UHC: Old wine in a new bottle? If so, is that so bad? Adam Wagstaff Development Research Group, The World Bank

At the start, the idea of UHC must have seemed straightforward enough Lots of countries "covered" only part of their population, and several were making efforts to expand coverage to "uncovered" populations UHC was all about extending coverage to “uncovered” groups Thailand led the way in the terminology, and somewhat confusingly even had a “UC scheme” (that covered only part of the population)!

But wait a minute! Didn’t we already have UHC? Govt. facilities are subsidized everywhere—nobody pays the full cost In which case isn’t coverage already universal? So what really is the problem? – It’s not that some people lack coverage – Rather it’s that some people have deeper coverage than others – People outside a "scheme" (the poor?) are liable for higher out-of-pocket payments than those inside a "scheme" So we need a 2 nd coverage dimension—depth Q1: How deep? "Full" coverage?

It’s not just financial coverage What about the health benefits associated with expanding and deepening coverage? Could “UHC” initiatives be skewed – against low-cost but highly effective interventions – in favor of costly inpatient and pharmaceutical-based interventions with limited effectiveness? Don’t we need to think about what is covered, not just who is covered and how deeply? Q2: What do we cover? Everything—i.e. "comprehensive" coverage?

A cube is born It helps, but… Only one dimension is reflected in the name UHC—the “U” And it’s the one that’s least helpful, because everyone already has (some) coverage! Soon people also started asking awkward questions about what’s meant by the edges of the cube Who? (Everyone) How deep? What? UHC

De jure vs. de facto—services What if a country promises services but doesn't actually deliver them? People may not get the services they're entitled to given their needs Health workers are absent, drugs aren’t available, etc. Studies using standardized/fake patients show that providers often fail to make the correct diagnosis. And when they, do they often fail to prescribe the right treatment Use of vignettes to assess competence reveal it’s not always due to ignorance. Providers often they fail to do everything they know they should do—there’s a “know-do” gap

De jure vs. de facto—payments Financial coverage is about what people pay in practice And it’s about how "affordable" these payments are Patients may end up paying more out-of-pocket than they expect to on the basis of what's written on paper Providers may deliberately overprescribe to make money Or they may deliberately switch to a more resource- intensive style of care Paradoxically expanding coverage may lead to larger out-of-pocket payments, and hence shallower coverage

Old wine in a new bottle Ultimately what we’re interested in is that in practice – Everyone—rich and poor—should get the health services they need – Nobody should suffer undue financial hardship as a result of getting the health care they need Note that first aspect (service coverage) captures quality: – If people are misdiagnosed, or get the wrong treatment despite the right diagnosis, they’re not getting the care they need UHC isn’t really new after all

The ethical imperative of UHC Everyone—rich and poor—should get the health services they need – Being healthy is a precondition to flourishing as a human being – It’s hard to argue for anything other than an equal distribution of health – People don’t choose to get ill—they get unlucky – Leads to the injunction “treat according to need and not according to ability-to-pay” Nobody should suffer undue financial hardship as a result of getting the health care they need – Having sufficient resources is also a precondition to flourishing as a human being – Together with the points above leads to the injunction “ensure payments for needed health care don’t cause undue financial hardship”

A practical and easily understood approach Everyone—rich and poor—should get the health services they need Agree on a set of “tracer” service needs that ought to be covered spanning (a) all types of health service (including curative care), and (b) all stages of the lifecycle. Vary list by level of development Use surveys w/ gadgets for preventive care and management of NCDs, and fake patients to see whether people get the services they need We’d like to see faster progress among the poorest 40% Nobody should suffer undue financial hardship as a result of getting the health care they need Interpret “undue financial hardship” as a household being forced into poverty Look at actual out-of-pocket payments sampled households make, and see whether they’re sufficient to push the household below the e.g. $1.25-a-day poverty line We’d like to see the number of “medically impoverished” households fall over time and ultimately reach zero

Immunization Green means faster progress among the poorest 40%