Achieving Universal Health Coverage
I first heard about Universal Health Coverage (UHC) in 2010. At the time, I was working with a group of economists who had just returned from the First Global Symposium on Health Systems Research in Switzerland. After asking the requisite chocolate, skiing, and fondue-related questions, I wanted to know what they thought about the conference and where they thought health systems work was heading.
The major topic of discussion, Universal Health Coverage, was new to me, as my work was predominantly civil society and governance issues. In their telling, UHC was primarily a technical exercise in expanding insurance, focused on reimbursement mechanisms, premium subsidies, and risk pooling. While economists understood these elements in OECD countries, they did not yet understand how to address these issue in most low and middle-income countries.
I found these discussions fascinating, yet the focus on technical financing issues also left me uneasy. I had just moved back to the United States from Rwanda, where I had been involved in the startup of the country’s Mutuelles (health insurance) program. While Rwanda had succeeded in increasing coverage in a short amount of time, there were still significant concerns about management capacity and sustainability. Rwanda’s decision to move toward the Mutuelles system was not purely health related — rather, the decision incorporated a complex set of factors including state security and legitimacy, historical governance patterns, international agreements, and donor requests. These are not technical issues, rather they originated from political economy and incentive structures that are inherent to any complex system.
I kept wondering why the disconnect. Yet, I was working on other things and if economists wanted to run around the world designing health insurance schemes, more power to them.
Fast forward to 2017 and the disconnect I once saw is diminishing. While the nuts and bolts of insurance schemes remain critically important, there is now increased attention to the political and management challenges inherent in UHC.
The major topic of discussion, Universal Health Coverage, was new to me, as my work was predominantly civil society and governance issues. In their telling, UHC was primarily a technical exercise in expanding insurance, focused on reimbursement mechanisms, premium subsidies, and risk pooling. While economists understood these elements in OECD countries, they did not yet understand how to address these issue in most low and middle-income countries.
I found these discussions fascinating, yet the focus on technical financing issues also left me uneasy. I had just moved back to the United States from Rwanda, where I had been involved in the startup of the country’s Mutuelles (health insurance) program. While Rwanda had succeeded in increasing coverage in a short amount of time, there were still significant concerns about management capacity and sustainability. Rwanda’s decision to move toward the Mutuelles system was not purely health related — rather, the decision incorporated a complex set of factors including state security and legitimacy, historical governance patterns, international agreements, and donor requests. These are not technical issues, rather they originated from political economy and incentive structures that are inherent to any complex system.
I kept wondering why the disconnect. Yet, I was working on other things and if economists wanted to run around the world designing health insurance schemes, more power to them.
Fast forward to 2017 and the disconnect I once saw is diminishing. While the nuts and bolts of insurance schemes remain critically important, there is now increased attention to the political and management challenges inherent in UHC.
Dr. Tedros has emphasized achieving Universal Health Coverage as “a matter of political commitment.”
For example, Dr. Tedros Adhanom, the newly elected Director-General of the World Health Organization, is emphasizing that UHC is “a matter of political commitment”. Dr. Tedros frames this political choice as a moral one, noting that it is unacceptable for 400 million people to not have access to essential health services. This framing, however, assumes that everyone agrees UHC is desirable.
The recent M8 Alliance Declaration from the World Health Summit in Berlin echoes this sentiment, recognizing that, under the framework of the Sustainable Development Goals (SDGs), all United Nations members agreed to achieving UHC. The challenge is that countries and regional organizations must make “political choices required to ensure the implementation of the 2030 SDG agenda”.
Yet, I’m not so sure that framing UHC as an agreed upon goal is entirely accurate. Research from Jesse Bump, Ashley Fox, and Vin Gupta have shown that political landscapes that lead to UHC adoption involve a great deal of back and forth about ideological questions such as “Is health really a human right?”; “Should the government cover this group of people?”; and “Why is government involved in health at all?”.
Reading these papers makes me wonder if we, as development and global health practitioners, are not making assumptions based on our pre-existing ideological inclinations. That, for example, the answers to the above questions are clearly “Yes!”, “Of course, it is!”, and “Are you kidding me?”
So perhaps we should reconsider our assumptions, if we want to fully consider what we mean by “UHC is a political choice”.
On the “governance as policy and management” front (h/t to Derick Brinkerhoff for that phrase), the new Health Systems Governance Collaborative seeks to focus stakeholders on “locally relevant governance problems” related to UHC. This collaborative comes as a critical time for UHC. As governance challenges start to receive attention, UHC advocates need a network to share experiences, formulate best “fit” policies, and design systems.
From my perspective, one of the major management challenges to UHC is allocating roles and responsibilities between different levels of government. Thinking back to my experience in Rwanda, there was a great deal of concern about putting districts in charge of administering Mutuelles funds. Specifically, would districts have the incentives and capacity to collect premiums and pay for care? Were the accountability mechanisms put in place by the central government sufficient to address these concerns? Or was the government just decentralizing corruption?
I think Rwanda has been largely vindicated in taking this approach, especially in increasing coverage and reducing catastrophic health expenditures. Yet, there are also some examples of mismanagement in Rwanda. Decentralization continues to be a major challenge for the National Health Insurance Scheme in Ghana and Jaminan Kesehatan Nasional in Indonesia as well, and analyses of how local governments operate more efficiently could, and do, fill many books.
So where do we go from here? Decentralization and the political dimensions of UHC are becoming major drivers of concern for ministries of health. They want to know how to work with local governments that they do not directly control and how to improve engagement with political actors, such as legislators, and processes. I will be discussing these issues in future blogs here and on Global Health Hub.
