Progressive Pathways to Universal
Health Coverage
David B Evans, Director
Health Systems Governance & Financing
Background
1. Grand Convergence: once in a lifetime opportunity
2. It will cost money – in low-income countries,
increases in external financial will be necessary
unless exceptional growth
3. Nevertheless, virtually all countries could raise or
spend more on health if they wished - Sanjay
Gupta IMF gave options for raising and spending
wisely
4. What to do with the money?
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The Objective: Universal Health Coverage
 All people have access to needed services
 Without the risk of financial ruin linked to paying
for care
Universal Health Coverage:

coverage with needed health services (of good
quality);

coverage with financial risk protection

for all
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Financial Risk Protection
1. Requires:
 Prepayment and pooling of resources - compulsory
 Minimizing user fees and charges – zero for the poor and
vulnerable (possibly "negative fees")
 Good quality services are available
2. The combination of financial risk protection with the
availability of good quality services – instrumental to
increasing health and economic wellbeing, but also valued
for its own sake
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Resource Scarcity and Progressive
Universalism
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Progressive Universalism: Features
1. The poor and vulnerable should be covered from the start –
do not start with insurance for the formal sector and civil
servants with the intention of bringing in the poor and
informal sector later
2. Start by covering interventions against infectious diseases,
targeting RNMCH, expanding to NCDs rapidly – the most
highly cost-effective interventions
3. Limited if any payments at the point of service – poor and
vulnerable exempted if fees are charged
4. Expand health services over time as rapidly as possible –
prevention, promotion, treatment, rehabilitation, palliation
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Country Choices: Practicality and Politics
1. Begin by targeting poor and vulnerable versus universal from
the start – practical questions: how easy to identify, restrict
2. Ways of ensuring poor can afford: zero user fees/copayments vs. exemptions (or cash transfers) – efficiency
question
3. What to call compulsory prepaid contributions: taxes, charges
or compulsory insurance? Sometimes people more willing to
contribute to a tax called insurance than pay increases in
overall taxation used to fund health
4. How many pools? Less fragmentation better
5. How to purchase services from pooled funds: fee for service
inefficient, what role for results based payments?
Commission on Investing in Health, London, December 2013
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What Does Not Work
1. Voluntary insurance cannot get to UHC –
at best, a supplement to compulsory
pooling
2. Catastrophic insurance – e.g. insurance
for unpredictable high cost items such as
inpatient care - cannot get to UHC
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9.0
Total Health Expenditure as % GDP: Selected Low
Income Countries
8.0
7.0
Low income
6.0
Bein
Cambodia
5.0
CAF
Chad
Eritrea
4.0
Guinea
Haiti
Myanmar
3.0
Nepal
2.0
1.0
0.0
2001
2002
2003
2004
2005
2006
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2007
2008
2009
2010
Thank you
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