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  • 1. Under JPG Teaching Fellowship Permission from JPGSPH CoE-UHC
  • 2. Concepts and Principles of Universal Health Coverage Tim Evans, Dean, James P. Grant School of Public Health June 6, 2013,
  • 3. Outline • What is Universal Health Coverage? • Why focus on Universal Health Coverage ? • Moving towards Universal Health Coverage
  • 4. What is Universal Health Coverage (UHC) ? • A widely shared objective across all health systems – World Health Assembly Resolutions 2005, 2012 • A “consensus value”: – a universal right or entitlement to health – justice, fairness and equity in health – an intolerance of inequities in health
  • 5. Health as a Special Good “Without health nothing is of any use, not money nor anything else” Democrit, 5th Century B.C. “The preservation of health is … without doubt the first good and the foundation of all other goods of this life” Descartes,1637 "The health of the people is really the foundation upon which all their happiness and all their powers as a state depend" Disraeli,1877
  • 6. The right to health The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition (...)” WHO Constitution 1946
  • 7. Health Equity The absence of unfair and avoidable or remediable health differences between more or less disadvantaged groups defined socially, economically, demographically, or geographically (Evans et al. 2001; Braveman & Gusman 2002) Based on principles of social justice, it implies that everyone should have a fair opportunity to attain their full health potential (Whitehead 1990, Sen 2002)
  • 8. Inequities in health " there is no good biological reason why someone living in Sierra Leone's life expectancy should be a full 50 years lower than someone living in Japan". Sir Michael Marmot, the Chair of the Commission on Social Determinants of Health "spectacular progress, spectacular inequities". – Bill Foege, looking back on progress in health in the 20th century,
  • 9. What is Universal Health Coverage (UHC) ? • WHO definition – – Access for all to a full spectrum of services of good quality ranging from prevention through to rehabilitation according to need – Affordable cost to consumers
  • 10. Three Dimensions of Coverage Expansion WHO, World Health Report, 2010 16
  • 11. Why focus on Universal Health Coverage? • Worrisome Shortfalls in Coverage –Extremely Low levels –Endemic Inequities –Evidence of harm
  • 12. Why focus on Universal Health Coverage? • Extremely Low levels of Coverage – Single interventions – Packages of interventions – Key health systems inputs • health workforce • essential drugs • health facilities
  • 13. 3 m estimated annual deaths from malaria Only between 2-15% African children are sleeping under bednets (2001) 1/21/2014 Information, Evidence and Research
  • 14. Equity and survey data Dipping-in-and-out of the health system: Nepal 2006 120 100 80 60 40 20 0 Poorest 2 3 4 Richest
  • 15. ® ® ® ® ® Coverage patterns: a blueprint for saving lives ®  Of 18 life-saving interventions, only ® vaccinations are reaching 80% coverage ® 24H 24H 24H 24H Interventions able to be scheduled routinely (®) have higher coverage than those needing functional health systems and 24-hour availability (24H) Trends in coverage since 1990 follow similar patterns
  • 16. World Health Report 2006 Critical shortage of health workers in 57 countries; 4.3 million more health workers needed to provide essential interventions.
  • 17. Poor coverage of vital events World Health Report 2003 17
  • 18. Why focus on Universal Health Coverage? • Endemic Inequities –“Poorer” less likely to be covered – widespread evidence of “inverse care”
  • 19. the “inverse care laws” • Rich consume more hospital and public health care than the poor (Tudor Hart, 1971) • Immunization coverage strongly correlated with socioeconomic status (Gwatkin et al., 1999) • Poor with illness don’t access care: 2x more likely to self treat; 10x more likely to do nothing (Uganda, HH Survey, 1994/5). • Poor that access health care risk medical impoverishment (Voices of the Poor, 2000)
  • 20. Trends in skilled birth attendance by income quintile Bolivia 1.00 Egy[t 1.00 0.90 0.90 0.80 0.80 0.70 0.70 0.60 1994 0.60 1995 0.50 1998 0.50 2000 0.40 1989 0.40 1992 0.30 0.30 0.20 0.20 0.10 0.10 0.00 0.00 1 2 3 4 1 5 Indonesia 1.00 1.00 0.90 2 3 4 5 Zimbabwe 0.90 0.80 0.80 0.70 0.70 0.60 1994 0.50 1997 0.60 0.50 1991 0.40 0.40 0.30 0.30 0.20 0.20 0.10 0.10 0.00 1 1/21/2014 0.00 2 3 4 5 1 2 3 5 Information, Evidence and4Research 1994 1999 1988
  • 21. Why are poorer populations…  2x more likely to have TB?  3x less likely to access TB care?  4x less likely to complete TB treatment?  5x more likely to suffer impoverishment due to the costs of TB care?
  • 22. Why focus on Universal Health Coverage? • Evidence of harm –Unsafe care • Selection of super-bugs e.g. XDR TB –Lack of financial protection
  • 23. "poor TB services" deemed the underlying reason for emergence of XDR-TB. •Insufficient vehicles •Inadequate supervision of patients beyond hospital •Interruption in supply chains •Unacceptable rates of "first line" treatment failure •No response to evidence of "first line" failure •Sloppy "second line" treatment practices •Poor infection control in hospitals (over-crowding) •Missing laboratory support structures (resistance monitoring)
  • 24. Number of People Suffering Financial Catastrophe and Impoverishment Due to Health Spending EMR impoverishment AFR catastrophic EUR SEA AMR WPR - 30 60 Number of people (million) 90
  • 25. Inequitable and Inefficient Financing of Health • Out of pocket expenditure (OOP) >65% of total health expenditure (THE) – Major cause of household impoverishment (Sen 2003) – 4 to 5 million impoverished annually (Van Doorslaer 2007) – 22% of all shocks in the lives of the poor (World Bank 2008) – Discourages accessing health care when needed – Most important cause of micro-credit default • Out of pocket expenditure as share of THE is increasing over time (NHA 2007). • All evidence, everywhere indicates OOP is most inefficient and inequitable way to finance health care (WHR 2010).
  • 26. Catastrophic health expenditure Source: Van doorslaer et al. 2007
  • 27. A major deficit on fair financing • Government health expenditure: – Vastly insufficient at $4/capita relative to need of $24/capita – decreasing as share of total health expenditure – regressive – rich benefit more than the poor – demand side financing – innovative but not clear that is “scalable” to whole country or beyond MNH
  • 28. A major deficit on fair financing • NGOs efforts – While micro-credit has mushroomed, microhealth insurance has failed to grow! – Coverage is very shallow – no clear evidence of financial protection • Private sector health insurance – Insurance industry show little activity in health (<!% of total health expenditure). – Employers only just beginning to provide health insurance benefit
  • 29. Why Focus on Universal Health Coverage? • Policy relevance: – strongly linked to MDGs attainment – a widely agreed policy objective • • • • World Health Assembly Resolutions 2005, 2011 World Health Report 2008: Primary Health Care Commission Social Determinants of Health 2008 First World Social Security Report 2010, International Labour Organization • World Health Report 2010: Health financing
  • 30. The World Health Report 2010 HEALTH SYSTEMS FINANCING The path to universal coverage
  • 31. The path forward: Universal Health Coverage (UHC)
  • 32. Are we missing the big picture? .
  • 33. Changes in Global Landscape 2 1 3 6 Chronic diseases 5 Aging Env. issues 4 Health concerns Megacity Migration Youth bulge Environmental degradation will increase in countries that have already experienced 1 some of the world’s worst environmental problems 2 Europe and Japan will face the most immediate impact of aging 3 The infectious disease burden will aggravate other demographic problems in the developing world 4 Global migration could be a partial solution to other demographic imbalances Urbanization 5 Some of the world’s poorest and most politically unstable countries will have the largest populations 6 Urban growth and stresses will be particularly great in developing countries, especially in Asia Emerging Market Economies Footprint Countries Innovative Developing Countries Emerging Donor Nations BRICs
  • 34. Tanahashi Framework for Service Delivery Coverage 1/21/2014 Information, Evidence and Research
  • 35. The Imperative of Political Commitment “As the movement for UHC intensifies in other parts of the world, there is an imperative to prepare Bangladesh for it!” Honourable Prime Minister Sheikh Hasina. Inaugural address at the 64th World Health Assembly, Geneva May 2011 ( ha64/sheikh_hasina_speech_20110517 /en/index.html )
  • 36. The need to begin now • Opportunities: – Increased UHC activity in the region and globally – New 5 year health sector plan - HPNSDP 2012-2016 – Sustained economic growth, middle income country status in next 10-15 years likely – Rapid growth in the health sector • >10% per annum in total health expenditure – Better than expected performance in MDG achievement….can build on some strengths
  • 37. Three dimensions of coverage expansion for universal health coverage Three Dimensions of Coverage Expansion WHO, World Health Report, 2010 16
  • 38. Strengthening supply of services • Comprehensive package of quality services – Responsive to users • Respect for persons (dignity, autonomy, confidentiality) • Client orientation (health needs, basic amenities) • • • • Skilled workers – right place, right time Infrastructure – sturdy, clean, functioning Drugs, diagnostics – in stock, minimal co-pays Info Tech facilitated – – Cashless transactions with single “smart card” – Electronic medical records, m-health
  • 39. MOVE-IT Bangladesh CONTEXT: • New health strategy “Scale-up” maternal child health services “Results focus” investment in information • “Digital Bangladesh” Innovative use of digital technologies such as E-health and M-health
  • 40. MOVE-IT Bangladesh Aims: 1. Universal registration of all pregnant mothers and their newborns; 2. Unified electronic information system that: - tracks vital events (births, deaths, and cause of death), - non-fatal health events; - coverage of priority services Mothers – Ante-natal care; delivery; post-natal care Newborns – neo-natal, infant and child care.
  • 41. Fix the financing system I • Mobilize more resources – – taxes – direct and indirect i.e. sin taxes • Improve allocation – – According to need –essential interventions – Can demand-side financing be scaled up? – Set up separate purchaser agency e.g. National Health Security Office as in Thailand • Better payment systems – Needs-adjusted capitated systems – Remove incentives for “over” and “under” coverage
  • 42. Fix the financing system II • Regulatory framework to promote health insurance in private sector: • Subsidies to private insurers for coverage of below poverty line populations • Incentives for larger pools to avoid the microinsurance trap • Long-term plans for “federation” of private insurance plans to minimize duplication and promote efficiencies
  • 43. Educate and empower beneficiaries 1 Communicate the health and economic benefits of insurance 5 2 Expedite claims adjudication process with prospective reimbursement Engaged in designing benefit package to meet needs and expectations a) 4 Everyone experiences “benefits” through health promotion and wellness checkups 3 Based on ability to pay b) Make Premium payment simple and sustainable Part of a compulsory, group membership c) Part of a larger financial transaction
  • 44. Learning by doing • No one size fits all • All ambitious policies require course corrections • Set time-bound targets for performance i.e. decrease in OOP below 30% THE • Generate evidence to inform, implement and evaluate UHC efforts • Investing in individual and institutional capacities to make reforms work
  • 45. Experiences from other countries • Thailand: A long but successful road to UHC • Ghana: UHC through community-based Health Insurance schemes • India: Health Insurance for the ‘below poverty line’ population • Rwanda: Community-based health insurance schemes in a low income country
  • 46. Thank you all !