PHM-Exch> UN adopts Universal Health Coverage (3)

[Claudio Schuftan]

From: John Ashmore <jdashmore at gmail.com>


Late last year, I was at the Beijing Symposium on health systems research
where international universal health coverage (UHC) strategy was discussed
in some detail by quite a few high level players. I am here sharing my
personal notes on the conference which may be of some use to
others in understanding this debate.

It seemed to me that UHC is not a privatization agenda, but can
involve the private sector heavily as in the case of obamacare, which
does expand coverage (UHC) but of course is far from ideal. But in its
overall drive, UHC aims to increase the number of people covered by
insurance mechanisms (public and/or private) and number of services
delivered, as well as protection from 'catastrophic' health care
payments. Which, in the grand scheme of things, is a good thing,
though of course, it is imperfect. It focuses minimally on social
determinants of health, for example, but this is since it is a
political comprimise to get everyone on board...

However, I think it's good that the world is starting to look at
health systems through an equity lens as the principal way to evaluate
progress, and we should get behind this; but I also think we should
also stress: a) the need to consider social determinants of health and
redistribution as part of these goals; b) that while improvements in
UHC are good in terms of being progressive, ultimately it's not about
having 'essential' services but services for all, as comprehensive as
possible within a country's means, and based on Alma Ata principles.

Having said all that, it has taken quite some effort to get to the UN
framework for UHC that is out there and from what I know I don't think
strong opposition to this would be very constructive. I wouldn't want
to see this replaced by a new set of MDGs that only focus on combating
specific diseases without any mention of equity or tackling
ineffective health systems that, in part, caused the problems to begin
with...

*Brief notes on 2nd Global Symposium on Health Systems Research, Beijing*

John Ashmore, for CHAI

General notes:

1,800 attended the conference, which focused around the interdisciplinary
field of health systems
research, which in turn is about problem-based research to address policy
dilemmas and attain
universal health coverage worldwide. Virtually all the talks were
UHC-related, and there were high-
level stakeholders there including the CEO of Rockefeller, the South
African DG, the Chinese Minister
of Health, and many others from government… Funders for the conference
included the Rockefeller
Foundation, WHO, and the Chinese government. The fact China hosted the
conference was seen as
important since that was where the barefoot doctors program started in the
60’s which spawned Alma Ata and the PHC movement; and since China is now
making strides towards UHC again.

Universal Health Coverage, in general:

Margaret Chan calls UHC ‘the most powerful tool we have in public health’
The overall WHO framework for Universal Health Coverage (UHC) was brought
up a lot. This is
depicted conceptually as a box within a box, where increasing coverage
involves increasing the
little box to reach the limits of the big box which represents total health
care coverage, in terms
of:
o Number of people covered (should be everyone, ultimately)
o Services covered (should be at least ‘essential’ if not ‘comprehensive’)
o Coverage of ‘catastrophic’ financial expenditures through an insurance
mechanism,
such as public risk pooling or private insurance basically; but basically
the key is one way
or another to scrap user fees.
A number of participants raised the point that UHC doesn’t necessarily
ensure equity unless all
the above conditions are met (including by Lincoln Chen, President of
Chinese Medical board),
since you may have everyone covered, but not covered for very many health
services (e.g.
outpatients is often not covered by health insurance companies) and thus
people are pushed
below poverty line by their expenditures.
o Ways to measure progression towards UHC across countries explored in some
sessions, and WHO now has a publication on this.
The sessions generally focused on the need for:
o PHC approach, under current financial climate since this is more cost
efficient
o Single funder to negotiate drug and personnel costs in both public and
private sector,
to keep prices down, and in this respect having strong government
purchasing power.

Piloting UHC interventions at the district level, for a decentralized
approach, and
learning what works in a country and what doesn’t. Virtually all countries
used this
approach.
Improve the hardware and software of the health system (i.e. management
reform,
particularly at district level; and reinvigorate infrastructure and get
more HR into public
system)

BRICS Country experiences highlighted at the conference plenary (for UHC):

Brazil was the best example in my opinion (‘the only country with >100m
population that has
achieved free UHC’), as their strategy is integrated with their development
strategy (including
Bolsa Familia, i.e. conditional cash transfers for the poor), and their
universal primary health
care, in particular, is making a huge difference to maternal mortality (20%
drop in one year).
o Life expectancy has gone from 67 to 73 years recently. In short, they’re
not just
providing universal health care but they’ve tackled SOCIAL DETERMINANTS OF
HEALTH
and as a result inequity has fallen and LE risen.
o They’ve seen a 50% drop in malaria cases in 10 years, 84% decrease in
dengue fever,
and have a lot of indicators in place to measure progress (say there’s not
point doing
anything unless you can measure your progress).
o Their hospital system is still not great, but the PHC advances are most
important and
they’re even going as far with the SDH interventions to build gyms in poor
areas…
o Brazil sees its investments in health as investments, not money thrown
away. They
can afford to do this due to strong economic growth, but also political
will (right to
health enshrined in consititution).
§ This contrasts with the World Bank’s session on health care financing
where the
strong message was that sustainability should come first. (and not
everyone’s
growing like Brazil, obviously)
o They also stressed the strong PURCHASING POWER of the state through
single payer
(contracting for public and private) as key to keeping costs down.
South Africa (Matsoso’s speech) has a lot of political will now, but facing
piloting challenges
o Still looking at options of a payroll tax and ‘innovative financing
mechanisms’ (nothing
was said about what these might be however). Have however rolled out school
health
program buses with range of services, and want to make sure of district
specialist
teams and ward-based municipal PHC teams for their PHC approach.
o Also doing a management competency survey to improve ‘software’ of health
system.
o Stressed needing a ‘new cadre’ of health workers who ‘think differently’
– not sure if
this means different kind of doctor or something else, but probably the
former, relating
to the 1000 doctors they’re currently training in Cuba.
o NHI will rely on a single funder, ‘publicly administered’.
o Says social justice is behind the political will for NHI

India and China are more behind, but there has been a ‘GROUNDSWELL’
globally in UHC and
they have rolled out rural programs which are being expanded
o The rural programs have limited number of diseases they treat, and
nothing like UHC
should be in terms of being a universal package of benefits, but they are
committing
more and more to the ideals of UHC and programs are being expanded (in
terms of
services covered and individuals reached). Indian gov. aims for UHC by 2022
§ India provides financial incentives (CCTs) for institutional deliveries,
and has
had a big effect on maternal mortality where they’ve worked.
o India only spends 1.3% of GDP on public health, but they are tripling the
absolute
number spent on public health now.
o China has 98.3% health coverage, but limited services provided… same deal
as India in
terms of greater momentum now though.
Russia (the first country to introduce UHC, in 1918) has seen its UHC
system destroyed by a
shift to capitalism, after doctors were allowed to start charging user
fees, which have become
very corrupt, and the country’s health system is in tatters. They have a
lot of doctors, but the
government is not behind PHC or UH C at all right now (this was noted by an
academic, since
this was the only country who didn’t send a government representative to
the conference).
o Interestingly, in mid-60’s, after Cuban missile crisis, Russian health
care started to
decline anyway as they shifted a lot of spending from health care to
military.
§ Compare this with Costa Rica who got rid of its military altogether in
order to
spend more on social services under a tough economy.

Other country experiences later in conference:

Japan has UHC, 80% privatized, but government basically controls private
health care industry
(high regulation) and forces national-level single-payer negotiations
(drugs and services) to keep
prices down.
o Also other interesting approaches to being efficient with their money.
§ They do market price research and then only offer drug companies 2% markup
in their tenders!
§ They put out a reference list of prices they will reimburse providers, and
incentivize behavior through this: e.g. they reduced the MRI fee by 20% last
year as there were too many MRIs being performed unnecessarily (this kind of
central control is what’s missing in the US)
o But age profile very important, as the vast majority of their health care
costs are
coming from the ageing population, and basically now they have to make hard
choices
and younger people have to contribute more since their system is
unsustainable after
20 years of 0 economic growth, in spite of the above.
Costa Rica - has free care, financed by employers, government and workers.
Has had problems
with the government paying providers on time, but otherwise very successful
system for
decades.

Their success lay in the President being willing to go against the Catholic
Church who
were powerful and tried to stymie UHC. Nowdays nobody dares criticize the
national
health system. Health care and education are rights in Costa Rica.
Key for the speaker was that UHC and systems won’t work if they’re
financially
dependent on external donors.
Life expectancy now very high in Costa Rica and Burden of Disease shifted
from
infectious to chronic.

Some other interesting health financing points:

In terms of health financing, OECD SAYS BEST TYPE OF TAX IS PROPERTY TAX
(as people are
immobile and easy to collect), income tax in the middle, and WORST IS
CORPORATE TAX (since
corporations very good at avoiding, and discourages growth).

BRAC center for Health System Excellence in Bangladesh set up a voluntary
basic private
community insurance scheme that costs $15 per year and is being expanded…
(to expand
coverage in a very poor country where public sector is essentially
hopeless, or that was the
argument)
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