Shaping UHC Policy for Post 2015:
Opportunities & Risks
Jeanette Vega MD, DrPH
Managing Director of Health
NHIS 10 Anniversary Conference
Accra, November 4th, 2013
Presentation Overview
Universal Health Coverage (UHC)
contribution to the Sustainable
Development Goals
UHC: Definition and components
Health financing situation in Africa
Achievement of MDGs in the region
Concluding remarks
2
Post-2015 Development Agenda: Wellbeing for All
The contributions of the health sector and other sectors
Sustainable Wellbeing for All
Poverty eradication, health,
education, nutrition, environment,
security, etc.
Healthy Lives at All Stages
Child survival, maternal survival,
MDG6, adolescent health, NCD
burden reduction.
Universal Health Coverage
Health promotion, prevention,
treatment, financial risk protection.
Health Sector
Contribution
Other Sector
Contributions
3
Universal Health Coverage: What?
Definition:
All people can access the health services they
need without incurring financial hardship.
Indicators:
1. Financial protection
2. Access
4
Financing for UHC: Overall questions to be
addressed by any country
1
How to alter the system in a way that
2
… given our starting point in terms of
– Reduces the gap between the need for and use of
services, across the population,
– Improves quality of health services,
– Improves financial protection…
– existing configuration of the health system, including coverage
arrangements,
– overall current and expected fiscal constraints, and
– other key contextual factors, such as labor market (informality),
public administration structure (e.g. decentralization), geography
and population density, politics, etc.?
5
Policy options for universal funding
coverage
1
Fund coverage for everyone secured from
general budget revenues, automatic
entitlement: Non- contributory
2
100% Contributory: No subsidy; everybody must
contribute a “full premium” or has no
entitlement
3
Guarantee (fund from budget) certain services
for all; entitlement to “full package” requires
contribution
– Complementarity between direct contributions
and government subsidies for coverage expansion
4
Subsidized participation with strong public
commitment to universality
6
Two conditions for financing
UHC when using contributory arrangements
1
2
Subsidization: because some will be too
poor or too sick to be able to afford
coverage
Compulsory contribution: because some
who can afford it are unwilling to pay for it
One without the other won’t work (subsidies alone
not sufficient because rich/healthy will not join; and
compulsory without subsidies imposes a heavy burden
on the poor and sick)
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Some broad lessons on health
financing policy
1
No country gets to UHC via voluntary health
insurance
2
All countries with universal health coverage rely
in whole or in part on general budget revenues
3
Need to manage resources efficiently: Strategic
purchasing is essential
– Compulsory or automatic entitlement is essential, with
subsidies
– Because there are always some who can’t contribute
directly,
– And the larger the informal sector, the greater the
need for using general revenues
– Move away from the extremes of provider payment
methods – unmanaged fee-for-service and rigid line
item budgets – as these contribute to system
inefficiencies
8
Common elements of few countries that have high
coverage with “voluntary”contributory schemes
Cost of the “premium” much less than the perceived value of
the benefit, stimulating demand
– Substantial subsidies on the supply side and the demand side,
and same benefit package as rest of population in the scheme
– Population aware that not being covered means risk of high outof-pocket spending
Strong role of local governments
– Strong incentives/instructions for local officials to inform people
and enroll them into the coverage program, (ie. Rwanda), and
– Explicit role for local budgets to subsidize (ie China)
Very strong (authoritarian) governments able to implement
these measures
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15
Chad
Eritrea
Kenya
Angola
Congo
Namibia
Gabon
C?te d'Ivoire
Guinea
Equatorial Guinea
Nigeria
Mozambique
Guinea-Bissau
Cape Verde
Burundi
Algeria
Cameroon
Botswana
Seychelles
Mauritius
Benin
Democratic Republic of the Congo
Uganda
Mauritania
Niger
United Republic of Tanzania
Gambia
Sierra Leone
Ghana
Senegal
Mali
Central African Republic
South Africa
Burkina Faso
Comoros
Ethiopia
Lesotho
Swaziland
Togo
Zambia
Malawi
Liberia
Rwanda
Health as a % of government expenditure
African governments increasingly
giving priority to health.
25
Ghana is higher than the average globally
20
Average per country globally =11.5%, Ghana= 11,9%
10
5
0
10
African countries have low public spending
on health relative to the size of the economy
Total government expenditures on health as a % of GDP
Ghana is lower than the average globally =2.6%
10
9
8
7
6
5
Average per country globally= 3.9%
4
3
2
1
0
Source: WHO estimates for 2011
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It matters because higher public spending on health
reduces dependence on out-of-pocket spending
12
In summary: two critical issues to increase
financial access coverage in Africa
1
How to advance towards pre-paid
Universal financial coverage
2
How to increase overall fiscal space for
health and increase health as a priority in
the general budget
All people can access the health services they need
without incurring financial hardship.
13
Achievement of MDGs in the region
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Reduce by two-thirds the <5 mortality
rate between 1990 and 2015
15
Reduce by three quarter the maternal
mortality rate between 1990- 2015
Target :
213 per 100,000 livebirths
Only 2 countries on track:
Eritrea
Equatorial Guinea
16
Maternal health: Increase % of skilled
birth attendance to 80%
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One reason for no achievement has been the
absence of UHC as a goal in the current objectives
1
UHC reflects health sector’s inherent responsibility to
provide universal and equitable access to health that
ensures improved health outcomes.
2
UHC links to other sectors, and enables healthy,
sustainable development.
3
UHC is a recommitment to health as a human right.
Universal Health Coverage is an integrated, efficient
approach to improve health outcomes. It is aspirational, but
there is growing global and national commitment to UHC.
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Why UHC in the Post 2015
Development Agenda?
When designed with an equity, rights
and fiscally prudent focus, UHC
is an accelerator towards
better health outcomes and overall
social wellbeing.
19
Emerging Consensus on Health in the
Post-2015 Development Agenda?
MDGs + more ambitious health outcome targets.
– E.g., ending preventable maternal and child deaths,
universal access to reproductive health, new HIV, TB,
malaria targets, NCDs and their risks.
Universal health coverage emerging as the specific
health sector contribution to health
Equity – realizing the right to health for all.
Recognition that achieving health outcome targets a
require actions beyond the health sector –
determinants of health.
– E.g. income distribution, education and labor policies, food
security and nutrition, water and sanitation, urbanization.
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Processes Feeding Into the Post-2015
Development Agenda
Source: UN Foundation and Dalberg analysis
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