic financing is the “solidarity” mind-set in cases where health is funded through direct or ear-marked taxation. When people have to pay a health tax, those with higher income subsidize the care of those with lower incomes, while receiving the exact same care.
The potential role of the private sector in mobilizing domestic financing must also be explored: large businesses can pool their employee base and so create incentives for private insurance companies to underwrite policies, much like the recent announcements by Berkshire Hathaway, Amazon and JP Morgan.
2) From traditional funding to innovative financing mechanisms: innovative financing gained prominence following the International Conference on Financing for Development in Monterrey, Mexico, in 2002 as a means to provide additional financing for global health.
Currently, innovative financing instruments and mechanisms are deployed mainly for funding immunization campaigns, research and development, insuring against disaster, and public debt for the health sector.
The role of innovative finance in UHC has to be thought through, as investors require financial returns; these often mean direct payments are made by patients to providers for basic health services, which could compromise access to care for the poor, and the equitability of the health system.
So, new mind-sets and approaches are required to ensure we are deploying not just innovative financing, but innovative and equitable financing.
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3) From public funding to a mix of public and private co-operation: it’s generally agreed that governments play a leading role in providing finance and regulation for UHC, and that the private health sector can contribute to service delivery.
However, the private sector can contribute in a number of other ways. It can develop new technologies and business models that deliver better care; it can provide care for its employees, it can train the health workforce, co-finance public health campaigns, or new product introductions, and it can contribute to policy development through its experience on the ground.
Furthermore, other sectors, such as education, environment, transport, and infrastructure are critical for the delivery of quality UHC services, which highlights the importance of long-term cooperation not only between the public and private sectors, but also across the sectors, in order to deliver on a shared agenda of healthier and more productive populations.
4) From paper to technology: as new UHC programmes are designed, the key consideration, in addition to sustainability, needs to be scalability.
Technology innovations in health – or e-health and telemedicine – can help ensure that resources are used more efficiently and effectively.
ICT solutions can also help empower patients to actively engage in their own care and therefore influence the health system. Elements of care can also be moved from hospitals to homes using connected technology. This can allow remote support, and tracking therapy adherence. This happens, for example, with Proteus Discover, a set of digital medical tools comprised of ingestible sensors, a small wearable sensor patch, an application on a mobile device, and a provider portal that unlocks insights into patients’ health and helps physicians improve clinical outcomes.
Another example is the nationwide electronic Health Record System in Estonia, which removed data silos and improved the quality and efficiency of diagnosis and treatment.
A question that we often hear is, “How can we do better?” which often means doing more of the same, but better. Yet, the question should be: “How can we do things differently?” And the answer is not by merely adding layers of coordination to existing efforts, but through step changes; not only adopting modern technologies and new business models, but also by nurturing inclusive values and new mindsets.