WHO The world health report - Health systems financing: the path to universal coverage

“…..The objective was to transform the evidence, gathered from studies in a diversity of settings, into a menu of options for raising sufficient resources and removing financial barriers to access, especially for the poor. As indicated by the subtitle, the emphasis is firmly placed on moving towards universal coverage, a goal currently at the centre of debates about health service provision. 
The need for guidance in this area has become all the more pressing at a time characterized by both economic downturn and rising health-care costs, as populations age, chronic diseases increase, and new and more expensive treatments become available. As this report rightly notes, growing public demand for access to high-quality, affordable care further increases the political pressure to make wise policy choices.
At a time when money is tight, my advice to countries is this: before looking for places to cut spending on health care, look first for opportunities to improve efficiency. All health systems, everywhere, could make better use of resources, whether through better procurement practices, broader use of generic products, better incentives for providers, or streamlined financing and administrative procedures.
This report estimates that from 20% to 40% of all health spending is currently wasted through inefficiency, and points to 10 specific areas where better policies and practices could increase the impact of expenditures, sometimes dramatically. Investing these resources more wisely can help countries move much closer to universal coverage without increasing spending.
Concerning the path to universal coverage, the report identifies continued reliance on direct payments, including user fees, as by far the greatest obstacle to progress. Abundant evidence shows that raising funds through required prepayment is the most efficient and equitable base for increasing population coverage such mechanisms mean that the rich subsidize the poor, and the healthy subsidize the sick. Experience shows this approach works best when prepayment comes from a large number of people, with subsequent pooling of funds to cover everyone’s health-care costs.
No one in need of health care, whether curative or preventive, should risk financial ruin as a result.
As the evidence shows, countries do need stable and sufficient funds for health, but national wealth is not a prerequisite for moving closer to universal coverage. Countries with similar levels of health expenditure achieve strikingly different health outcomes from their investments. Policy decisions help explain much of this difference.
At the same time, no single mix of policy options will work well in every setting. As the report cautions, any effective strategy for health financing needs to be home-grown. Health systems are complex adaptive systems, and their different components can interact in unexpected ways. By covering failures and setbacks as well as successes, the report helps countries anticipate unwelcome surprises and avoid them. Trade-offs are inevitable, and decisions will need to strike the right balance between the proportion of the population covered, the range of services included, and the costs to be covered.
Yet despite these and other warnings, the overarching message is one of optimism. All countries, at all stages of development, can take immediate steps to move towards universal coverage and to maintain their achievements. Countries that adopt the right policies can achieve vastly improved service coverage and protection against financial risk for any given level of expenditure. It is my sincere wish that the practical experiences and advice set out in this report will guide policy-makers in the right direction. Striving for universal coverage is an admirable goal, and a feasible one – everywhere…..”
[Dr Margaret Chan, Director-General, World Health Organization]

Website:  http://bit.ly/dotQNz 
  • Message from the Director-General
  • Executive summary
  • Why universal coverage?
  • Where are we now?
  • How do we fix this?
  • Raising sufficient resources for health
  • Removing financial risks and barriers to access
  • Promoting efficiency and eliminating waste
  • Inequalities in coverage
  • An agenda for action
  • Facilitating and supporting change
  • Practical steps for external partners
  • A message of hope


Empty words

Hi Remco Van de Pas
I am presently studying Global Health at TCD in Dublin. At present I am trying to put together some sentences for essays and I came across your refreshing comments on 'bubbles'. The elite of Global Health Networks using soft words to pass engaging moments while forgetting the hard facts. Finding comments like yours helps me to pursue what I feel at present to be a fruitless exercise.
I wish you the very best,
Phil Beary

Ministerial Conference "Health Systems Financing - Key to Univer

Thomas Gebauer

Short Report on the Ministerial Conference "Health Systems Financing - Key to Universal Coverage" held in Berlin, Nov. 22-23, 2010.

The conference was convened by two German Ministries on the occasion of the presentation of the “World Health Report 2010”. It turned out to be a most interesting gathering of almost 30 Ministers of Health from all over the world plus government officials, politicians, some researches and a few NGOs.

Everyone agreed on the aim to achieve universal coverage. The model that was presented by WHO concerning this doesn’t speak about just going for “some coverage” or essential packages, but demands from all countries to do their utmost to set up pooled funds that cover three dimensions: expanding the number of people covered, expanding the scope of services and reducing cost sharing (direct payment such as user fees).

Dr Margaret Chan had demanded to get rid of user fees, because "user fees punish the poor". Everywhere there are people too poor to contribute financially to health care, therefore they need to be subsidised from pooled funds, generally tax-based health systems. “Out of pocket” payments have to be reduced by promoting prepayment und pooling systems (tax-based or mandatory social heath insurance). All agreed that there is no "silver bullet" that serves as a solution for all countries. There is no global scheme that has to be "adopted" by all countries, but the need is to “adapt” a way to move forward in the three dimensions (population covered, the scope of services expanded and cost sharing reduced) at national level. This opens space for national adaptations and provides civil society organizations with the chance to continuously challenge their governments, e.g. to expand the scope of services.

With exception of only few participants nobody mentioned private companies as relevant actors. Achieving universal coverage requires the strengthening of health systems. Ensuring affordable access to health is ultimately a public responsibility and not related to private assurance companies.

To ultimately realize the right to health, governments have to create the needed fiscal space. In this regard, the “World Health Report” mentions as possible new sources of revenue: a special levy on large and profitable companies, a currency transaction levy, a financial transaction tax, and the so-called sin-taxes (alcohol, tobacco). No reference is made to for profit PP Partnerships.

In the context of global responsibility, the “Report” stated that donor countries should do more to meet their international commitments by providing a more predictable and long-term aid-flow.

It should not be surprising that a ministerial conference tends to produce documents with nice and bubbly words. Most of the presenters mixed up risk-sharing with solidarity-actions, and when it came to actions (with exception of the Brazilian Minster of Health), almost al preferred to be vague in their statements.

Nevertheless, there is an interesting shift in the international debate on global health. 32 years after its coinage, the concept of” Health for all” is back on the agenda.

Thomas Gebauer
medico international

Reflections on NRHM in India

 one is "theoretically" covered to some extent in rural India with the National Rural Health Mission that offers a fixed package of services for free. That is, provided everyone can get past the limitations of social exclusion (caste and class biases), gender biases at home and sometimes simple geographical distance from the nearest health centre.

Would insurance improve the coverage for those excluded now? We do not know. Still the coverage is better in some states in some ways than before the Scheme. But universal coverage? It is "theoretically" existent and practically difficult even when services are free for all.
With reference to  the "payment for services" model, it is being applied under this Scheme for the Community Health Workers (called ASHA ). Early evidence in some states shows that this has resulted in directing the focus of CHW efforts more towards the higher paid services like facilitating institutional deliveries to the detriment of other services. 
On the other hand, better attendance of doctors is seen now after an increase in salary scales. 
The point-one fix for all may not work. 
 Policy fixes for all nations may not work, particularly if not backed politically.   
Univeral coverage seems more likely if attempted locally. When planning and implementing any steps for widening coverage, the powers-that-be must ensure that everyone is informed and avenues for involvement during implementation are localised to the extent possible.
In the National Rural Health Mission of India, this has been attempted by involving local representatives by way of Health and Sanitation Committees. Such attempts must be strengthened largely for any policy changes in health services or even insurance to become truely universal.  
Kavita Bhatia

'Privatisation' of health care in South-Darfur

From: Remco van de Pas

Was glad to read Massimo's reply on the 'privatisation' of health care in South-Darfur, Sudan. It reminds me of the period that i worked in Nyala for an international NGO in 2005/2006.  I reflected at that time that humanitarian assistance had become big business while responding to a disastrous conflict situation. This analysis can be found here: http://www.phmovement.org/en/node/250 

We should indeed be careful how we position ourselves as non-state actors in both humanitarian crises and while working in more stable health systems. The NGO code of conduct for health systems strengthening that we discussed last month is a clear effort to that. It is now up to us to walk our talk. This would imply 

  • (a) To be humble in the way we relate ourselves towards the people we work with, not only in ownership and priority setting for health improvements, but also how we present ourselves. Even beyond salaries; the big cars, fenced compounds and sometimes 'exclusive' behavior will add to the divide between 'us' and 'them'. It is indeed not so strange that it pulls high skilled health workers to be part of it, or to try via both public and  private sector to reach a similar status. 
  • (b) To be conservative with consultancy fees for international short term assignments, M & E and capacity building programs. Domestic assignments, with a moderate budget and with less initial capacity might be implemented for a longer period and in the long term prove more sustainable. 
  • (c) To refrain ourselves from blaming  governments to be corrupt and non-trustworthy in health development. This agenda is often 'hidden' in international health cooperation. We must first be introspective and transparent on how we allocate our budgets and what our own agenda is. The global health market is a competitive one, and each of us has to 'sell his brand approach or particular organization'. This leads to fragmentation and further undermining domestic health systems. We should have the courage to cooperate beyond our program frameworks on strategies for basic health systems strengthening. There is no magic bullet to it, but it is no magic either. Supporting integrated primary health care with clear community involvement; in coordination with stakeholders working on the six building blocks for health systems, intra- and inter sectoral coordination, providing stewardship and capacity on health systems reforms, listen and responding to local priorities in global contexts...In theory it is so clear, but health as a public good does provide friction with those having vested financial interests both at the local and global levels. Health cooperation (or its derivative medical aid) is too often a trade-off that accompanies economic and business deals . We as health community should understand and position ourself in the politico-economic context we work in. We are too often used as trade-offs while we actually want to improve health and rights of the people.  

Situation in Sudan

From: massimo serventi

I agree with what Remco van der Pass has written. It depicts well the situation here in Nyala, South Sudan.
There is a war from years, people are poor,agriculture that was florid because of enough rain is abandoned,food is distributed in camps.....
Children malnutrition is a problem every year. Maternal mortality is high, vaccination coverage is 31%(!).

So, in this scenario one is surprised to see that most of health care is provided through private medicine. Inside the main governmental hospital of Nyala there is a 'second' hospital, totally private, where you may find all laboratory and investigation facilities including CT scan and specialist consultations performed by the same doctors of the hospital.
Antenatal care in Nyala is not free:mothers have to pay for the examination AND for tablets of ferrous-sulphate. Delivery is also not for free. Most mothers opt to deliver at home...but also here they must pay the midwife or TBA.

This situation is well known to Sudanese doctors, they are professional and skilled. But....their salaries do not allow them to maintain decently their families, therefore private medicine becomes the 'obvious' source of income. I was told that 70% of the government budget goes to military spending, and less than 2% goes to health. Is it true? What to do? what to say?which is the role that NGO should play? I wrote to them(all) this kind of letter but none replied to me.

One point is clear to me: can I ,Massimo, who gets a salary that is 10 times higher than that of my Sudanese colleague blame him because of conducting private health businness? I cannot! but also my international colleagues, working in UN agencies and international NGOs...CANNOT!


What's the "universal health coverage" push really about?

Here is a blog from the WB's Adam Wagstaff (edited)


"We are trying to make 2010 the year of a big push toward universal health coverage. Just recently, over a thousand health systems researchers gathered in Switzerland for the First Global Symposium on Health Systems Research; the theme of the symposium was "science to accelerate universal health coverage". Now, health ministers from around the world will gather at an international ministerial conference on "Health Systems Financing - Key to Universal Coverage" hosted by the German government. At the conference, the World Health Organization will launch its 2010 World Health Report entitled "Health Systems Financing: The Path to Universal Coverage".

The Lancet just published a map showing the fraction of the population currently with health insurance coverage; it is a neat tool for the participants in these exercises to see where they're starting from. Or it would be if it were accurate. Unfortunately, it's not. According to the map, the US already has universal health coverage! In which case, what was President Obama doing risking his political capital by trying to expand insurance coverage? And according to the map, Brazil has incomplete coverage despite the fact that in 1988 the government amended the constitution to guarantee all citizens access to health care and introduced a tax-financed universal health system. In fact, all Latin Americans would probably be rather confused by the map, since they all live in a country whose ministry of health (MOH) operates facilities that are open to everyone. The same is true of African countries too. And India. And Indonesia. And the Philippines. In fact, come to think of it, it's true of most countries.

Unfortunately, then, the map is completely misleading. The problem with the map-and indeed with much if not most of the debate on universal coverage-is that it portrays the universal health coverage challenge as an either-or problem. People either have coverage or they don't. In actual fact, everyone everywhere has some coverage. The stark reality, though, is that in many-if not most-countries there are large inequalities in coverage, typically mirroring pretty closely the income distribution.

The challenge, it seems to me, is not to cover everyone (already achieved). Or even to give everyone the same cover (desirable but equality of effective coverage is best seen as a long-term goal). Rather, the coverage challenge to my mind is really about narrowing inequalities in coverage.

Many countries have segmented health systems. Government facilities often charge for services, so while people have access to them, they have to pay for them. And in some countries, when people arrive at government facilities for treatment, they find no staff, no drugs, and no equipment. So, people have access to services that don't actually exist!

By contrast, more privileged sections of the population-civil servants and formal-sector employees-are often covered by one or more social health insurance (SHI) schemes. These either reduce out-of-pocket payments in government facilities or give enrollees access to an altogether separate network of (public or private) providers. These providers may or may not charge a lower price, but at least when patients arrive, they find doctors, nurses, drugs and equipment.

It is this segmentation that countries are trying to reduce. They're doing so in different ways.

Some-like the Philippines and Vietnam-have tried to bring informal-sector workers and their families into the SHI scheme, often offering partial or complete subsidies for the poor. Other countries have set up insurance schemes that operate in parallel to the SHI schemes. Sometimes, as in China and Mexico, these are located in the health ministry. In others, like India, the labor ministry operates the parallel scheme.

Irrespective of who runs it, voluntary schemes have proven vulnerable to adverse selection, and to low enrollment rates and/or low revenues from contributions (on paper some governments apply means-testing, but in practice haven't done so rigorously). And enforcing mandatory enrollment has proven hard.

An alternative model is the Thai model. Thailand set up what is in effect a parallel insurance scheme within its health ministry for those outside of the SHI programs; however, everyone is covered, and the costs are covered through additional taxes.

All these parallel schemes-however financed and wherever located-leave open the possibility of narrowing gaps in coverage, but not eliminating them, a useful strategy for a government with limited revenues to play with.

But they all raise the question of what enrollees gain from the 'insurance' process, especially when the health ministry operates the scheme. What's different from the original MOH model that was seen as the cause of poor quality care and high out-of-pocket spending in the first place?

One answer seems to be that the schemes give their enrollees a card that explicitly entitles them to a specified set of services-a type of patients' charter. Providers have to deliver.

Another advantage seems to be that it provides governments with an opportunity to change the way providers are paid. They can shift from salaries and budgets (that do nothing to incentivize providers to turn up to work and make sure drugs and equipment are in stock), to higher-powered payment methods like fee-for-service or payments per case (which encourage doctors to show up for work and to make sure they have drugs and equipment).

So, what should the Lancet's map have shown?

It wouldn't be straightforward to calculate but one possibility would be the amount of spending needed to bring everyone up to the de facto coverage enjoyed by the group with the most generous benefit package. Does anyone have any other ideas?

And am I right that the coverage challenge is not actually about achieving universal coverage, but rather about reducing inequalities in coverage? If so, where do we go wrong in policy discussions-if at all-by misleadingly talking of reaching "universal coverage" when everyone already has some coverage?"

shift in health systems thinking

From: Remco van de Pas

There is some shift in health systems thinking, both for the good and the bad. The good one: More than 60 years after the adoption of the WHO constitution and more than 30 years after the Alma Ata declaration the right to health as an entitlement that every human on this planet has is back on the political stage. Universal health coverage has become an issue – and the topic of this year’s World Health Report.

Recently, a “joint action and learning initiative on national and global responsibilities for health” has been initiated (4). It wants to research and provide action on the following key questions:

· What are the essential services and goods guaranteed to every human being under the human right to health?

· What is the responsibility that all states have for the health of their own populations?

· What is the responsibility of all countries to ensure the health of the world’s population?

· What kind of global health governance is needed to ensure that all states live up to their mutual responsibilities?

Basically the initiative breaks away from the concept that health care is a matter of self-determination and autonomy of states and that international assistance should only temporarily support countries financially to overcome the health problems they face. From a rights-based perspective there is mutual obligation and dependence between the international community and states to guarantee universal health coverage. On the other hand, well functioning health systems should not only provide people with qualitative care for better health outcomes, but should also protect them against catastrophic health-care expenditures. This idea is further explained in a background paper of the recent forum on health systems research. It describes the difference between national universal health coverage (a state obligation) and global universal health coverage (including international responsibilities). The authors promote consorted global health action as health is a global public good. The public good concept, like the human security concept, emphasises that consorted global action can contribute to international political stability as communicable diseases containment, national social cohesion, economic growth and reduced population growth benefit from this action.

According to one African activist, three sets of actors are necessary to improve health and country ownership in Africa: African governments should take up their responsibilities as they committed themselves to several international health declarations; civil society in Africa must become stronger to hold their governments accountable for their right obligations on health; although some of the international community supports country ownership, others still see African counterparts as enclaves to extend their own missions and are very patronizing.

What is intriguing during these international health gatherings is the big difference between the health reality in so many places in the world versus the bubbles in which the global health elites reside and talk about equity, universal coverage and strengthening systems for the poor. After the workshops and seminars that offer discussion on how to move forward the state of the health in the world, the donors, policymakers, academics and NGOs come together over a copious buffet where some alcohol smoothens out disagreements if they already exist. We, representing the “global health community” in those meetings, should keep our focus very much on why we are there and that we bear accountability for those who entrust us to be there. Strategic action plans or concrete policies should come out of these meetings that will really matter to reduce the gap in health equities. Missed are debates on and definitions of what universal health coverage actually means. Does it mean coverage to a selected number of health care interventions or a right based package of appropriate, curative, promotive, preventive, integrated, participative and rehabilitative health care as envisaged in the Primary Health Care concept of Alma Ata?