by Barbara Ayotte
Universal health coverage received a lot of play at the recent Women Deliver conference. Universal health coverage (UHC) is a mechanism for health that ensures affordable, accessible, quality care for all. Over 50 countries are on their way toward achieving UHC, and several have already attained it. Many have supported UHC as an overall framework for the health goals in the Post-2015 development agenda.
One of the first questions arising with UHC is how to pay for it. At a session on Wednesday afternoon, May 29th, panelists gathered to discuss UHC and financing. The panel was organized by Population Services International (PSI). According to Ben Bellows of Population Council, who started off the discussion, “UHC systems are characterized by quality and low out-of-pocket costs to consumers.” Bellows spoke about Kenya’s scaling up of voucher programs for family planning and other services. The government of Kenya budgeted for procurement of voucher services and the program resulted in addressing 70 percent of unmet needs in two of the poorest quintiles. “Family planning vouchers are an entry point for UHC, targeting uncovered populations. They bring quality improvement, reduced out-of-pocket spending, and are a useful entry point for a more expanded package of services later. “
Panelist Dr. Jonathan D. Quick, MSH President and CEO, highlighted two goals of UHC: improve health (including maternal health and family planning) and reduce medical impoverishment due to out-of-pocket payments. Quick suggested taking a look at the delivery side as a way to transform a health system toward UHC–especially a look toward medicines, where 50 percent of out-of-pocket spending is spent on medicines and 150 million are medically impoverished. “If we are to restructure funds and financing, we have to look at pharmaceuticals, including contraceptives. Informal drug shops are where most people get their medicines—typically poor quality at a high price. But in Tanzania, with funding from the Bill and Melinda Gates Foundation, MSH and the private sector transformed these drug shops into licensed drug sellers, selling items that included sanitary products, so girls can stay in school, and antimalarials. Ninety percent of these sellers are women. We need to ask, ‘Are informal drug shops included in UHC programs?’” said Quick. “In Tanzania, yes, the national insurance fund is reimbursing them. In Ghana, they are part of the program. “
Rob Yates of the World Health Organization (WHO) asserted, “Public financing is key to UHC in order for all people to receive the quality health services they need without suffering financial hardship.” But who is covered, what services, what do people pay out of pocket?
Yates spoke about health financing in Sierra Leone. In Sierra Leone, the president launched free care for women and children. Health centers that had been empty before due to high cost were suddenly full. “Private, voluntary, financing mechanisms are not a good way to finance a health system,” he said. Yates noted that Jim Kim, President of the World Bank, recently stated that user fees are unjust. “Public compulsory insurance works—it forces the healthy and wealthy to subsidize the poor,” said Yates. “More groups in the formal and informal sector have emerged to join social and voluntary insurance schemes. Some countries use public monthly tax funding to cover the untargeted informal sector. Sri Lanka, Brazil, Thailand, Mexico, China, Malaysia, Fiji, Ghana, Rwanda, and Costa Rica have all achieved UHC. Three to watch in the next decade are South Africa, India, and Indonesia. Public financing can come from income tax, natural commodities tax, oil revenue.”
Yates continued, “UHC is easy to understand—an attainable goal—especially as countries make the transition to become middle income states. UHC brings politics into the health systems agenda. It is an opportunity to celebrate national successes. “
UHC and Sexual and Reproductive Health Rights
International Planned Parenthood Foundation (IPPF) and WHO sponsored another UHC session on Wednesday evening, moderated by Dr. Quick of MSH.
Dr. Quick began the session with four propositions: 1. Global momentum for UHC is accelerating; 2.) UHC is the only approach for women and girls; 3) Understand potential risks of UHC; 4) Informed advocates will make all the difference in minimizing those risks.
Yates offered UHC as the health umbrella in the Post-2015 development framework. “UHC is not a great insurance plot or communism by the back door. It is a whole movement. UHC is about ALL people receiving the quality services that they need. It’s about curative services—and also about financial protection and about what should be in a benefits package. ..UHC is inherently political— which is a good thing.”
Yates continued: “UHC is a good idea for the health community to rally around. Everyone can understand it. It is inspiring and motivational. People understand ‘We demand universal health care.’ People get it. They don’t get ‘we want healthy life expectancy.’ UHC captures the imagination of politicians and the UN. It’s political for all the right reasons and sensible to unite the health community around it—otherwise, divided we fall.”
Panelist Anjali Sen of International Planned Parenthood Federation (IPPF) said that IPPF works to provide access to quality sexual and reproductive health right (SRHR) services regardless of ability to pay. “We know the health risks to women and children. Populations are younger.Young women give birth. Maternal mortality is high and the contraceptive prevalence rate is low. Women are denied basic health care. IPPF supports a concept of UHC that is enshrined in our philosophy of equity and links care to need: Give the poorest and most vulnerable access without pushing them further into poverty. “ Sen stated that IPPF hopes UHC is included in Post- 2015 framework and wants UHC to include sexual reproductive health rights in essential benefit packages: ”SRHR must be part of the package. For the right to health to be truly universal, it must look at the health of women. SRHR is a critical component yet often neglected in global schemes. Only 20 UHC schemes include SRHR/FP in their essential benefits package. We all know that SRHR was belatedly added to the MDGs—too little, too late. Progress toward meeting the unmet need for family planning has cost women dearly. “
Panelist Caroline Halmshaw of Interact/Action for Global Health asserted that there is no guarantee that SRHR will be in the Post -2015 development framework. But we need to ensure SRHR is embedded in other goals. “We also need unity in the health sector on UHC,” said Halmshaw.” For UHC to succeed, we must address the stigma and discrimination toward women and overcome it. UHC has to make sure people who are excluded are covered now. How will we include the most marginalized? People in sex work, criminals; all those who have no access to government services? UHC is huge opportunity for the SRHR community. UHC is a health systems approach.”
Panelist Jackson Chekweko of Reproductive Health Uganda, spoke to an example in Uganda: “Uganda abolished user fees in 2011, resulting in an uptake in family planning and maternal health services. UHC will be a given—yet how do we get governments to secure funding for UHC? Civil society pushed government to improve on this.“
Yates concluded, “UHC is a developing country agenda. [Developing countries] are the ones pushing UN resolutions. The UHC movement is happening worldwide; we can’t ignore it. And it is a safe goal. Yet, each country will need to grapple with rationing. No country has universal coverage for everything immediately— not everything is free or even high quality. For example, cancer treatments are expensive. It is naive to think we will get everything. All of civil society has to decide what’s in or out, when we think UHC. “
UHC: A Women’s Issue
Dr. Quick conducted a TED-style talk during Thursday’s “To the Point” series on “Why UHC is a Women’s Issue.”
Barbara Ayotte is director of strategic communications at MSH.