UHC: Old wine in a new bottle?
If so, is that so bad?
Adam Wagstaff
Development Research Group, The World Bank
At the start, the idea of UHC must
have seemed straightforward enough
• Lots of countries "covered" only part of their
population, and several were making efforts to
expand coverage to "uncovered" populations
• UHC was all about extending coverage to
“uncovered” groups
• Thailand led the way in the terminology, and
somewhat confusingly even had a “UC scheme”
(that covered only part of the population)!
But wait a minute!
Didn’t we already have UHC?
• Govt. facilities are subsidized everywhere—nobody
pays the full cost
• In which case isn’t coverage already universal?
• So what really is the problem?
– It’s not that some people lack coverage
– Rather it’s that some people have deeper coverage than
others
– People outside a "scheme" (the poor?) are liable for higher
out-of-pocket payments than those inside a "scheme"
• So we need a 2nd coverage dimension—depth
• Q1: How deep? "Full" coverage?
It’s not just financial coverage
• What about the health benefits associated with
expanding and deepening coverage?
• Could “UHC” initiatives be skewed
– against low-cost but highly effective interventions
– in favor of costly inpatient and pharmaceutical-based
interventions with limited effectiveness?
• Don’t we need to think about what is covered,
not just who is covered and how deeply?
• Q2: What do we cover? Everything—i.e.
"comprehensive" coverage?
A cube is born
• It helps, but…
• Only one dimension is reflected
in the name UHC—the “U”
• And it’s the one that’s least
helpful, because everyone
already has (some) coverage!
• Soon people also started asking
awkward questions about what’s
meant by the edges of the cube
How deep?
UHC
What?
Who?
(Everyone)
De jure vs. de facto—services
• What if a country promises services but doesn't actually
deliver them?
• People may not get the services they're entitled to given
their needs
• Health workers are absent, drugs aren’t available, etc.
• Studies using standardized/fake patients show that
providers often fail to make the correct diagnosis. And
when they, do they often fail to prescribe the right
treatment
• Use of vignettes to assess competence reveal it’s not
always due to ignorance. Providers often they fail to do
everything they know they should do—there’s a “know-do”
gap
De jure vs. de facto—payments
• Financial coverage is about what people pay in practice
• And it’s about how "affordable" these payments are
• Patients may end up paying more out-of-pocket than
they expect to on the basis of what's written on paper
• Providers may deliberately overprescribe to make
money
• Or they may deliberately switch to a more resourceintensive style of care
• Paradoxically expanding coverage may lead to larger
out-of-pocket payments, and hence shallower coverage
Old wine in a new bottle
• Ultimately what we’re interested in is that in
practice
– Everyone—rich and poor—should get the health
services they need
– Nobody should suffer undue financial hardship as a
result of getting the health care they need
• Note that first aspect (service coverage) captures
quality:
– If people are misdiagnosed, or get the wrong
treatment despite the right diagnosis, they’re not
getting the care they need
• UHC isn’t really new after all
The ethical imperative of UHC
• Everyone—rich and poor—should get the health services
they need
– Being healthy is a precondition to flourishing as a human being
– It’s hard to argue for anything other than an equal distribution
of health
– People don’t choose to get ill—they get unlucky
– Leads to the injunction “treat according to need and not
according to ability-to-pay”
• Nobody should suffer undue financial hardship as a result
of getting the health care they need
– Having sufficient resources is also a precondition to flourishing
as a human being
– Together with the points above leads to the injunction “ensure
payments for needed health care don’t cause undue financial
hardship”
A practical and easily understood
approach
Everyone—rich and poor—should get
the health services they need
Nobody should suffer undue financial
hardship as a result of getting the health
care they need
• Agree on a set of “tracer” service
needs that ought to be covered
spanning (a) all types of health
service (including curative care),
and (b) all stages of the lifecycle.
• Vary list by level of development
• Use surveys w/ gadgets for
preventive care and management
of NCDs, and fake patients to see
whether people get the services
they need
• We’d like to see faster progress
among the poorest 40%
• Interpret “undue financial
hardship” as a household
being forced into poverty
• Look at actual out-of-pocket
payments sampled households
make, and see whether
they’re sufficient to push the
household below the e.g.
$1.25-a-day poverty line
• We’d like to see the number of
“medically impoverished”
households fall over time and
ultimately reach zero
Immunization
Green means faster progress among the poorest 40%