Global momentum on Universal Health Coverage (UHC) is high; its place within the post-2015 agenda is being hotly debated; and it was the thematic focus of the Global Symposium on Health Systems Research, which I recently attended.
Joe Kutzin from WHO chaired a fantastic session on classifications and what we do know about appropriate and equitable pathways to UHC, citing from his succinct article.
Archaic jargon hinders
UHC terminology remains framed by the authors of Britain and Germany’s welfare states: Beveridge and Bismarck, and are charged with ideology. A national health system typically denotes a tax-financed approach; health insurance refers to a contribution-based model. Using these terms conjures ideological associations that distract us from existing evidence of what works.
These terms are rigid and increasingly inappropriate as countries are adopting mixed models. Many countries are pooling general revenues with compulsory insurance contributions – for instance in Kyrgyzstan, Moldova and Germany.
In many other countries, tax is the main financing source, with a split between purchaser and provider functions, such as Thailand, Georgia, Latvia and the UK.
Time to bury Beveridge and Bismarck
It’s time to bury Beveridge and Bismarck and to understand health systems by the functions they provide – how resources are raised, pooled and spent – not what they are called.
For instance, ‘insurance’ may resonate politically in a country, but it might refer more to an objective (increasing access and expanding financial risk protection) than to a financing model per se.
He cited the example of Rwanda, where community-based health insurance is compulsory, government-led, integral to the system’s design, and heavily subsidized, with integrated pools for redistribution. There is no pretence that it’s self-financing. These are the details that matter, not the label of CBHI.
From ‘schemes’ to systems
Joe urged for a move away from ‘schemes’ and consider the health system as a whole. Subsidized participation in a universal system is preferable to separate schemes with different benefit packages and risk pools.
Targeting is also ridden with challenges, and the most poor and vulnerable often remain missed, not to mention the stigma associated with being labeled as the most poor.
We heard that not all pathways to UHC are appropriate. Many countries are doing very different things in the name of UHC, but it is not the case that anything goes.
While every pathway will be informed by the country’s context, we know certain criteria that are relevant to all countries: compulsory, public, with consolidated risk pools, a single payer, purchasing based on evidence of population needs and provider performance.
Untapped opportunities to expand general revenues
Di McIntyre shared concern with countries’ enthusiasm for contributory mechanisms, based on an assumption that there isn’t fiscal space for sufficient revenues from general tax: “trying to get contributions from the informal sector is like a mantra”.
She noted impressive efforts to improve tax collection in Kenya and South Africa, and the often-untapped opportunity of indirect taxes to expand general revenues such as VAT, which can be progressive if designed as such.
She also shared the finding from recent research (awaiting publication) that contributory schemes can be very inefficient, with higher administrative costs than net revenues.
Davidson Gwatkin emphasized that equity is not a given in UHC. Too often the most poor and vulnerable are left ‘til last to benefit from the health system. The current drive towards UHC in many countries risks widening disparities if equity isn’t an explicit priority from the outset. It’s vital that the poor and vulnerable participate fully in any overall increase in coverage – what Gwatkin calls ‘progressive universalism’.
That’s why we are working with key partners to redefine UHC so that the needs of the poor and vulnerable are sufficiently met. This must be measured and all stakeholders must be held accountable for ensuring that the right to health is realized for all.