Health systems and economies around the world have been challenged as never before by COVID-19. Even as countries wage battles to counter and curb this threat, there are concerns as to whether the pandemic will undermine or alter global commitment to the Sustainable Development Goals (SDGs) or delay the attainment of targets to far beyond 2030. Of particular concern is the vulnerability of target 3.8 on universal health coverage (UHC).
Concerns about the feasibility of vigorously pursuing the UHC agenda during the post-COVID recovery are misplaced. The pandemic underscores three clear messages on health systems. First, if a swift and strong response has to be mounted against a public health emergency, countries must have an efficient and equitable health system, well established and competently functioning in a steady state. Second, comprehensive primary care must form the foundation of such a health system. Third, if countries do not invest in a well-resourced health system focused on UHC, their economies will keep slipping on the banana skins of unanticipated or poorly handled public health emergencies. Indeed, the historical evidence of the last 75 years shows that those countries which did invest in health and ushered in plans for UHC during or immediately after a crisis reaped rich dividends in health gains and economic growth.
UHC is the hallmark of a society that invests in the health of its people not only because it makes sound economic sense but also because it recognizes health as a human right that must be respected and protected. Economic gains from investments in health are wide-ranging. They include the increased productivity of the population and reduced healthcare costs for averted or abbreviated illness. Gains also arise from expanded employment opportunities in the health sector, and the social stability of a society that is not severely challenged by physical and mental health disorders. The right of an individual to lead a healthy life must not be undermined by failures of the health system to prevent, recognize, or effectively care for an illness. UHC is a solemn affirmation of social solidarity, which is the most ennobling attribute of an advancing civilization.
UHC requires that all essential health services be available to every person, based on need and with assured quality, without anyone suffering financial hardship. This means that UHC must greatly reduce the risks of high out-of-pocket expenditure (OOPE), catastrophic health expenditure caused by episodes of illness that are expensive to treat, and healthcare-related descent into poverty.
Since it is not possible for all countries to immediately meet all of these requirements, the World Health Organization recommends a path of progressive universalization, in the form of a cube with three dimensions:
- population coverage
- service coverage
- cost coverage
At each stage of the evolution of UHC, based on the resources available, priorities set in each of these dimensions must be reconciled to meet the health needs of the population. An essential health package, delivered through periodically revised standard management guidelines, becomes the vehicle for delivering UHC.
Since financial resources are always finite, the choices of service package components must be guided by their cost-effectiveness (how much health is gained for the money spent) and extended cost-effectiveness (how much financial protection is also provided to people). Equity too must play a major role in balancing priorities. ‘Horizontal equity’ ensures that all people are entitled to a common package of services. ‘Vertical equity’ seeks to address the needs of vulnerable groups (such as children and disabled people) and bridge existing health equity gaps that have been created by income, gender, geographic, or social disadvantages. This is addressed through additional services or resources. While such targeting may be accommodated within UHC, the overall program must remain universal.
Primary healthcare (PHC) should be the major delivery vehicle of UHC. It is truly universal in population coverage, as everyone needs primary care services sometime in their life, from childhood vaccination to therapeutic and rehabilitative services for the elderly. PHC provides the broadest package of services and is also the most cost-optimizing. Since outpatient health services over many years contribute to high OOPE, UHC packages which prioritize PHC will reduce poverty. Provision of essential medicines, free of cost, must be assured. PHC is not highly doctor-dependent, as community health workers and technology-enabled allied health professionals can provide many of the required services in rural and urban primary care. By engaging community participation, it democratizes the health system and makes it directly accountable to citizens.
Strengthening every component
Other components of the health system too need be strengthened, to provide advanced care when needed. Even as secondary and tertiary care facilities are strengthened, they must be bi-directionally connected to primary care, which must be the pivot that operates the health system. While governments must remain the guarantors of UHC, they need not be the sole providers. They may engage private and voluntary healthcare providers, as per need and opportunity, but must create the architecture and regulatory systems within which they operate as partners providing contracted UHC services with accountability. A strong public-sector healthcare delivery system will help to set cost and quality standards for UHC.
The quality of healthcare services too must be measured. Are they beneficial? Are they safe? Are they cost-optimizing? Do they provide satisfaction to recipients, their families, and providers? As a number of innovative health technologies offer themselves in a rush to impress, these questions must form part of their assessment, even as existing health services are subjected to periodic technical, financial, and social audits.
Financing of UHC must be mainly through tax-based public financing. Contributory health insurance, through payroll deductions (labor taxes), are not a feasible option in low and middle-income countries with a high proportion of informal workers, and poor families with low incomes. Even if employer-provided insurance and private insurance are additional sources of financing, a single-payer system that channels all funds will create a large risk pool, provide the purchaser the power to negotiate cost and quality standards and enable an expanded service package. A capitation fee system is more efficient than a fee-for-service mode of purchase of services from care providers. Ultimately, UHC has to operate on the principle of cross-subsidy, where many healthy people subsidize the fewer sick people at any one time, and the rich subsidize the poor through a progressive tax system.
Apart from health financing, all other elements of the health system too must be assured. They include:
- adequate infrastructure at all levels of care
- a multi-layered, multi-skilled health workforce
- uninterrupted supply of essential drugs, vaccines, and technologies
- accurate and time-sensitive health information systems
- community engagement
- good governance and administrative efficiency
The social, environmental, and commercial determinants of health too must be addressed, both through coordinated planning at a policy level and convergent service delivery at the primary-care level.
As the post-pandemic period dawns, we must build forward broader, better, and fairer. PHC-led UHC lights up that path to our collective future.