Research & Policy Briefs From the World Bank Malaysia Hub No. 13, September 2018 The Drive toward Universal Health Coverage Young Eun Kim and Norman V. Loayza Universal health coverage is a social goal that enables everyone to receive the quality health care they need, irrespective of ability to pay, without suffering financial hardship in the process. To move toward that goal, policy makers should address three main considerations: the population to be covered, the health services to be provided, and the financing mechanism to be used. Successful cases show that to achieve universal health coverage, a change of perspective is essential, from seeing health care benefits as a contingent good to considering them as an essential public service. While expanding the demand for health care is necessary, improving the quantity and quality of the supply of health services is essential. Getting diverse stakeholders to cooperate, making cost-efficient and people-centered choices, and ensuring fiscal sustainability are needed to expand health coverage for everyone who needs it. Universal health coverage (UHC) has gained prominence on the global coverage index. This is a composite index based on selected indicators health agenda. UHC is a social goal that enables everyone to receive representing various aspects of comprehensive health coverage, such the quality health care they need, irrespective of ability to pay, without as health outcomes, receipt of a health care intervention, the suffering financial hardship in the process. Achieving UHC will enhance availability of human and physical health care resources, and relevant the health of the population—and in turn, strengthen the foundation regulations (WHO and World Bank 2017). for a country’s sustainable economic growth and development—by covering people marginalized under existing health care systems, Figure 1 concentrates on the dimension of service coverage, plot- improving medical benefits for those who are covered, and protecting ting the UHC service coverage index against GDP per capita. As against the financial risks associated with illness, injury, or disease. expected, the figure shows that the coverage of essential health services is related to national income per capita. It also shows, The World Bank and the World Health Organization (WHO), in however, that the relationship is not deterministic; health service collaboration with other international agencies, are supporting coverage can be driven by policy choices and implementation. Kenya developing countries as they move toward UHC (Cotlear et al. 2015; and Vietnam, for instance, have higher UHC service coverage indexes WHO and World Bank 2017). UHC can be advanced by expanding the than Nigeria and Indonesia, despite having much lower GDP per capita. demand for health care and, crucially, by increasing the quantity and quality of the supply of health services. UHC reaches everyone who Figure 2 concentrates on the dimension of financial protection. needs health care but does not preclude complementary or additional Progress in this area can be partly assessed using indicators on health insurance and services contracted on a voluntary and private catastrophic spending on health (WHO and World Bank 2017). The basis. figure plots the incidence of catastrophic spending on health—defined as household expenditure on health exceeding 10 percent of total Measuring Progress toward Universal Health Coverage household expenditure or income—versus the UHC service coverage index. The figure shows that catastrophic spending on health does not UHC is a challenging goal for most countries, yet substantial progress necessarily decrease as health service coverage increases. This has been made in recent decades. The progress toward UHC can be suggests that providers deliver and charge for additional—and measured with respect to service coverage and financial protection. To sometimes unnecessary—services (Wagstaff et al. 2018). The policy measure the provision of essential health services, WHO and the implication is clear: it is important not only to cover more World Bank have devised and recently made available a UHC service people, but also to cover a larger share of total health expenditure Figure 1. UHC Service Coverage Index versus GDP per capita, 2015 Figure 2. Incidence of Catastrophic Spending on Health versus UHC Service Coverage Index, 2005-15 CHE 35 >80 PRT USAAUTAUS NOR GBR BEL JPN CHL Catastrophic health spending, PER 30 UHC service coverage index 80 ECU THA MEX ARG DEU percent of populationa ESP NPL NIC VNM DOM CHN BRA TUR EGY 70 UZB NIC JOR COL LBNMYS CHL 25 NGA BRA EGY PRY BGR TJK KGZ UKRHND AZE ZAF MAR LKA RUS 60 IND BOLPHL IRN 20 KEN ZMB GTM COL CHN PRT RWA LAO ZWE YEM IND TUN 50 TGO NPL BGD IDN 15 BDI IRN DOM CMR BGD MOZ UGA GHA BGR BDI GIN PAK TJK BEL 40 ZAR BEN SEN CMR ETH BFA TZA NGA 10 TZA TGO VNM NER SLE YEM PHL AZE PER MLI GIN UKR MEX 30 MDG KEN JOR ESP JPN 5 BFA GHA RWA RUS BLR USA NER MLI SEN IDN KGZ AUS LAO GTM LKA UZB TURTHA 20 PAK MOZ ZMB ZAF KAZ GBR 0 MDG 5 6 7 8 9 10 11 ($150) ($400) ($1,000) ($3,000) ($8,000) ($22,000) ($60,000) 20 30 40 50 60 70 80 >80 UHC service coverage index GDP per capita (constant 2010 US$), 2016, log scale (absolute value) OECD East Asia and Pacific OECD East Asia and Pacific Europe and Central Asia Latin America and Caribbean Europe and Central Asia Latin America and Caribbean Middle East and North Africa South Asia Middle East and North Africa South Asia Sub-Saharan Africa Sub-Saharan Africa Source: WHO and World Bank 2017. Note: Data are for the latest year available. Data labels use ISO country codes. OECD Source: WHO and World Bank. 2017. includes high-income countries that have been members of OECD for more than 40 Note: Data labels use the International Organization for Standardization (ISO) country years. UHC = universal health coverage. codes. OECD includes high-income countries that have been members of OECD for a. Household expenditure on health exceeding 10 percent of total household expendi- more than 40 years. GDP = gross domestic product; UHC = universal health coverage. ture or income. Affiliation: Development Research Group, World Bank. Acknowledgment: Ximena Del Carpio, Muharrem Cevher, Daniel Cotlear, Emiko Masaki, Harry Moroz, Nancy Morrison, Somil Nagpal, Carol Dayo Obure, Philip O'Keefe, Ana María Oviedo, Toomas Palu, Karima Saleh, and Adam Wagstaff contributed with insights, comments, and suggestions to this brief. Objective and disclaimer: Research & Policy Briefs synthesize existing research and data to shed light on a useful and interesting question for policy debate. Research & Policy Briefs carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions are entirely those of the authors. They do not necessarily represent the views of the World Bank Group, its Executive Directors, or the governments they represent. Global Knowledge & Research Hub in Malaysia The Drive toward Universal Health Coverage with efficient financing mechanisms and improve management of are usually established early in life and have long-term effects. providers through effective provider-payment reforms and training. People who are unemployed or work informally are another Three Main Considerations for Universal Health Coverage vulnerable group. In a country where health care financing is mainly based on contributions from workers in the formal sector, the Policy makers need to address three considerations in relation to UHC: unemployed and informal sector workers are likely to have lower the population to be covered, the health services to be provided, and access to quality health care than workers in the formal sector (Hsiao the financing mechanism to be used (WHO 2010; Cotlear et al. 2015). and Shaw 2007; Wagstaff 2010). Consideration 1. The Population to Be Covered: Targeting the Most Consideration 2. The Health Services to Be Provided: Choosing Vulnerable Groups Priorities Under current health care systems, some population groups have had UHC covers all promotive, preventive, curative, rehabilitative, and difficulty accessing health services or have been excluded. To achieve palliative health services. However, developing countries must UHC, policy makers should identify and target these vulnerable groups prioritize and select which health services to provide first, given their (Cotlear et al. 2015): primarily people with low income or limited limited financial and human resources. The main criteria for selecting assets, those with low levels of education, the very young or old, health services generally include the basic needs of the population pregnant women and new mothers, people living in rural areas, and and cost-effectiveness. Primary (or basic) health services include those lacking consistent employment. These groups often overlap with reproductive, maternal, and child health care; prevention and one another and with groups that are historically marginalized or treatment of infectious diseases; and information and policy measures stigmatized in society. Because barriers and solutions differ across to prevent non-communicable diseases (Cotlear et al. 2015). UHC can communities for many reasons (including geography, economic status, include more advanced medical treatments as resources increase. and social and cultural norms), a locally tailored approach is required Monitoring and evaluating health care services are important to to increase coverage. sustain high quality and cost-effectiveness. Reporting and studying these results can help countries learn from one another (WHO Children are vulnerable in many developing countries, particularly 2017a─2017d). in rural areas. Various studies show that the under-five mortality rate is higher in rural areas than in urban areas because access to health care High-quality primary health care is not only universally needed but facilities is difficult, parents’ level of education is lower, and the quality has also proven to be cost effective (WHO 2014). Yet, the provision of of infrastructure is poorer (see, for example, Fink and Hill 2013). As primary health care varies considerably across countries. Consider the case of contraceptives, an essential health service for family planning. figure 3 shows, in countries where the coverage of essential health As figure 4 shows, in low-income countries, less than 40 percent of services is lower, more children die before reaching the age of five. women aged 15─49 in marriage or union use modern contraceptive Pregnant women or those who have recently given birth are an- methods, while the figure ranges from 30 percent to 80 percent in other vulnerable group, especially if they live in poor communities. most middle-income countries, and exceeds 60 percent for nearly all Maternal mortality is higher in rural areas and in poorer and less OECD countries. educated communities (WHO 2015a). More than 99 percent of Or consider basic vaccination for infants. Figure 5 examines maternal deaths and complications from pregnancy occur in how many 1-year-olds are receiving a vaccine to prevent illness, developing countries with weak health care systems. Young mothers disability, or death from diphtheria, tetanus toxoid, and are especially vulnerable. Childbirth is the leading cause of death pertussis (DTP3). Although DTP3 coverage for 1-year-olds has among girls aged 15─19 years. Early marriage is a risk factor (WHO increased to a global average of 86 percent over recent decades 2015a). (WHO 2018a), as of 2016, it was below 80 percent in many People at the low end of the socioeconomic scale are particularly countries in Sub-Saharan Africa, as well as some in other regions. vulnerable to death from non-communicable diseases (NCDs) such as These and other gaps need to be addressed. cancer and diabetes. NCD mortality and its risk factors vary depending As NCDs become more prevalent, the need for prevention and on a country’s economic development and health policies, but tend to treatment is increasing (Di Cesare et al. 2013). Prevention programs be higher for people living in poor communities and for those with low such as public campaigns against alcohol and tobacco abuse and early education and income (Di Cesare et al. 2013). Behavioral risk factors screening and diagnosis of NCDs would protect health and save such as smoking, physical inactivity, and unhealthy diets are responsible money. A major risk factor of NCDs is obesity, which has been for most deaths from non-communicable diseases. These behaviors increasing in all regions. More than half the adults in high-income Figure 3. Under-Five Mortality Rate versus UHC Service Coverage Figure 4. Prevalence of Modern Contraceptive Use, 2003-16 Index, 2015 140 90 Under-5 mortality per 1,000 live births marriage or union who use a modern CHN PRT GBR NOR Percent to women aged 15-49 in 80 ARG 120 SLE NIC THA BRA MLI COL NGA 70 PRY ECU USA CHE contraceptive method VNM DOM BEL AUS 100 NER BEN ZWE MEX CHL GIN ZAR 60 UHND ZB IDN ZAF ESP AUT KEN MAR DEU IRN RUS BFA BDI BGD EGY LKA PER KAZ 80 PAK 50 TUN BLR MOZ RWA IND GTM NPL LBN TUR ZWE ZMB UKR JPN LAO ZMB JOR 40 KGZ LAO BGR 60 ETH GHA ETH PHL UGA KEN TZA BOL MYS MDG TZA 30 UGA SEN IND TJK ZAF BDI YEM PAK 40 YEM BGD RWA BO MDG BFA TJK GHA L NPL GTM AZE UZB DOM 20 SEN CMR IDN PHL MAR NIC NER SLETGOMLI IRN HND PR NGA AZE 20 Y ECU PER MOZ BEN LKATUN EG Y VNM BRA ARG USA GBR JPN 10 TUR CHL PRT ZAR BGR LBN CHN MEX CHE BEL GIN RUS UKR THA MYS ESP DEU AUT NOR 0 AUS 0 20 30 40 50 60 70 80 >80 5 6 7 8 9 10 11 ($150) ($400) ($1,000) ($3,000) ($8,000) ($22,000) ($60,000) UHC service coverage index GDP per capita (constant 2010 US$), 2016, log scale (absolute value) OECD East Asia and Pacific OECD East Asia and Pacific Europe and Central Asia Latin America and Caribbean Europe and Central Asia Latin America and Caribbean Middle East and North Africa South Asia Middle East and North Africa South Asia Sub-Saharan Africa Sub-Saharan Africa Source: Under-5 mortality rate from www.childmortality.org as reported by the World Source: United Nations, World Contraceptive Use 2017. Bank World Development Indicators, 2017. Note: Data are for the latest year available. Data labels use ISO country codes. OECD Note: Data labels use ISO country codes. OECD includes high-income countries that includes high-income countries that have been members of OECD for more than 40 have been members of OECD for more than 40 years. UHC = universal health coverage. years. 2 Research & Policy Brief No.13 OECD countries, and developing countries in Europe and Central Asia, even for advanced countries. For example, 127 years elapsed in Latin America and Caribbean, and the Middle East and North Africa Germany, 72 years in Luxembourg, and 36 years in Japan between the were overweight in 2016 (authors’ calculations based on WHO 2018b). time that the first law on social health insurance was passed to a law to Early prevention of obesity is especially important because overweight implement UHC was approved (Carrin and James 2005). and obese children tend to stay obese into adulthood and are more likely to develop conditions such as diabetes and cardiovascular One of the main challenges under the employment-based disease. To prevent obesity, information and education about healthy contribution mechanism is to cover the unemployed and informal diet choices, urban planning and design to encourage a physically sector workers (Hsiao and Shaw 2007; Wagstaff 2010). Governments active lifestyle, and fiscal policies using taxes and subsidies as have resorted to complementary health care services to cover them. incentives for choosing healthy diets are required (WHO 2016). Studies show that interventions such as subsidies and information campaigns have limited effects in encouraging informal workers to As developing countries have become increasingly urbanized, more enroll voluntarily (Wagstaff et al. 2016; Capuno et al. 2016). In people have been exposed to road traffic injuries. Road accidents have addition, the complementary programs require administrative efforts become the main cause of death among people aged 15─29 years, and to identify and enroll beneficiaries and demand substantial financial 90 percent of worldwide fatalities on the roads occur in developing resources to maintain inefficient and fragmented health care systems. countries (WHO 2015b). Road traffic injuries place a heavy financial burden on households not only because of medical costs but also Moreover, these complementary services often overlap with those because accidents often happen to people of working age. Road safety provided by formal social health insurance, thus distorting the education along with strong enforcement of road safety laws will save incentives for formal employment (Levy 2008). Indeed, studies of developed and developing countries show that social health insurance people from injuries and avoidable financial burden. systems funded by formal workers’ contributions are associated with a Consideration 3. The Financing Mechanism to Be Used: Sharing Costs decreased share of formal employment (Levy 2008; Wagstaff 2009). Fairly and Efficiently General tax revenues can also be used to fund a prepayment and In many developing countries, individuals must pay a considerable pooling system. This financing mechanism aims to cover the entire proportion of their total health expenditure out of pocket (Cotlear et citizenry from the start. It is more likely to improve equity in health al. 2015). Figure 6 shows that out-of-pocket expenditure is less than care as compared to the contribution-based mechanism that covers 30 percent of total health expenditure for OECD countries, but ranges formal sector workers first. OECD countries such as Australia, Canada, from less than 30 percent to more than 70 percent for developing and the United Kingdom as well as some developing countries such as countries. Moreover, a low level of out-of-pocket payment does not Sri Lanka and Thailand have chosen this mechanism and are necessarily mean that people are protected from financial risk: often successfully moving toward universal health coverage (OECD 2016; in developing countries and sometimes even in wealthier countries, Rannan-Eliya and Sikurajapathy 2009; Hsiao and Shaw 2007). people forego health care because medical costs and indirect costs, Sri Lanka succeeded in providing health services free of charge to all such as transportation expenses and foregone wages, are too high citizens by reforming its health care system in the 1930s and 1940s to relative to their income (WHO and World Bank 2017). When out-of- be financed exclusively through taxes (Rannan-Eliya and Sikurajapathy pocket payment is the main method to finance health services, poor 2009). Its public health expenditure for the two decades between 1995 people spend a larger share of their income than better-off people do. and 2014 ranged from 1.2 percent to 2.1 percent of GDP (World Bank For the poor, high-cost health services, such as surgery and 2017). Thailand shifted from a fragmented health care system hospitalization, can lead to catastrophic health expenditure and including a social health insurance scheme for formal workers to an destitution (Shrime et al. 2015). integrated system financed through general tax revenue in the early 2000s, expanding health care coverage to almost the entire population Acknowledging the disadvantages of out-of-pocket payment, many (Hsiao and Shaw 2007). Its public health expenditure increased from countries have adopted prepayment and pooling health insurance 1.9 percent to 3.2 percent of GDP from 2000 to 2014 (World Bank systems. A common financing mechanism uses mandatory 2017). Notwithstanding structural and institutional differences, Turkey contributions to a social health insurance scheme from employees and followed a similar path toward UHC (see box 1). employers. Many OECD countries and some developing countries, including Chile, Ghana, and Peru, have adopted this arrangement as Using general tax revenues for health care coverage requires a the main funding mechanism (OECD 2016; Bitran 2014). However, the sustainable budget allocation and a strategy to use the limited transition to UHC under a contribution-based system has been difficult budget efficiently. For example, to prevent health care providers Figure 5. Diphtheria-Tetanus Toxoid-Pertussis (DTP3) Immuniza- Figure 6. Out-of-Pocket Health Expenditure and GDP per capita, 2014 tion Coverage among 1-Year-Olds, 2016 100 ZB MAR IRN THA CHN RWA TJK VNM U JPN 80 Out-of-pocket health expenditure, BOL TUN BLR MYS percent of total health expenditure NIC PRT BEL YEM HND JORLKA AZE AUS CHE who received the DTP3a vaccine TZA SEN y KGZ MEX RUS TUR ESP NOR 95 BDI CHL DEU NGA AZE GHA EGY PRY BGR GBR USA 70 BFA ARG BGD CMR 90 TGO ZMB COL Percent of 1-year-olds ZWE PER IND NPL KEN IND PHL DOM BRA AUT 60 SLE TJK MAR 85 SLE PAK EGY CMR BEN LAO GTM ECU LBNKAZ PHL GTM ECU 80 MOZ 50 TGO M LI PRY RUS ZAR UGA IDN NPL UKR IDN IRN KAZ ETH GIN HND LKA BGR 75 MDG 40 MDG UGAKGZ UZB MEX ZAR BFA BEN LAO TUN LBN PAK ZWE NVN M 70 YEM NER ETH SEN IC BLR CHN MYS MLI 30 ZM B CHL NER RWA PER ARG PRT 65 ZAF KEN GHA BRA CHE TZA BOL ESP BDI DOM 60 20 JOR TUR BEL AUS COL JPN AUT DEU NOR 55 GIN 10 MOZ T HA USA ZAF GBR 50 0 5 6 7 8 9 10 11 5 6 7 8 9 10 11 ($150) ($400) ($1,000) ($3,000) ($8,000) ($22,000) ($60,000) ($150) ($400) ($1,000) ($3,000) ($8,000) ($22,000) ($60,000) GDP per capita (constant 2010 US$), 2016, log scale (absolute value) GDP per capita (constant 2010 US$), 2016, log scale (absolute value) OECD East Asia and Pacific OECD East Asia and Pacific Europe and Central Asia Latin America and Caribbean Europe and Central Asia Latin America and Caribbean Middle East and North Africa South Asia Middle East and North Africa South Asia Sub-Saharan Africa Sub-Saharan Africa Source: WHO, Global Health Observatory, 2017. Source: WHO, Global Health Expenditure, 2017. Note: Data labels ISO country codes. OECD includes high-income countries that have Note: Data labels use ISO country codes. OECD includes high-income countries that have been members of OECD for more than 40 years. been members of OECD for more than 40 years. a. DPT3 = the third dose of Diphtheria-Tetanus Toxoid-Pertussis vaccine. 3 The Drive toward Universal Health Coverage Box 1. A Journey to Universal Health Coverage in Turkey: From a service by revising a policy so that the reform applied only to newly hired Fragmented to a Unified Health Care System civil servants. To engage health workers who initially opposed the change, the MoH adopted new financing schemes, such as a pay-for- Turkey successfully unified fragmented health care schemes through a performance scheme that led to higher salaries for many doctors and comprehensive social security reform from 2003 to 2012, increasing nurses. Although the main medical associations remained health care coverage from 64 percent to 98 percent of the population. opposed, their impact was diminished as health workers organized Public health expenditure increased from 3.8 percent to 4.2 percent of new unions and the government won over public opinion. GDP over the period, while household out-of-pocket health expenditure has declined by nearly half since 1999 (World Bank 2017, 2018). Along with the strategic management of opposing stakeholders, the MoH gradually expanded a health care scheme for the poor and In the initial stage of the reform, the Ministry of Health (MoH) narrowed the gap with the traditional schemes. As a result, the benefi- commissioned a stakeholder analysis to identify possible opposition ciaries of the traditional health care schemes reduced their opposition to groups—mainly trade unions, white collar civil servants, and health a unified system. By 2012, the health care scheme for the poor was workers—and developed strategies to deal with them. The MoH won integrated with the traditional ones into a unified health care system over trade unions by reassuring them that the reform would not affect with a single package of benefits and a single purchaser. their social security benefits, and reduced the opposition of the civil Source: Authors’ summary based on Bump et al. 2014. from delivering unnecessary services, some countries have adopted a the most difficult part of health reforms for many countries because of capitation system, which sets a maximum payment per case (Hsiao the conflict of interests among stakeholders (see box 1). and Shaw 2007). Likewise, to control the overutilization of services, some countries use a co-payment system, which requires patients to Conclusion pay a portion, albeit small, of medical costs (Hsiao and Shaw 2007; Reviewing the considerable literature on UHC, this brief provides a World Bank 2013). Also, when introducing a scheme funded through guide for moving toward UHC based on three main components: general tax revenues to a system funded by contributions, countries people, health services, and finance. A first step is addressing need to establish incentives for people to stay in or shift to the formal vulnerable populations and providing primary and preventive sector, such as delinking the payroll tax from health care entitlements services. Financing health care services using general taxes in a (Wagstaff and Manachotphong 2012). sustainable and strategic way can achieve more equity and efficiency For both financing mechanisms, splitting the purchasing agent than a system based on payroll taxes and a patchwork of health care from the health care provider makes each party’s responsibility more regimes. As with other dimensions of social protection, health care explicit and leads to higher accountability. The separation of health coverage should not be tied to employment status: it should serve care funding and delivery responsibilities is increasingly common in people as such and not only as workers. As shown by successful UHC programs in many developed and developing countries (Cotlear cases, to achieve universal health coverage, a change of perspective et al. 2015). is essential from seeing health care benefits as a contingent good to viewing them as an essential public service. Getting diverse Finally, for countries whose financing mechanisms differ depending stakeholders to cooperate—or at least diffusing strong pockets of on their health care schemes, harmonizing the schemes under the opposition—and managing societal and political obstacles same financing and regulatory system will increase efficiency in strategically are required to make universal health coverage a administration and budget allocation. However, this has been among reality. 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