UHC Forward: Towards Universal Health Coverage

Two newly released UNICEF publications demonstrate that while reaching universal health coverage (UHC) is possible in most countries, this requires a comprehensive social protection system of which health insurance is a crucial component. Health insurance, and how it can contribute to achieving universal health coverage, is the subject of UNICEF’s recently released 72-country “National health insurance in Asia and Africa” study. This study finds that even in middle and low-income countries that have adopted a formal policy of universal health coverage (UHC), many socio-economic barriers to access persist. It is for this reason that the study has been framed in the broader approach recommended by UNICEF’s first global Social Protection Strategic Framework, which stresses the importance of developing and strengthening integrated social protection systems.

The “National health insurance in Asia and Africa” study, published in March 2012, was conducted in two-phases. The first aimed to provide a baseline of information on health protection schemes for mothers, children and vulnerable groups, which it achieved through a survey of 72 countries, interviews with experts, and a global literature review. In the second phase, a few case studies were used to hone in on countries’ use of insurance to reduce financial barriers and protect households from the consequences of ill-health. The study found that a UHC policy exists in most countries but that actually implementing it equitably remains a challenge given the mix of existing ad hoc financing mechanisms and the diversity of barriers to access. The study points to three different kinds of barriers:

• Inability to enrol in schemes – due, for example, to lack of birth registration systems, overly restrictive citizenship requirements, inadequate poverty level indexes, or lack of administrative staff.

• Inability to use the scheme when enrolled – due to the non-portability of schemes, inadequate protection against the loss of wages, and high out-of-pocket, transportation, co-payment, and informal costs.

• Barriers to receiving appropriate and quality care – vulnerable populations routinely receive a lower standard of care due to the presence of perverse incentives or discrimination.

This typology is meant as a practical framework for managers to assess policy, strategy and implementation gaps. In particular, it is useful for identifying some of the “demand-side” barriers that exist even when healthcare providers and infrastructures are available. In other words, the existence of doctors or clinics is of little use to groups that cannot access them due to poverty, discrimination, exclusion or other constraints. The importance of investing in demand-side interventions alongside service provision and of coordinating, or “integrating,” demand and supply-side mechanisms is one of the main messages of UNICEF’s Social Protection Strategic Framework.

In addition to promoting integrated systems, the Framework also suggests that health insurance alone is unlikely to tackle the numerous barriers to healthcare faced by vulnerable groups. Countries need a broader set of social protection programs with the potential to further health outcomes. A combination of different instruments, including cash transfers, home-based care, user-fee abolition, birth registration, and legislation preventing discrimination can be a crucial way to ensure that high out-of-pocket payments (formal and informal), discrimination, geographical location and other barriers do not stand in the way of UHC. Crucially, many of these instruments act not only on economic but also social vulnerabilities, thereby promoting inclusion in a more holistic and effective manner.

The two publications are intrinsically linked by their common focus on the importance of removing social and economic access barriers to services, both at the national and sub-national levels. Countries are increasingly recognizing the importance of moving from isolated programs to integrated systems in order to enhance the reach, as well as the long-term outcomes of programs. Going forward, UNICEF and its partners will strive to operationalize the findings and recommendations of these two publications in order to promote equitable policies and enhance the performance of district-level health management.

At the same time, perfecting the design and implementation of integrated social protection programs is not always enough. It should be noted that, in practice, the feasibility of UHC is not merely a technical question but also a social and political one. Engaging civil society and fostering an enabling political environment, focused on achieving equity in health access and coverage, are therefore prerequisites to any program. It is also an on-going challenge, given that any health or social protection system must be robust enough to survive major changes in political, economic and socio-cultural circumstances.