The strategic aim of universal health coverage is to ensure that everyone can use the health services they need without risk of financial ruin or impoverishment, no matter what their socio-economic situation. The over-arching concept of universal health coverage takes a broad view of the services that are needed for good health and well-being.
These services range from clinical care for individual patients to the public services that protect the health of whole populations. They include services that come from both within and beyond the health sector. Financial risk protection is one element in the package of measures that provides overall social protection, as well as the protection against severe financial difficulties in the event of illness gives the peace of mind that is an integral part of well-being.
In essence, to support the goal of universal health coverage is also to express concern for equity and for honouring everyone’s right to health globally. These are personal and moral choices regarding the kind of society that people wish to live in, taking universal coverage beyond the technicalities of health financing, public health and clinical care.
With a greater understanding of the scope of universal health coverage, many national governments around the world now view progress towards that goal as a guiding principle for the development of health systems, and for human development generally. It is clear that the al their environments mean healthier people.
In addition, preventive and curative services protect health and protect incomes. Healthy children are better able to learn, and healthy adults are better able to contribute socially and economically.
The path to universal health coverage has also been termed “the third global health transition”, after the demographic and epidemiological transitions.
Universal coverage is now an ambition for all nations at all stages of development. The timetable and priorities for action clearly differ between countries, but the higher aim of ensuring that all people can use the health services they need without risk of financial hardship is the same everywhere.
Under the concept of universal coverage, there would be no out-of pocket payments that exceed a given threshold of affordability – usually set at zero for the poorest and most disadvantaged people. All governments should therefore decide what health services are needed, and how to make sure they are universally available, affordable, efficient, and of good quality.
The services that are needed differ from one setting to another because the causes of ill-health also vary. The balance of services inevitably changes over time, as new technologies and procedures emerge as a result of research and innovation, following the changes in the causes of ill-health.
In every country, there are people who are unable to pay directly, out-of-pocket, for the services they need, or who may be seriously disadvantaged by doing so. When people on low incomes with no financial risk protection fall ill they face a dilemma. Ultimately, if a local health service exists, they can decide to use the service and suffer further impoverishment in paying for it, or they can decide not to use the service, remain ill and risk being unable to work.
The general solution for achieving wide coverage of financial risk protection is through various forms of prepayment for services. Prepayments allow funds to be pooled so that they can be redistributed to reduce financial barriers for those who need to use services they could not otherwise afford. This spreads the financial risks of ill-health across whole populations. Prepayment can be derived from taxation, other government charges or health insurance, and usually comes from a mixture of sources.
Financial risk protection of this kind is an instrument of social protection applied to health. It works alongside other mechanisms of social protection – unemployment and sickness benefits, pensions, child support, housing assistance, job-creation schemes, agricultural insurance and so on – many of which have indirect consequences for health.
Governments, especially in low-income countries, cannot usually raise sufficient funds by prepayment to eliminate excess out-of pocket expenditures for all the health services that people need. It is therefore a challenge to decide how best to support health within budgetary limits.
Even with an understanding of the determinants and consequences of service coverage, the balancing of investments in health services is more than a technical matter. The allocation of public money to health also has ethical, moral and political implications. Public debate is the mechanism for obtaining consensus on, for instance, who should be entitled to health care paid from the public purse, under what conditions, and for what range of services. Decisions on these issues, which involve a combination of ethical imperatives and political possibilities, place constraints on the analysis of how to maximize health impact for the money spent.
In summary, the first challenge in moving towards universal health coverage is to define the services and supporting policies needed in any setting, including financial risk protection, the population that needs to use these services, and the cost. This requires an understanding of the causes of ill-health, the possible interventions, who currently has access to these services and who does not, and the extent of financial hardship incurred by paying out-of-pocket.
Acting on behalf of their populations, governments must decide how to move closer to universal coverage with limited financial resources.
Lee-Roy Chetty holds a masters degree in media studies from the University of Cape Town and the University of Massachusetts, Amherst. A two-time recipient of the National Research Fund Scholarship, he is currently completing his PhD at UCT and an economics degree with Unisa.
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