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"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.
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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