PHM-Exch> Final Report: WHO Consultative Group on Equity and UHC (2)

[Claudio Schuftan]

*Brief summary*



Since 2010, more than seventy countries have requested policy support and
technical advice from the World Health Organization (WHO) for how to move
toward universal health coverage (UHC). As part of the response, WHO set up
a Consultative Group on Equity and Universal Health Coverage.

This final report by the Consultative Group addresses the key issues of
fairness and equity that arise on the path to UHC by clarifying these
issues and offering recommendations for how countries can manage them.

To achieve UHC, countries must advance in at least three dimensions.
Countries must expand priority services, include more people, and reduce
out-of-pocket payments.

However, in each of these dimensions, countries are faced with a critical
choice: Which services to expand first, whom to include first, and how to
shift from out-of-pocket payment toward prepayment? A commitment to
fairness—and the overlapping concern for equity—and a commitment to
respecting individuals’ rights to health care must guide countries in
making these decisions.

The following three-part strategy can be useful for countries seeking fair
progressive realization of UHC:

Categorize services into priority classes. Relevant criteria include those
related

to cost-effectiveness, priority to the worse off, and financial risk
protection.

First expand coverage for high-priority services to everyone. This includes

eliminating out-of-pocket payments while increasing mandatory, progressive

prepayment with pooling of funds.

While doing so, ensure that disadvantaged groups are not left behind. These

will often include low-income groups and rural populations.

As part of an overall strategy, countries must carefully make choices
within and across the dimensions of progress. These decisions depend on
context, and several different pathways can be appropriate. Nevertheless,
some trade-offs are generally unacceptable.

For example, one generally unacceptable trade-off is expanding coverage for
low- or medium-priority services before there is near-universal coverage
for high-priority services.

When pursuing UHC, reasonable decisions and their enforcement can be
facilitated by robust public accountability and participation mechanisms.
These mechanisms should be institutionalized, for example, through a
standing national committee on priority setting, and the design of
legitimate institutions can be informed by the Accountability for
Reasonableness framework. A strong system for monitoring and evaluation is
also crucial for promoting accountability and participation and is
indispensable for effectively pursuing UHC.



*Executive summary*



Universal health coverage (UHC) is defined as all people receiving quality
health services that meet their needs without being exposed to financial
hardship in paying for the services. Given resource constraints, this does
not entail all possible services, but a comprehensive range of key services
that is well aligned with other social goals. UHC was firmly endorsed by
the World Health Assembly in 2005 and further supported in the World Health
Report 2010. Since then,

more than seventy countries have requested policy support and technical
advice for UHC reform from the World Health Organization (WHO). In
response, WHO developed a plan of action that included providing guidance
on how countries can manage the central issues of fairness and equity that
arise on the

path to UHC. The WHO Consultative Group on Equity and Universal Health
Coverage was set up to develop this guidance.

This document is the Consultative Group’s final report. The report
addresses the key issues of fairness and equity by clarifying these issues
and offering recommendations for how countries can manage them. The report
is relevant for a wide range of actors and particularly for governments in
charge of overseeing and guiding the progress toward UHC.

To achieve UHC, countries must advance in at least three dimensions.
Countries must expand priority services, include more people, and reduce
out-of-pocket payments.

However, in each of these dimensions, countries are faced with a critical
choice: Which services to expand first, whom to include first, and how to
shift from out-of-pocket payment toward prepayment? A commitment to
fairness—and the overlapping concern for equity—and a commitment to
respecting individuals’ rights to health care must guide countries in
making these choices. For fair progressive realization of UHC, the three
critical choices and the trade-offs between the dimensions must be
carefully addressed.



Expanding priority services



When expanding services, the crucial question is which services to expand
first. Services can be usefully categorized into three classes:
high-priority, medium-priority, and low-priority services. Relevant
criteria for ranking and categorizing services include those related to
cost-effectiveness, priority to the worse off, and financial risk
protection.

When selecting which services to expand next, it is often useful to start
with cost-effectiveness estimates and then integrate the concern for the
worse off as well as other relevant criteria. The specification, balancing,
and use of these criteria should take place in the context of robust public
deliberation and participatory procedures. This will enable a wide range of
groups to provide input to the priority-setting process and promote
accountability for the decisions made. Countries will also benefit from
having a standing national committee on priority setting to handle
particularly difficult cases.



Including more people



When seeking to include more people, an inescapable question is whom to
include first. To include more people fairly, countries should primarily
first expand coverage for low-income groups, rural populations, and other
groups disadvantaged in terms of service coverage, health, or both. This is
especially important for high-priority services. Fair inclusion of more
people may call for targeted approaches where these are effective.



Reducing out-of-pocket payments



Many countries rely heavily on out-of-pocket payments to finance health
services. Such payments represent a barrier to access to health services,
especially for the poor. In addition, for those who do use the services,
out-of-pocket payments are often a substantial financial burden on them and
their families and may even cause financial catastrophe. To improve access
and financial risk protection, countries should therefore shift from
out-of-pocket

payment toward mandatory prepayment with pooling of funds. A critical issue
is how to do so. Fairness suggests that out-of-pocket payments should first
be reduced for high-priority services and for disadvantaged groups,
including the poor. Regarding mandatory prepayments, fairness suggests that
they should generally increase with ability to pay and that contributions
to the system should be progressive. At the same time, the access to
services should be based on need and not ability to pay.



Overall strategy and pathways



A three-part strategy can be useful for countries seeking fair progressive
realization of UHC:

Categorize services into priority classes. Relevant criteria include those
related

to cost-effectiveness, priority to the worse off, and financial risk
protection.

First expand coverage for high-priority services to everyone. This includes

eliminating out-of-pocket payments while increasing mandatory, progressive

prepayment with pooling of funds.

While doing so, ensure that disadvantaged groups are not left behind. These

will often include low-income groups and rural populations.

As part of an overall strategy, countries must carefully make choices
within as well as across the dimensions of progress. These choices will
depend on context, and several different pathways can be appropriate.
However, when pursuing fair progressive realization of UHC, some trade-offs
are

generally unacceptable:



Unacceptable trade-off I:

To expand coverage for low- or medium-priority services

before there is near universal coverage for high-priority services. This
includes

reducing out-of-pocket payments for low- or medium-priority services before

eliminating out-of-pocket payments for high-priority services.

Unacceptable trade-off II: To give high priority to very costly services
whose

coverage will provide substantial financial protection when the health
benefits

are very small compared to alternative, less costly services.

Making fair choices on the path to universal health coverage

Unacceptable trade-off III: To expand coverage for well-off groups before
doing

so for worse-off groups when the costs and benefits are not vastly
different. This

includes expanding coverage for those with already high coverage before
groups

with lower coverage.

Unacceptable trade-off IV: To first include in the universal coverage
scheme only

those with the ability to pay and not include informal workers and the
poor,

even if such an approach would be easier.

Unacceptable trade-off V: To shift from out-of-pocket payment toward

mandatory prepayment in a way that makes the financing system less

progressive.



Mechanisms and institutions



Fair progressive realization of UHC requires tough policy decisions.
Reasonable decisions and their enforcement can be facilitated by robust
public accountability and participation mechanisms. These mechanisms are
essential in policy formulation and priority setting and specifically in
addressing the three critical choices on the path to UHC and the trade-offs
between dimensions of progress. These mechanisms are also crucial in
tracking resources and results. To properly play these roles, public
accountability and participation should be institutionalized, and the
design of legitimate institutions can be informed by the Accountability for
Reasonableness framework.

A strong system for monitoring and evaluation is also needed to promote
accountability and participation and is indispensable for effectively
pursuing UHC in general.

Countries must carefully select a set of indicators, invest in health
information systems, and properly integrate the information into policy
making. The selection of indicators should be closely aligned with the goal
of UHC and in most settings include at least four types of indicators:
indicators related to the priority-setting processes and indicators of
coverage, financial risk protection, and health outcomes. The latter three
types of indicators should reflect both average levels and equity in
distribution.
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