Comfort was able to access Ghana's free healthcare facilites. Photo: Abbie Trayler-Smith/Panos
Everyone – whether rich or poor – should get the health care they need without suffering financial hardship.

Universal Health Coverage: key to the success of the World Bank’s new vision

23 October, 2013 | Health and Education For All

"We must be the generation that delivers universal health coverage.” – WBG President Jim Yong Kim in a speech to the World Health Assembly, May 2013

At the World Bank Group’s Annual Meetings in Washington this month, the Development Committee — a joint World Bank-IMF forum that advises the two institutions — approved a new World Bank Group Strategy to achieve the institution’s updated vision: to end extreme poverty by 2030 and promote “shared prosperity,” Bank-speak for reducing inequality.

We would argue that pursuing Universal Health Coverage (UHC) – alongside robust investments in other aspects of human development – must be utterly central to the Bank’s strategy to achieve its two goals. While Dr. Kim’s opening speech at the Annual Meetings touched on the importance of health (and education) in achieving its goals, human development is not articulated as a central component of the Bank’s new strategy to achieve the goals.

The Bank says this is because the strategy is meant to describe an overall approach rather than privileging any particular sector.  That may be, but it is hard to see how the Bank’s two goals can be met without a clear vision for how the fruits of economic growth can be equitably shared through transformative essential public services. We hope to see this change as the implementation details of the strategy become clearer.

Ensuring access to quality, affordable health services worldwide

Nevertheless, President Kim’s recent speeches and writing provide clues to his vision of the importance of health in reducing poverty and inequality. In a recent article he wrote that “to free the world from extreme poverty by 2030, countries must ensure that all their citizens have access to quality, affordable health services.” At the World Health Assembly in May, he pointed to a hopeful new direction for the Bank by committing to help countries work towards UHC and stating that point-of-service fees are “both unjust and unnecessary.” But will these high level statements really translate to a change in the way the Bank works in countries?

We hope so. The Bank’s expertise in building health systems can be powerfully harnessed for the cause of Universal Health Coverage, but this means a break from business as usual. Building health systems isn’t enough; they must be the right kinds of systems — systems that are equitable and truly universal.

 Universal health care report coverKey conditions for its success

Oxfam’s new paper, “Universal Health Coverage: Why health insurance schemes are leaving the poor behind,” examines the conditions necessary for health systems to be equitable and universal. The paper looks at four key ingredients to successful financing for UHC: removal of direct payments and other financial barriers, compulsory pre-payment, large risk pools, and financing from general revenues to cover the uncovered. In our analysis, conventional insurance schemes – whether private, community-based or European-style social health insurance – come up short when measured against these criteria.

Since UHC is about access to quality care for everyone regardless of ability to pay, governments must move away from relying on employment-based and contributory insurance models. Instead, health care must become a right of citizenship (or residency), financed in large part through general government revenues. As the diverse but successful UHC experiences of Mexico, Thailand, Sri Lanka, Brazil and Kyrgyzstan show, equity must be designed into the system from the beginning, rather than starting with the easiest to reach in the formal sector.

The World Bank Group has a history of promoting health insurance as a financing mechanism to generate revenues in the health sector in environments of fiscal constraints. Some examples include a recent policy series on private health insurance, previous work in countries such as Ghana, and IFC investments to support insurance schemes in Africa.

But things may be changing at the Bank. In a series of 22 recently released case studies on UHC, the Bank finds that, across countries, the use of financing from general taxation to expand coverage is an important commonality, and that prioritizing equity is a key lesson. We also hear the Bank is playing a more constructive role in certain countries to encourage universal system design. And new leadership in the health sector and from the President should be cause for optimism.

A real test of the potency of the new World Bank strategy will be whether the World Bank Group throws its full weight behind equitable, universal health systems – systems that are financed largely through tax-based general revenues and which include all members of society – through its global knowledge products, its policy advice and technical assistance, and through its lending choices.

Originally published on Global Health Check website.

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Universal Health Coverage: leaving the poor behind

Thank you for this helpful report highlighting the problem that national insurance schemes may help the employed and better off but may not benefit the poor.

Your readers may be interested in an alternative model that does fully engage the poor.  Church of Uganda (COU) Kisiizi Hospital have run a Community Health Insurance Scheme in a remote rural area of south-west Uganda since 1996. The scheme started with support from the Uganda Ministry of Health and DfiD UK and built on existing community burial groups as a natural progression. The scheme now has 180 groups with over 35,000 members up to 60 km from Kisiizi Hospital. The motivation is to bring good health care to very poor communities and we do not seek to make a profit.

In 2013 the premiums ranged between 10,000 and 15,000/-UGX (approximately US$ 4.0 – 6.0 ) per annum. 

The scheme covers accident and emergency and acute out - patient services, in - patient services and surgery, and medicines prescribed according to agreed protocols.  The scheme also covers maternity and dental care.

Exclusions include routine medical check- ups for employment, complications from deliberate self harm or from treatments against medical advice.  Patients with chronic conditions such as diabetes, hypertension, asthma etc are covered for in-patient care if they have properly attended their specialist clinics but the scheme does not cover out-patient chronic medication.  This exclusion is in order to keep the annual premiums as low as possible to ensure that the very poor have access to life-saving emergency treatment.  However, recognising the severe financial challenge of chronic illness, COU Kisiizi Hospital operates a “Good Samaritan Fund” which subsidises the care of some of these patients.  In addition, certain vulnerable groups including patients with mental illness, neonates and patients with disability receive subsidised care from the hospital in line with its Christian ethos.

Members of the scheme make a co-payment equivalent to US$ 0.4 for out-patient visits or US$ 2.0 for admission  but then have no further charges for their hospital stay, investigations and treatments including medication and surgery.  Women admitted in labour pay US$ 8.0 flat fee and do not have to pay any extra if complications arise, for example the need for caesarean section or for extra medications e.g. antibiotics, blood transfusion, intravenous fluids etc.

The enthusiasm of the groups and rising membership numbers year on year are encouraging.  In the financial year to 30th June 2013 the scheme broke even.  Our income was around US$ 176,431, treatment costs US$ 161,610 and administration costs US$ 10,022 giving a balance of US$ 4,798.  There is no external donor funding for this scheme which is currently generating interest from a range of bodies including WHO as they review different models to achieve Universal Health Coverage.

We are now seeking to further expand the numbers in the scheme and to further develop Health Promotion through the groups to prevent avoidable diseases.  We are making some local-language videos to facilitate this with provision of generators / screens to use in remote rural areas.

Dr. Ian Spillman

Medical Superintendent

Church of Uganda Kisiizi Hospital