PHM-Exch> universal health coverage (2)

[Claudio Schuftan]

>From l <peterhall at doctorsforhumanrights.org> :

> For those, who like me, need some background on health systems research to
> understand it better, here is a blog from the WB's Adam Wagstaff (edited)
>
>
>
> https://blogs.worldbank.org/developmenttalk/what-s-the-universal-health-coverage-push-really-about
>
> "What's the "universal health coverage" push really about?
>
> Submitted by Adam Wagstaff on Wed, 2010-11-10 09:02
>
> We are trying to make 2010 the year of a big push toward universal health
> coverage. Just recently, over a thousand health systems researchers gathered
> in Switzerland for the First Global Symposium on Health Systems Research;
> the theme of the symposium was "science to accelerate universal health
> coverage". Now, health ministers from around the world will gather at an
> international ministerial conference on "Health Systems Financing - Key to
> Universal Coverage" hosted by the German government. At the conference, the
> World Health Organization will launch its 2010 World Health Report entitled
> "Health Systems Financing: The Path to Universal Coverage".
>
> The Lancet just published a map showing the fraction of the population
> currently with health insurance coverage; it is a neat tool for the
> participants in these exercises to see where they're starting from. Or it
> would be if it were accurate. Unfortunately, it's not. According to the map,
> the US already has universal health coverage! In which case, what was
> President Obama doing risking his political capital by trying to expand
> insurance coverage? And according to the map, Brazil has incomplete coverage
> despite the fact that in 1988 the government amended the constitution to
> guarantee all citizens access to health care and introduced a tax-financed
> universal health system. In fact, all Latin Americans would probably be
> rather confused by the map, since they all live in a country whose ministry
> of health (MOH) operates facilities that are open to everyone. The same is
> true of African countries too. And India. And Indonesia. And the
> Philippines. In fact, come to think of it, it's true of most countries.
>
> Unfortunately, then, the map is completely misleading. The problem with the
> map-and indeed with much if not most of the debate on universal coverage-is
> that it portrays the universal health coverage challenge as an either-or
> problem. People either have coverage or they don't. In actual fact, everyone
> everywhere has some coverage. The stark reality, though, is that in many-if
> not most-countries there are large inequalities in coverage, typically
> mirroring pretty closely the income distribution.
>
> The challenge, it seems to me, is not to cover everyone (already achieved).
> Or even to give everyone the same cover (desirable but equality of effective
> coverage is best seen as a long-term goal). Rather, the coverage challenge
> to my mind is really about narrowing inequalities in coverage.
>
> Many countries have segmented health systems. Government facilities often
> charge for services, so while people have access to them, they have to pay
> for them. And in some countries, when people arrive at government facilities
> for treatment, they find no staff, no drugs, and no equipment. So, people
> have access to services that don't actually exist!
>
> By contrast, more privileged sections of the population-civil servants and
> formal-sector employees-are often covered by one or more social health
> insurance (SHI) schemes. These either reduce out-of-pocket payments in
> government facilities or give enrollees access to an altogether separate
> network of (public or private) providers. These providers may or may not
> charge a lower price, but at least when patients arrive, they find doctors,
> nurses, drugs and equipment.
>
> It is this segmentation that countries are trying to reduce. They're doing
> so in different ways.
>
> Some-like the Philippines and Vietnam-have tried to bring informal-sector
> workers and their families into the SHI scheme, often offering partial or
> complete subsidies for the poor. Other countries have set up insurance
> schemes that operate in parallel to the SHI schemes. Sometimes, as in China
> and Mexico, these are located in the health ministry. In others, like India,
> the labor ministry operates the parallel scheme.
>
> Irrespective of who runs it, voluntary schemes have proven vulnerable to
> adverse selection, and to low enrollment rates and/or low revenues from
> contributions (on paper some governments apply means-testing, but in
> practice haven't done so rigorously). And enforcing mandatory enrollment has
> proven hard.
>
> An alternative model is the Thai model. Thailand set up what is in effect a
> parallel insurance scheme within its health ministry for those outside of
> the SHI programs; however, everyone is covered, and the costs are covered
> through additional taxes.
>
> All these parallel schemes-however financed and wherever located-leave open
> the possibility of narrowing gaps in coverage, but not eliminating them, a
> useful strategy for a government with limited revenues to play with.
>
> But they all raise the question of what enrollees gain from the 'insurance'
> process, especially when the health ministry operates the scheme. What's
> different from the original MOH model that was seen as the cause of poor
> quality care and high out-of-pocket spending in the first place?
>
> One answer seems to be that the schemes give their enrollees a card that
> explicitly entitles them to a specified set of services-a type of patients'
> charter. Providers have to deliver.
>
> Another advantage seems to be that it provides governments with an
> opportunity to change the way providers are paid. They can shift from
> salaries and budgets (that do nothing to incentivize providers to turn up to
> work and make sure drugs and equipment are in stock), to higher-powered
> payment methods like fee-for-service or payments per case (which encourage
> doctors to show up for work and to make sure they have drugs and equipment).
>
> So, what should the Lancet's map have shown?
>
> It wouldn't be straightforward to calculate but one possibility would be
> the amount of spending needed to bring everyone up to the de facto coverage
> enjoyed by the group with the most generous benefit package. Does anyone
> have any other ideas?
>
> And am I right that the coverage challenge is not actually about achieving
> universal coverage, but rather about reducing inequalities in coverage? If
> so, where do we go wrong in policy discussions-if at all-by misleadingly
> talking of reaching "universal coverage" when everyone already has some
> coverage?"
>
> DO YOU AGREE WITH THIS VISION? LET US KNOW.

Claudio
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