Last week I had the privilege of joining delegations from nine countries who came together in Marrakech to share experiences, learn from each other, and discuss how to reach the most vulnerable in efforts to achieve universal health coverage (UHC).
This forum is an exciting model to foster peer exchange, with increasing relevance as the momentum of UHC builds and more countries commit to achieve it.
UHC stems from the human right to health, defined in the 2010 World Health Report as all people having access to an essential package of quality health services without financial burden.
It encourages countries to consider three dimensions in health financing policy – population covered, package of services for which they are covered, and the extent to which the population shares care costs.
Yet weak routine data and infrequent household surveys impede our ability to monitor progress and use evidence to inform planning.
Equity: an afterthought
Equity is implicit in UHC, as universality requires all people to have financial risk protection. There are different interpretations of UHC and each country will pursue a unique path, shaped by its history and culture, with variations in how prominently equity features as a defining objective.
Yet in many countries it appears that equity has been considered as an afterthought. Once the wealthy, civil servants and the formal sector are covered by some form of insurance, another strategy is devised to target the poorest and provide coverage for an often minimal package.
Very few countries have been able to merge these schemes, causing fragmentation, which is costly to administer and leaves the wealthy with better access to services and financial risk protection than the poor.
There was much rich discussion and debate between countries, probed by a few academics and technical experts, and we heard accounts of courageous efforts to improve health policies for the poor.
Participants were encouraged to be honest and frank about prevailing challenges.
The absence of local civil society in country delegations was a missed opportunity. Engaging civil society can ensure the voices of the intended beneficiaries are heard.
It can also build accountability, empowering civil society to demand access to quality healthcare through more equitable policies. I hope future CoP meetings will be more inclusive.
A few persistent preconceptions emerged in the country dialogues, despite the existing strong and fast-growing evidence base:
No longer whether to remove user fees, but how
At a global level, the consensus that user fees should be removed is loud and clear – Margaret Chan referred to them as “the single biggest barrier” to UHC and the Lancet recently called for them to be scrapped. Valery Ridde also presented on this during the workshop.
However, we heard delegates raise concerns that user fee removal will worsen the quality of care, and that people won’t value services if they don’t pay for them. There’s no evidence in support the latter, but there is excellent evidence that utilisation falls with fees, particularly among the poor.
As for the quality of care, any strategy to eliminate fees should be coupled with increased resource through progressive prepayment such as tax, and increased donor support in the case of low-income countries, as well as efforts to strengthen service provision to deal with increase demand and disincentivise health workers from charging fees – such as improving health worker incentive packages, increasing salaries and drug supplies, and providing a budget to cover recurrent costs at the facility level.
Recent evidence from Burkina Faso supports this. We need to move on from the debate as to whether user fees should be removed to one of how to do this in an integrated way so as to avoid the implementational challenges we have seen in many countries.
Targeted or universal?
The other preconception is the disposition towards a targeted rather than a universal approach.
Universal systems can be progressive, if designed appropriately. In an insurance model, exemptions and waivers are necessary to subsidise the contributions from the poor and vulnerable.
Yet effective targeting of the poor and vulnerable is no easy endeavour and efforts to do this consistently fail to reach those most in need, particularly where data and administrative capacities are weak.
In a region, where UNICEF has estimated that 50% of children aren’t registered at birth, what chance is there that they’ll be successfully targeted?
In such contexts, why not start with a universal system that is accessible to all, then find effective ways to raise revenues from those who can afford to contribute? Further, self-sufficiency in achieving UHC should not be expected of low-income countries, as Sachs so eloquently stated.
For too long, the poor and vulnerable have been an afterthought; now is time to put them first.