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Universal health coverage: Old wine in a new bottle? If so, is that so bad?

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Patricio V Marquez

February 12, 2013

Adam--Excellent blog!. Your comments are right on the mark! Indeed, we have been working all along for a long time in different regions and countries pursiuing the three dimensions of UHC as you noted: expansion of coverage, standarizing the content of services and minimizing risks associated with out-of-pocket payments, and on the elusive quality dimentsion (structure, yes it matters, processes, the new battlegroung, and outcomes, still in the future) in service provision.

A little institutional memory or a simple review of the literature will confirm the above.

And as you suggested, UHC can be a "rallying cry for the goals of equity, financial protection, and quality of care."

So let's move on remembering the past!

Well done.

Patricio

Gyorgy Fritsche

February 12, 2013

This is a very nice blog Adam.

We have indeed known for ages the problem: inequitable health systems that deliver low quality inaccessible health care to the poorest.

The question for us - implementers and practitioners - is as follows. How do we move from what we know (for ages) to solutions that work in the most difficult of circumstances. Let us say: how we can we get the Nigeria’s and the DRCs to work better - soon. Can we use all we know so far to deliver in moving such health systems to deliver better? The money is there. The knowledge is there. But how can we move with our knowledge to delivering solutions that work?

Solutions are available, and such solutions also are in need of being branded differently, to move into a world where UHC has become the new slogan. It is indeed old wine in a new bottle. We need people like you to help us frame this better and to help us explain to others why we do what we do.

Paul Shaw

February 12, 2013

While the UHC agenda may be somewhat akin to ‘old wine in a new bottle’, I think it’s also a more refined, complex wine with sharper operational prompts and more satisfying, intellectual ‘ah-ha’s’.
The ultimate goal of UHC, as I see it, is to improve both health status outcomes and financial risk protection. If you want to say, ‘reduce inequalities’ in these joint goals, I can work with that too. Accordingly, UHC is not an ‘end’ but a ‘means to an end’. And progress will surely be incremental.

A problem, however, is that without greater clarity on the ‘engines’ of UHC, almost anything could be construed as fitting within the UHC envelope. For example, one could argue that a politically motivated tertiary hospital offering free services in a remote rural area contributes to UHC because at least someone is likely to benefit from improved health status and/or financial risk protection. But such broad inclusiveness – and watering down – surely isn’t what the UHC agenda wants to imply.

So what are the ‘engines’ of UHC, and what kinds of ‘sharper operational prompts’ do they facilitate? I submit there are two, (i) prepayment and risk pooling, and (ii) public health goods and services. As the latter ‘engine’ has been in the headlines for ages, I focus on the former, ‘prepayment and risk pooling’. My take is that getting this core engine of UHC to function (better than in the past) demands clear thinking on four sets of enabling/disabling conditions.

The first set of conditions has a lot to do with fiscal space. Expanding prepayment and risk pooling requires some combination of (i) improved general tax efforts, (ii) increased share of government budget devoted to health, (iii) reducing interest payments on national debt, (iv) mobilization of SHI, CHI, PHI premiums, and (v)attracting donor subsidies to pay for the poor. This puts health financing squarely on the map as a policy lever to incrementally expand UHC. In response to this challenge, domestic governments are working hard to accomplish (i) through (iv), whereas donors have merely been fringe contributors to (v).

The second set of conditions has to do with making purchasers or providers – reimbursed by prepayment and pooled funds -- perform better. They include (i) more efficient purchasing and contracting, (ii) designing cost-effective benefit packages, (iii) incentivizing providers through payments, and (iv) better targeting to poor households and the informal sector. These aim to improve capacity of both public and private providers on the supply-side to honor demand-side entitlements to benefits under the UHC banner. Donors have been quite active in this area, though their funding has been marginal, usually for pilots, M&E and research.

The third set of conditions has to do with WHO-type building block inputs for health system functioning – drugs, HR, infrastructure, quality enhancement, behavior change, regulation. This category of conditions typically includes supply-side financing of inputs (not outputs) that are a necessary but not sufficient condition for achievement of UHC. Donors have been most active here with the lion’s share of domestic and donor investments unclearly aligned with strategies to scale up prepayment and risk pooling.

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