1. Under JPG Teaching Fellowship
Permission from JPGSPH
CoE-UHC

2. Concepts and Principles of
Universal Health Coverage
Tim Evans,
Dean, James P. Grant School of Public
Health
June 6, 2013,

3. Outline
• What is Universal Health Coverage?
• Why focus on Universal Health Coverage ?
• Moving towards Universal Health Coverage

4. What is Universal Health Coverage (UHC) ?
• A widely shared objective across all health
systems
– World Health Assembly Resolutions 2005, 2012
• A “consensus value”:
– a universal right or entitlement to health
– justice, fairness and equity in health
– an intolerance of inequities in health

5. Health as a Special Good
“Without health nothing is of any use, not money nor
anything else” Democrit, 5th Century B.C.
“The preservation of health is … without doubt the first
good and the foundation of all other goods of this life”
Descartes,1637
"The health of the people is really the foundation upon
which all their happiness and all their powers as a
state depend" Disraeli,1877

6. The right to health
The enjoyment of the highest attainable
standard of health is one of the fundamental
rights of every human being without distinction
of race, religion, political belief, economic or
social condition (...)”
WHO Constitution 1946

7. Health Equity
The absence of unfair and avoidable or
remediable health differences between more or
less disadvantaged groups defined socially,
economically, demographically, or
geographically (Evans et al. 2001; Braveman & Gusman 2002)
Based on principles of social justice, it implies
that everyone should have a fair opportunity to
attain their full health potential (Whitehead 1990, Sen 2002)

8. Inequities in health
" there is no good biological reason why someone
living in Sierra Leone's life expectancy should be a
full 50 years lower than someone living in Japan".
Sir Michael Marmot, the Chair of the Commission on Social
Determinants of Health
"spectacular progress, spectacular inequities".
– Bill Foege, looking back on progress in health in the
20th century,

9. What is Universal Health Coverage (UHC) ?
• WHO definition –
– Access for all to a full spectrum of services
of good quality ranging from prevention
through to rehabilitation according to need
– Affordable cost to consumers

10. Three Dimensions of Coverage Expansion
WHO, World Health Report, 2010
16

11. Why focus on Universal Health Coverage?
• Worrisome Shortfalls in Coverage
–Extremely Low levels
–Endemic Inequities
–Evidence of harm

12. Why focus on Universal Health Coverage?
• Extremely Low levels of Coverage
– Single interventions
– Packages of interventions
– Key health systems inputs
• health workforce
• essential drugs
• health facilities

13. 3 m estimated
annual deaths
from malaria
Only between 2-15%
African children
are sleeping under
bednets (2001)
1/21/2014
Information, Evidence and Research

14. Equity and survey data
Dipping-in-and-out of the health system: Nepal 2006
120
100
80
60
40
20
0
Poorest
2
3
4
Richest

15. ®
®
®
®
®
Coverage patterns:
a blueprint for saving lives
®  Of 18 life-saving interventions, only
®
vaccinations are reaching 80% coverage
®
24H
24H
24H
24H
Interventions able to be scheduled routinely (®)
have higher coverage than those needing
functional health systems and 24-hour availability
(24H)
Trends in coverage since 1990 follow similar
patterns

16. World Health
Report 2006
Critical shortage of
health workers in
57 countries;
4.3 million more
health workers
needed to provide
essential
interventions.

17. Poor coverage of vital events
World Health Report 2003
17

18. Why focus on Universal Health Coverage?
• Endemic Inequities
–“Poorer” less likely to be covered
– widespread evidence of “inverse care”

19. the “inverse care laws”
• Rich consume more hospital and public
health care than the poor (Tudor Hart, 1971)
• Immunization coverage strongly correlated
with socioeconomic status (Gwatkin et al., 1999)
• Poor with illness don’t access care: 2x more
likely to self treat; 10x more likely to do
nothing (Uganda, HH Survey, 1994/5).
• Poor that access health care risk medical
impoverishment (Voices of the Poor, 2000)

20. Trends in skilled birth attendance by income quintile
Bolivia
1.00
Egy[t
1.00
0.90
0.90
0.80
0.80
0.70
0.70
0.60
1994
0.60
1995
0.50
1998
0.50
2000
0.40
1989
0.40
1992
0.30
0.30
0.20
0.20
0.10
0.10
0.00
0.00
1
2
3
4
1
5
Indonesia
1.00
1.00
0.90
2
3
4
5
Zimbabwe
0.90
0.80
0.80
0.70
0.70
0.60
1994
0.50
1997
0.60
0.50
1991
0.40
0.40
0.30
0.30
0.20
0.20
0.10
0.10
0.00
1
1/21/2014
0.00
2
3
4
5
1
2
3
5
Information, Evidence and4Research
1994
1999
1988

21. Why are poorer populations…
 2x more likely to have TB?
 3x less likely to access TB
care?
 4x less likely to complete TB
treatment?
 5x more likely to suffer
impoverishment due to the
costs of TB care?

22. Why focus on Universal Health Coverage?
• Evidence of harm
–Unsafe care
• Selection of super-bugs e.g. XDR TB
–Lack of financial protection

23. "poor TB services" deemed the
underlying reason for emergence of
XDR-TB.
•Insufficient vehicles
•Inadequate supervision of patients
beyond hospital
•Interruption in supply chains
•Unacceptable rates of "first line"
treatment failure
•No response to evidence of "first
line" failure
•Sloppy "second line" treatment
practices
•Poor infection control in hospitals
(over-crowding)
•Missing laboratory support structures
(resistance monitoring)

24. Number of People Suffering Financial
Catastrophe and Impoverishment Due to Health
Spending
EMR
impoverishment
AFR
catastrophic
EUR
SEA
AMR
WPR
-
30
60
Number of people (million)
90

25. Inequitable and Inefficient Financing of
Health
• Out of pocket expenditure (OOP) >65% of total health
expenditure (THE)
– Major cause of household impoverishment (Sen 2003)
– 4 to 5 million impoverished annually (Van Doorslaer 2007)
– 22% of all shocks in the lives of the poor (World Bank 2008)
– Discourages accessing health care when needed
– Most important cause of micro-credit default
• Out of pocket expenditure as share of THE is increasing over
time (NHA 2007).
• All evidence, everywhere indicates OOP is most inefficient and
inequitable way to finance health care (WHR 2010).

26. Catastrophic health expenditure
Source: Van doorslaer et al. 2007

27. A major deficit on fair financing
• Government health expenditure:
– Vastly insufficient at $4/capita relative to need of
$24/capita
– decreasing as share of total health expenditure
– regressive – rich benefit more than the poor
– demand side financing – innovative but not clear
that is “scalable” to whole country or beyond
MNH

28. A major deficit on fair financing
• NGOs efforts
– While micro-credit has mushroomed, microhealth insurance has failed to grow!
– Coverage is very shallow – no clear evidence of
financial protection
• Private sector health insurance
– Insurance industry show little activity in health
(<!% of total health expenditure).
– Employers only just beginning to provide health
insurance benefit

29. Why Focus on Universal Health Coverage?
• Policy relevance:
– strongly linked to MDGs attainment
– a widely agreed policy objective
•
•
•
•
World Health Assembly Resolutions 2005, 2011
World Health Report 2008: Primary Health Care
Commission Social Determinants of Health 2008
First World Social Security Report 2010, International
Labour Organization
• World Health Report 2010: Health financing

30. The World Health Report 2010
HEALTH SYSTEMS FINANCING
The path to universal coverage

31. The path forward:
Universal Health Coverage (UHC)

32. Are we missing the big picture?
.

33. Changes in Global Landscape
2
1
3
6
Chronic
diseases
5
Aging
Env. issues
4
Health concerns
Megacity
Migration
Youth bulge
Environmental degradation will increase in countries that have already experienced
1 some of the world’s worst environmental problems
2 Europe and Japan will face the most immediate impact of aging
3
The infectious disease burden will aggravate other demographic problems in the
developing world
4 Global migration could be a partial solution to other demographic imbalances
Urbanization
5 Some of the world’s poorest and most politically unstable countries will have the
largest populations
6
Urban growth and stresses will be particularly great in developing countries,
especially in Asia
Emerging
Market
Economies
Footprint
Countries
Innovative
Developing
Countries
Emerging
Donor
Nations
BRICs

35. Tanahashi Framework for Service
Delivery Coverage
1/21/2014
Information, Evidence and Research

36. The Imperative of Political
Commitment
“As the movement for UHC intensifies in
other parts of the world, there is an
imperative to prepare Bangladesh for
it!”
Honourable Prime Minister Sheikh Hasina.
Inaugural address at the 64th World Health Assembly,
Geneva May 2011
(http://www.who.int/mediacentre/events/2011/
ha64/sheikh_hasina_speech_20110517 /en/index.html )

37. The need to begin now
• Opportunities:
– Increased UHC activity in the region and globally
– New 5 year health sector plan - HPNSDP 2012-2016
– Sustained economic growth, middle income country
status in next 10-15 years likely
– Rapid growth in the health sector
• >10% per annum in total health expenditure
– Better than expected performance in MDG
achievement….can build on some strengths

38. Three dimensions of coverage expansion for
universal health coverage
Three Dimensions of Coverage Expansion
WHO, World Health Report, 2010
16

39. Strengthening supply of services
• Comprehensive package of quality services
– Responsive to users
• Respect for persons (dignity, autonomy, confidentiality)
• Client orientation (health needs, basic amenities)
•
•
•
•
Skilled workers – right place, right time
Infrastructure – sturdy, clean, functioning
Drugs, diagnostics – in stock, minimal co-pays
Info Tech facilitated –
– Cashless transactions with single “smart card”
– Electronic medical records, m-health

40. MOVE-IT Bangladesh
CONTEXT:
• New health strategy
“Scale-up” maternal child
health services
“Results focus”
investment in information
• “Digital Bangladesh”
Innovative use of digital
technologies such as
E-health and M-health

41. MOVE-IT Bangladesh
Aims:
1. Universal registration of all pregnant mothers
and their newborns;
2. Unified electronic information system that:
- tracks vital events (births, deaths, and cause of
death),
- non-fatal health events;
- coverage of priority services
Mothers – Ante-natal care; delivery; post-natal care
Newborns – neo-natal, infant and child care.

42. Fix the financing system I
• Mobilize more resources –
– taxes – direct and indirect i.e. sin taxes
• Improve allocation –
– According to need –essential interventions
– Can demand-side financing be scaled up?
– Set up separate purchaser agency e.g. National
Health Security Office as in Thailand
• Better payment systems
– Needs-adjusted capitated systems
– Remove incentives for “over” and “under”
coverage

43. Fix the financing system II
• Regulatory framework to promote health
insurance in private sector:
• Subsidies to private insurers for coverage of
below poverty line populations
• Incentives for larger pools to avoid the microinsurance trap
• Long-term plans for “federation” of private
insurance plans to minimize duplication and
promote efficiencies

44. Educate and empower beneficiaries
1
Communicate the health
and economic benefits of
insurance
5
2
Expedite claims
adjudication process
with prospective
reimbursement
Engaged in designing
benefit package to meet
needs and expectations
a)
4
Everyone experiences
“benefits” through health
promotion and wellness
checkups
3
Based on ability to
pay
b)
Make Premium payment
simple and sustainable
Part of a compulsory,
group membership
c)
Part of a larger
financial transaction

45. Learning by doing
• No one size fits all
• All ambitious policies require course
corrections
• Set time-bound targets for performance i.e.
decrease in OOP below 30% THE
• Generate evidence to inform, implement and
evaluate UHC efforts
• Investing in individual and institutional
capacities to make reforms work

46. Experiences from other countries
• Thailand: A long but successful road to UHC
• Ghana: UHC through community-based Health
Insurance schemes
• India: Health Insurance for the ‘below poverty
line’ population
• Rwanda: Community-based health insurance
schemes in a low income country

47. Thank you all !