GNHE » December 12, 2015

Daily Archives: December 12, 2015

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Key messages on UHC measurement

Published by:

With the inclusion of universal health coverage (UHC) in the Sustainable Development Goals (SDGs), there is considerable discussion on how best to measure progress to UHC. This note summarises the perspective of the Global Network for Health Equity (GNHE), a network that brings together the views and experience of a diverse network of researchers based at country level in Africa, Asia and Latin America.

 

Guiding principles

  • Our concern is with UHC as defined according to outcomes, namely access to needed health services of sufficient quality to be effective, and financial risk protection for all. Within this context, measurement of these outcomes must be independent of the structure of financing and provision in a health system.
  • In order to allow comparison across all countries irrespective of their income level, UHC measures must use data that are likely to be available across a diverse range of health systems, or for which there are reasonable substitutes.
  • GNHE supports the use of a small number of key indicators rather than a single composite UHC indicator, which obscures the multi-dimensionality of UHC as a concept. However, indicators of the two key elements of UHC should be assessed and interpreted together.
  • Monitoring of progress towards UHC should not only be measured in terms of each indicator’s overall average, but also the narrowing of differentials across socio-economic groups to take account of equity.

 

UHC goal of access to health services for all

  • Due to the complexity of measuring access directly, we propose measuring actual use of services.
  • Instead of focusing on a few services (such as antenatal care and immunisations), GNHE proposes assessing the adequacy and equity of overall service utilisation.
  • We recommend a minimum average utilisation rate of 4 outpatient visits per person per year; utilisation rates below this threshold suggest that a country is unlikely to have adequate access to services.
  • For inpatient services, a minimum threshold of 100 inpatient discharges per 1,000 population per year is recommended.
  • To assess equity, these minimum thresholds should be achieved in all socio-economic groups. Given that service utilisation should be according to need, the difficulty of accurately measuring need for health care and the generally greater burden of ill health among lower-income groups, utilisation rates should be at least equal across socio-economic groups.
  • Further work is required to develop an appropriate means of assessing quality and effectiveness of services used.

 

UHC goal of financial risk protection

  • Indicators of catastrophic levels of out-of-pocket health expenditure and impoverishment from making out-of-pocket payments for health services should be used to assess financial risk protection.
  • Constraints on currently available data limit refinements to these existing measures. Priorities for improved data collection and future refinement of these measures include:
    • Including all direct costs related to using health services when needed (e.g. costs of transport to the health care provider) and possibly also health insurance contributions
    • Developing a common methodology to measure country-specific basic needs’ thresholds for use in impoverishment analyses instead of the global, minimalistic poverty lines (e.g. $1 per day)
  • It is important to recognise that these measures only reflect the proportion of the population who actually use health services and are impoverished or face financial catastrophe as a result. They do not take account of those who do not use health services due to a lack of financial resources. It is for this reason that measures of financial risk protection must be assessed together with measures of service utilisation; where utilisation rates are below the minimum threshold, this is likely to reflect the existence of unmet need.
South-East Asia Upper-middle-income countries

Public financing for universal health coverage in Malaysia

Published by:

Chiu-Wan Ng, of the Julius Centre for Clinical Epidemiology and Evidence-based Medicine in the Department of Social and Preventive Medicine at the Faculty of Medicine of the University of Malaya, has written an assessment of Malaysia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • The claim that Malaysia has achieved universal health coverage appears to be supported by the findings of the assessment of the country’s health system.
  • Financing of health care has a progressive distribution and average household out-of-pocket payments are relatively small, especially for poorer households. Overall, the population enjoys high levels of financial risk protection and the use of public health care services is equitably distributed.
  • The fact that the poor are spared a high burden of out-of-pocket payments can be partially attributed to the extensive network of public health facilities: this provides a wide range of very cheap health care services to those in need. Direct household out-of-pocket health payments in Malaysia are in fact almost exclusively for the purchase of private care. Out-of-pocket payment distributions favouring richer households indicate that, in general, private care is mainly purchased and consumed by the rich, a finding which should not be surprising since these households are more likely to be able to afford such care.
  • Increasing public demand for better quality care, as well as changing demographics and disease burdens, are putting the Malaysian public health system under tremendous strain. Major health reforms are being discussed within government although very few details have been released to the public. It is likely that a future system would involve social health insurance, a single purchaser and both public and private provision.

Ng C-W. 2015. Universal health coverage assessment: Malaysia. Global Network for Health Equity (GNHE). Available at: http://gnhe.org.

Africa Lower-middle-income countries

Achieving universal health coverage in Ghana

Published by:

Bertha Garshong and James Akazili of the Research and Development Division, and the Navrongo Health Research Centre, of the Ghana Health Service respectively, have written an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

 

  • Over the past few years there has been some improvement in access to health care in Ghana. However, there are still many challenges to the achievement of universal health coverage.
  • Ghana’s National Health Insurance Scheme (NHIS) is a pro-poor policy and offers a generous benefit package to its members. Yet many poor people find it difficult to pay registration fees as well as the premiums. The Scheme also has difficulties determining the socioeconomic status of applicants: flat-rate rather then income-related premiums therefore burden poorer members disproportionately. While there have been promises by policy-makers to improve the equity of the NHIS, not much progress has been made in this regard on the ground, and proposed premium reforms remain controversial. As a consequence, the NHIS still caters more for higher-income groups, leaving many poor families without any prepaid cover, despite contributing to the VAT-funded component of the Scheme. As a result, out-of-pocket expenditure remains relatively high.
  • For Ghana to move towards universal coverage, the country needs to find more money to replace the current out-of-pocket payment system. As the relative contributions of premiums is small, tax-based funding is the obvious source. However, increasing the fiscal space to fund the NHIS requires economic growth and improved tax collection.
  • For a modest increase in fiscal space for health for 3 to 5 years, Ghana needs to achieve a revenue collection rate of 20% of GDP by 2015. Currently the collection rate of tax revenue is below 13%. A World Bank report on the NHIS states that Ghana’s macroeconomic landscape is still fragile and any move must be done cautiously. With Ghana’s oil find the growth rate was modest but steady around 6% in 2013, and this gives some fiscal space for health in the next five years. However, this will depend on government spending and revenue collection efforts and priorities. Much as Ghana is not expected to get foreign aid because of its lower-middle-income status, it could benefit if it increases its credit rating and devises a clear exit strategy from aid. Lastly, Ghana has structural inefficiency in its health system as well as in the operations of the NHIS. Tackling these inefficiencies could release some additional fiscal space.
  • Apart from strengthening the financing and coverage of the NHIS, it is vital to expand access to health care services and raise the quality of care. This would include addressing the inequitable distribution of human resources and equipment, and improving the management and administrative capacity of the NHIS. The Community Health Planning Services programme, which is designed to provide a close-to-client service, needs to be expanded. Primary health care services are closer to the people and are within reach of the poor, but confidence in these facilities has dwindled due to lack of skilled staff, equipment and supplies and the poor quality of care, particularly in rural communities. These limitations necessitate referrals but, with the lack of transport and poor roads, many referred clients are unable to access higher levels of care.
  • Information barriers are another area that requires attention. There has not been a consistent and effective communication strategy for either providers or potential clients regarding the mechanisms of the NHIS, especially with respect to the poor.

 

Bertha Garshong and James. 2015. Universal health coverage assessment: Ghana. Global Network for Health Equity (GNHE). Available at: http://gnhe.org.

High-income countries South-East Asia

Achieving universal health coverage in Hong Kong

Published by:

Cheuk Nam Wong and Keith YK Tin, of the School of Public Health at the University of Hong Kong, have written an assessment of Hong Kong’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

 

The authors’ main conclusions are:

  • Hong Kong is a good example of a progressive health financing system. This is because there is a relatively large tax-financed, public health system that shields those with low incomes from out-of-pocket payments. It also requires the rich to pay more tax, both in absolute terms and as a proportion of income. Equally importantly, almost no-one in Hong Kong lives in poverty and health outcomes are good across the various socio-economic quintiles.
  • These features account for why a relatively high level of out-of-pocket expenditure (around a third of total health care financing) does not have a negative equity impact on vertical and horizontal equity. These payments are mainly made by the rich who have the ability to purchase health care services in the private sector.
  • In terms of efficiency, over the last decade total health expenditure in Hong Kong was amongst the lowest as a percentage of GDP compared with OECD countries. Despite this low level of spending, Hong Kong’s health care system achieved service quality and health outcomes that are outstanding by global standards (including the longest life expectancies and lowest infant mortality rates).
  • Further, given its universally accessible public sector, adverse selection in Hong Kong is virtually non-existent. Moral hazard is limited to the private system. Thus, one study suggested that third-party coverage in Hong Kong, be it through public entitlement or private insurance, mostly facilitated access that met genuine health need rather than encouraged inappropriate overuse of services. A supply-driven public sector with an effective referral system, and high out-of-pocket co-payments for private services, probably explain these observations.
  • Hong Kong does not fare as well in terms of equitable access to health services, however. There is pro-rich inequity in the delivery of general outpatient care (but not specialist care) and very marginally for inpatient care, when utilisation is considered in relation to need.
  • With respect to future reforms, the setting up of a closely regulated voluntary private health insurance scheme is a priority on government’s agenda. The government is currently going through a public consultation process but will have to overcome public scepticism and clarify the need for such a scheme as part of a sustainable model of health financing. Should the voluntary health insurance scheme be implemented, it can be expected that personal contributions will play a more important role in the financing of the Hong Kong health system in future, and facilitate risk cross-subsidies so that access to health care is improved.
  • However, no country in the world has reached universal population coverage based mainly on voluntary prepayments. Voluntary prepayment for private health expenditure does not diminish people’s demands for more public spending on health, and compulsory prepayments are essential for health financing to be sustainable, be it in the form of various taxes or mandatory health insurance. Hong Kong is not likely to be an exception. It has taken time for citizens to realise that the current system is not financially sustainable without help from mandatory prepayment.
  • The most pressing question therefore seems to be whether the share of the gross domestic product going to taxes should be increased, thereby allowing greater budget allocations to the health sector. An argument against this would be that this might lead to under-funding of other social pillars such as education, housing, and social assistance. In addition, in the past Hong Kong has made the political choice for low tax regime and stringent controls on government expenditure. In fact, when scaled against the public revenue base, Hong Kong’s public spending on health is only slightly lower than other comparable economies.
  • Apart from these questions around financing, there are two other challenges to universal health coverage. First, an ageing population puts pressure not only on the provision of health care services but also the financing mechanism driven by tax revenue. In future years, less people will be working and thus paying tax to support a health system that will be taking care of more people.
  • Second, demographic issues are further complicated by the Hong Kong government’s lack of autonomy in immigration control. A continuous population influx from mainland China will exert pressure on Hong Kong’s health system. The number of immigrants from the mainland is difficult to forecast as it is subject to policy changes that are unpredictable and are out of the Hong Kong government’s control. It is difficult to devise long-term plans for the health system if population forecasts are not accurate.
  • Finally, the extent to which government health expenditure is accepted by the public hinges on the accountability of the government. As shown by recent protests, the government does not enjoy the support of the whole population. When citizens have little confidence in the government, every policy that the government tries to put forward prompts a reaction which is not always positive. As a result, attempts to implement health reforms in Hong Kong have been made over more than a decade, but changes that have the potential to improve the health system are yet to materialise.

Wong CN,  Tin KYK. 2015. Universal health coverage assessment: Hong Kong. Global Network for Health Equity (GNHE). Available at: http://gnhe.org.

Africa Lower-middle-income countries

Financing options for universal health coverage in Zambia

Published by:

Bona Chitah and Dick Jonsson, of the Department of Economics at the University of Zambia, have written an assessment of Zambia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • Zambia is making continuous progress in all the key areas of its health system. However, there are gaps which need to be resolved for the country to be able to realise the goal of universal coverage, including universal financial protection and access to care.
  • A more equitable distribution of resources between urban and rural areas is required. Currently there is an urban bias in resource distribution. This is evidenced not only in the allocation of public health sector resources, but also in expenditures by the wealthy on private health care.
  • Resources need to be allocated to promote access to, and utilisation of, health care by the poorer socio-economic groups. The higher consumption of public inpatient health care services by wealthier groups is a striking example of inequitable utilisation, as is the relatively greater levels of government subsidy received by wealthier groups, even for primary health care.
  • The impoverishing effect of out-of-pocket payments exposes poorer households to financial risk, driving households into poverty or further into poverty. This requires reconsideration of public hospital user fees, both in terms of the level of fees and the application of bypass fees (which are charged when patients bypass primary health care facilities, including because of the severity of their conditions and their proximity to higher-level health facilities).
  • Finally, Zambia’s ambition to introduce social health insurance as a mechanism for improving the pooling and purchasing of services needs to be scrutinised for its possible impacts on equity. The proposed social health insurance scheme would require co-payments and perhaps other contributions, which would increase the financial burden on households. This means that the proposed scheme could effectively run counter to the ambition of attaining universal health coverage.
  • There should be a critical evaluation of the alternative option of simply continuing – and strengthening – the current tax-based financing system.

Chitah B, Jonsson D. 2015. Universal health coverage assessment: Zambia. Global Network for Health Equity (GNHE). Available at: http://gnhe.org.