Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals

Although countries take different routes in making progress toward UHC, based on their socio-economic and political context, a common trend emerges: different financing sources are used to cover different population groups. Public and private sector employees are covered by payroll-tax financed contributory schemes, often taking the form of mandatory social health insurance (SHI). The poor are usually covered by tax-financed mechanisms either directly managed by the Ministry of Health or as part of the SHI as in Vietnam and the Philippines. Coverage of the large informal sector is financed by a range of funding sources; from full premium contributions by households, to partial and fully tax subsidized premiums. Most countries in Asia gradually shift from full contributions to tax funding depending on the government fiscal space and, most importantly, political leadership. Countries find it difficult to expand coverage of the informal sector through contributory schemes because of ineffective mechanisms to enforce contribution payment [5].

Another trajectory is in countries where policy choice is to achieve UHC via services that are (in theory) provided free of charge in public health facilities. In this trajectory, in some countries public spending on health may not match the increased demand for health services, resulting in high levels of household out-of-pocket payments, for example 45% of total health spending in Sri Lanka [6]. Also, wealthier members of the population may opt out of government services, preferring to pay out of pocket for private services (Malaysia). But, on the other hand, in the Pacific Island States, publicly provided health services at relatively high cost to the governments have actually minimized out-of-pocket payments by the population.

The design and inter-relationship between health delivery and financing have major ramifications for health systems performance. Evidence from Organization for Economic Cooperation and Development (OECD) countries suggests that public contract where there is a direct relationship between purchaser organization and healthcare providers, or reimbursement systems where the purchaser organization reimburses patients for their medical bills, are more efficient than public integrated systems where healthcare providers are owned by a purchaser organization [7]. But this efficiency is also a function of strong institutions in OECD countries compared to those in developing countries.

To achieve a favorable UHC outcome, strengthening physical access by improving geographical coverage of health services, and financial access by extension of financial risk protection mechanisms, are two essential parallel synergistic interventions [8]. The higher the coverage of skilled birth attendance (SBA), the smaller the rich-poor disparities [9]. In countries with very low SBA coverage, that is, less than 30%, the rich-poor disparities are large, at around 60 percentage points. A smaller disparity, less than 20 percentage points, is observed in countries having high coverage.

Where 100% SBA coverage is reached, as in Thailand, there are no gaps whether by maternal education or by socio-economic status [10]. In Thailand, universal coverage of Maternal and Child Health (MCH) services resulted in rapid reduction in the rich-poor gap of child mortality between the 1990 and 2000 censuses [11]. Relative inequalities tend to be larger in countries with lower overall levels of health care use [12]. The US Affordable Care Act coverage expansion has resulted in improved access to a usual care provider for millions of black and Hispanic Americans, and reduced the likelihood of going without care because of cost [13].

Functioning close-to-client primary health care (PHC) which the majority of the poor can access [14] acts as a major hub in translating UHC political intentions into pro-poor outcomes such as service utilization and government subsidies [15]; a comprehensive benefit package results in high levels of financial risk protection, preventing non-poor households from becoming poor due to medical payments [16].

The health workforce is critical to functioning health services. Shortages and maldistribution of the health workforce, a common problem facing many MDG off-track countries, has been a constant challenge despite the 2008 Kampala commitment [17]. Investment in the health workforce remains low, with large gaps between demand and supply; health workforce planning is often weak without intersectoral coordination; policies on retention of the health workforce in rural areas and within countries are not fully implemented; scaling and transforming health professional education is at an early stage of reform [18].

Future projections demonstrate that low income countries will face a widening gap between the supply and need for health workers, but have limited capacity to employ more workers, even if supply can be increased. Upper middle income countries will face a similar widening gap, but created by demand factors, which could drive up health care costs or encourage in-migration of health workers. Projection by the International Labour Organization (ILO) shows that 10.3 million additional health workers globally are required to close the current gaps and ensure universal health coverage, of which 7.1 million are needed in Asia and 2.8 million in Africa [19]; these gaps are hardly met unless governments have strong commitments to produce and retain health workers in countries. OECD countries are the major destinations for international migration of health workers, often the highly skilled workers from low and middle income countries. Demand for health workers in high income and emerging countries due to aging and needs for long-term care stimulates international migration. This is exacerbated by the unresolved “push factors” in source countries, such as low pay, lack of career paths, and poor working conditions. Despite the World Health Assembly adopting by consensus the WHO Global Code of Practice on International Recruitment of Health Personnel [20], implementation of the Code is suboptimal, as reflected by the first report of the Code’s implementation [21]. But on the other side of equation is the macro-economic calculus of the professional migration from the demographic dividend countries that goes beyond individual push and pull factors. In the Philippines, the remittances from migrants, of which health professionals make up a significant part, contribute more than 10% to the gross national income (GNI). In a global economy, win-win situations may be possible if importing countries adhere to the Code, and donor countries organize their health professional educations system and labor markets so that local populations’ access to qualified health professionals does not suffer.

Skill mix, cadre mix, and task shifting [22], clinical and public health competency, performance, and social accountability are as important as numbers of health workers. These require transformation of the instructional and institutional dimensions of health professional education systems. A more diverse composition of the health workforce, and expansion of health workers in the community and of mid-level health workers, needs careful planning [23].

Progressively achieving UHC will require a significant increase in public investment. Countries would need to systematically review the opportunities under the five domains of fiscal space creation [24]. Macroeconomic conditions remain challenging over the medium term with slow growth in developed countries and slowing growth in Asia. But Africa has just had a decade of the fastest economic growth that should create opportunities for fiscal space for health. The recent Lancet Commission report on Global Health 2035 makes a strong economic case for health that should facilitate greater prioritization of health by the economic ministries in countries [25]. The Philippines has recently demonstrated success in raising additional resources for health through a sin tax reform for tobacco and alcohol, 80% of the revenues accruing to speeding up progress toward the UHC. In spite of global economic problems, the UK has just reaffirmed its commitment to allocate 0.7% of the gross domestic product (GDP) to overseas development assistance [26], and the recent Chatham House Global Health Financing report [27] calls for 0.15% to go toward health. But perhaps the most untapped resource for increasing fiscal space for health is efficiency gains from existing allocations by using evidence-based approaches to priority setting, resource allocation, performance-oriented provider payment mechanisms, and strengthened public financial management and accountability.