WHAT’S NEW THIS TUESDAY ON WWW.CHILDSURVIVAL.NET: TALKSPOT, W.H.O. / THE IMPACT OF UNIVERSAL HEALTH COVERAGE SCHEMES IN THE DEVELOPING WORLD

Monday, 25th of February 2013

WHAT’S NEW THIS TUESDAY ON WWW.CHILDSURVIVAL.NET: TALKSPOT, W.H.O. / THE IMPACT OF UNIVERSAL HEALTH COVERAGE SCHEMES IN THE DEVELOPING WORLD

• TALKSPOT, W.H.O.

• http://vimeo.com/channels/469489

Also at http://www.childsurvival.net/?content=com_articles&artid=1697

• THE IMPACT OF UNIVERSAL HEALTH COVERAGE SCHEMES IN THE DEVELOPING WORLD: A REVIEW OF THE EVIDENCE

Executive Summary below; full text is at

http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/IMPACTofUHCSchemesinDevelopingCountries-AReviewofExistingEvidence.pdf

Although the concept of universal health coverage (UHC) is not new, over the last few years its importance and visibility have significantly increased. In 2005, the 58th World Health Assembly adopted a resolution encouraging countries to plan the transition to UHC in their health systems. In 2010, the World Health Organization devoted its World Health Report to a discussion of health care financing alternatives for achieving universal coverage. The current movement to promote UHC has been accompanied by other key actors in the field of global health such as the World Bank, the United Nations Children’s Fund (UNICEF), the United States Agency for International Development, the Inter-American Development Bank, the Rockefeller Foundation, and the Bill and Melinda Gates Foundation, among others.

UHC initiatives have sought to create awareness in and provide guidance to countries on how to improve the design and functioning of their health systems based on evidence of what works for achieving the goal of universal coverage. Meeting this goal is, however, challenging, because the available evidence rarely explores the causal link between the design features of these UHC schemes and the outcomes observed, and substantial heterogeneity exists regarding the robustness of the available evidence. Under these circumstances, providing meaningful guidance is not easy. This report contributes to the debate by systematically reviewing and synthesizing evidence concerning the impact of universal coverage schemes and combining it with a structured assessment of the robustness of such evidence.

The review indicates that UHC interventions in low- and middle-income countries improve access to health care. It also shows, though less convincingly,2 that UHC often has a positive effect on financial protection, and that, in some cases it seems to have a positive impact on health status. The review also shows that the effect of UHC schemes on access, financial protection, and health status varies across contexts, UHC scheme design, and UHC scheme implementation processes.

The evidence available shows a favorable impact only on out-of-pocket expenditures, and, as we argue in the report, out-of-pocket expenditures and related measures are partial and imperfect measures of financial protection.

Regarding UHC design features, the review shows that there are several common features across countries and regions, such as the coexistence of UHC schemes, heterogeneity in design and organization, a widespread effort to include the poor in the schemes, and the prevalence of mixed financing sources (contributions plus taxes). Yet, in a majority of cases, evidence is scarce and inconclusive on the impact of specific UHC design features on their intended outcomes.

A closer look at UHC schemes and available evidence reveals the following four lessons, all of which have implications for both policy and future UHC research.

First, affordability is important but may not be enough. Although improving the affordability of services was often achieved by UHC schemes, improvements in affordability did not always translate into improvements in access. Evidence suggests that for UHC schemes to achieve improved access, a more holistic approach to the dimensions of access needs to be understood and incorporated in the intervention’s design, highlighting the fact that affordability is important but may not be enough to achieve full access to health services. vii

Second, target the poor, but keep an eye on the nonpoor. Since the common UHC scheme designs are less effective for the nonpoor (the impacts are usually diminishing and sometimes even negligible), when extending coverage to the nonpoor, other dimensions of access may gain in relative importance, and therefore different strategies may be needed. Also, in extending coverage to the nonpoor, it seems important to look at how moral hazard effects may change across income groups.

Third, benefits should be closely linked to target populations’ needs. Policy makers with a finite budget have to manage the tradeoffs between what and how much is covered. In doing so, they should carefully examine the target population’s needs by looking at indicators such as the population’s epidemiological profile, major barriers to access, unsatisfied demand, major sources of financial hardship, and so forth. Nevertheless, the evidence suggests difficulties in achieving UHC-scheme-specific goals of improvements in financial protection and health status when careful attention is not paid to how benefits match the target population’s needs.

Fourth, highly focused interventions can be a useful initial step toward UHC. A few studies that evaluate highly focused interventions, with clearly defined targets, usually find positive effects on access, financial protection, and even on health status outcomes. Although the evidence does not suggest steps for a transition from these targeted programs to broader population coverage, such interventions can be regarded as effective to tackle a country’s priorities, and may be a useful initial step toward UHC or toward complementing a larger and established UHC policy. In light of this evidence, policy makers in each country could evaluate their health needs and priorities and assess the role that targeted interventions can play on their path toward UHC.

Finally, in terms of future UHC research, the review shows that most of the studies fail to involve evaluators from the start, which has led to weak evaluation designs to assess the impact of UHC schemes. Because of this, most evaluations are retrospective and do not use monitoring data. A better understanding of the effects of UHC schemes on financial protection is also needed to address several drawbacks of the current available evidence, and more and better evidence on the impact of health status is also required. A key step to address these difficulties would be to incorporate the evaluation in the early stages of the program and, ideally, simultaneously design the intervention and the evaluation. This would result in better and more meaningful evaluations, which in turn should contribute to enhanced UHC interventions.