This blog post is part of a series by the authors of the recent report, “Universal Health Coverage: A Commitment to Close the Gap.” The report — a collaborative effort from The Rockefeller Foundation, Save the Children, UNICEF, and WHO — focuses on how and why inequity should be prioritized as countries progress on the path towards UHC.
Beyond the argument that provision of affordable care for all people in need is the right thing to do from an ethical perspective, the report Universal Health Coverage: A Commitment to Close the Gap seeks to highlight the message that equitable progress towards universal health coverage (UHC) makes sense from an economic standpoint too. There are reasons why this may be the case, at least in theory. Lower reliance on out-of-pocket payments when people seek care, a key marker of a country’s path to UHC, is likely to reduce financial barriers to care access mainly among the poor, favoring disease prevention and treatment at an early – and cheaper – stage. One additional dollar invested in health service provision for disadvantaged groups may result in larger health gains than if invested in services for the better-off in a particular country, given the often disproportionate concentration of unmet needs for services aimed at treatable illnesses among the former population. Consequently, expanding service coverage so as to include vulnerable populations from the outset may contribute to raise health system efficiency.
But do the available data actually provide any support for the theoretical benefits from equitable transition to UHC? The answer seems to be a firm “yes” – at least according to an econometric analysis I have carried out jointly with Peter Smith as background for the report. Our study used annual, publicly available data for 160 countries during 1995-2011 to look at the under-five mortality impacts of higher pooled prepaid health spending (i.e. payments not made out-of-pocket at the point of service use) as indicator of progress towards UHC. Even though the data point to higher pooled health spending per capita being linked to lower under-five mortality, a key message is that countries need not spend their way towards UHC in order to reap health benefits. We find that, if a country keeps the same level of national health spending but increases the share of that spending coming from pooled sources (say, taxation or social insurance contributions) by 10 percentage points, this would lead on average to a reduction of about 15 deaths per 1,000 in its under-five mortality rate. This could mean approximately 400,000 fewer annual child deaths in India or almost 100,000 in Nigeria.
Does the data support an equitable transition to Universal Health Coverage? The answer seems to be a firm “yes.”
Crucially, how equitable countries are in different areas – including important social determinants of health – does matter for the results countries will achieve by expanding pooled health financing. We found that countries with lower differences in skilled birth attendance coverage between rich and poor citizens, or urban and rural populations, see even larger average reductions in child mortality (up to 50%) for the same increase in the proportion of pooled spending than do countries where access to the health system is less equitable. And it is not only equity of access to healthcare that matters. More equitable countries with respect to access to piped water and primary education, for example, also tend to get stronger child mortality reductions from a given increase in the share of pooled health funding than their less equitable counterparts.
Summing up, national expansions in service coverage through pooled health financing may bring about sizeable health gains. As usual, however, the devil is in the detail. Ensuring wider access to the health system by the most vulnerable in society seems critical for countries to get the biggest “bang” from their health “bucks”. And national health systems will probably be unable to maximize the gains from transition to UHC in isolation from other areas of government policy, such as education and poverty relief, highlighting the need for concerted policy efforts.