Each year, the OHE sponsors a lecture that explores a timely issue in medicine or health economics. At the 22nd Annual Lecture, held in June 2014, the issues and challenges of universal health care coverage in low- and middle-income countries were presented by Professor Anne Mills of the London School of Hygiene and Tropical Medicine. What follows is a brief summary of her remarks.
Universal health coverage (UHC) in developing countries currently is the topic of intense debate in the global health community. With the Millennium Development Goals set to expire in 2015, momentum is growing towards making universal coverage a key global goal. At the World Health Assembly in 2014, the Director General of the WHO suggested a target of 80% effective coverage for key health services for all population groups within each country by 2030.
In part, the focus on UHC is a response to the concerns about the unintended consequences of the large increase in development assistance for health since the early 1990s. Most such assistance focused on specific diseases or disease areas, but neglected development of national health care infrastructures and sustainable financing systems. Access to care continues to be a serious challenge in low- and middle-income countries (LMICs), with comparatively high out-of-pocket payments still posing a serious problem.
To achieve UHC, countries must solve the puzzles created by three core challenges: sufficient and stable financing, reliable and effective financial intermediaries, and a sufficient supply of competent service providers.
The greatest challenge is coverage for low income workers and the self-employed — usually a large portion of the working-age population — and those outside the workforce, i.e. the young, elderly, disabled and unemployed. A mix of financing approaches and sources currently are used in the LMICs, including: social health insurance, general taxation, voluntary contributions and out-of-pocket payments. The particular mix varies by country; evidence is not yet available to suggest which specific mix may be most effective in a particular setting. However, experience does suggest that a core mandatory financing mechanism is essential – either social health insurance or general tax revenues.
Issues include whether systems should be single payer or allow more than one fund, and what the role of the private sector should be. Multiple funds can produce inequities, but many countries still use a mix. Although the public sector is the traditional intermediary, more countries are experimenting with a mix of public and private, contracting with private companies to manage arrangements. India’s RSBY, for hospital coverage, is an example.
To achieve UHC, the first concern should be care for those most vulnerable, i.e. the poorest sectors of the population. This requires, of course, that sufficient services be available in the appropriate locales, not just in the larger cities. Discussion of financing issues, especially insurance options, too often tends to eclipse the essential focus on extending service provision. Ensuring access to both primary and hospital care, and integrating the two, remains problematic. Providers may be either public or private, although the private sector is expanding and, with greater resources, often has superior infrastructure.
Research most often focuses on the evaluation of performance in relation to the design features of UHC, but just as important are the institutional underpinnings of UHC. More attention needs to be paid to what political, economic, social and cultural institutions might allow government to pursue and make progress towards UHC. This includes an effective civil service with recruitment and tenure based on merit; ensuring that the voice of those less well off are heard and factored into policy debates; incentives to encourage those better off to remain in the system, along with evidence of the impact of this; and sufficient social solidarity to support cross-subsidisation of income groups.
It is critical to put the necessary elements of UHC in place early on because it can be politically difficult to make changes later. Four elements are particularly important:
- A combination of financing sources
- Strong purchasing arrangements that make use of both public and private providers and include an emphasis on health promotion and disease prevention
- A payment system that includes incentives for both cost containment and quality of care
- Strong primary care and local-level infrastructure with appropriate geographic spread.
The evolution of health care systems towards UHC is, and will continue to be, very country-specific; what works in one simply may not work in another. Whatever the system or ideology, however, a strong government role is necessary, even if the government is not the only actor.
Although discussions — and the movement towards adopting UHC as a global goal — may suggest the opposite, it is crucial to understand that UHC is a process over time, not a fixed point that can be achieved once and for all.
 WHO defines universal health coverage as ‘ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.’
Professor Anne Mills CBE MA DHSA PhD FMedSci FRS is a world renowned expert in health economics, health care financing and policy in low- and middle-income countries.
She has a distinguished academic career at the London School of Hygiene and Tropical Medicine, where she is Vice Director of the School and Professor of Health Economics and Policy in the Department of Global Health and Development. She previously served as Director of the Health Economics and Financing Programme, which was supported by a variety of research grants from funders such as DFID, the Wellcome Trust, EU and WHO, and as the Head of the Faculty of Public Health and Policy. She has advised many multilateral, bilateral and government agencies; served on the WHO’s 2001 Commission on Macroeconomics and Health chaired by Jeffrey Sachs; and co-chaired one of the two Working Groups for the 2009 High Level Taskforce on Innovative International Finance for Health Systems, co-chaired by Prime Minister Gordon Brown.
In 2006 she was awarded a CBE for services to medicine and elected a Foreign Associate of the US Institute of Medicine. In 2009 she was elected Fellow of the UK Academy of Medical Sciences and received the Prince Mahidol Award in the field of medicine. She was President of the International Health Economics Association (iHEA) for 2012/13. She was elected a Fellow of the Royal Society in 2013.
This Annual Lecture will be available as a publication and, as for previous years, will be available for download from the publications section of this website. To view blog posts about earlier OHE Annual Lectures, click on the Annual Lecture tag in the right column of this blog.