Feb 2013. by Adam Wagstaff
It’s easy to see how the concept of universal health coverage (UHC) became so elusive.
At the start, the idea 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. China, for example, started out on this process in 2003, trying to expand coverage to the rural population that lost coverage when the old rural cooperative medical scheme collapsed following the de-collectivization of agriculture in 1978.
It didn’t take long, however, for someone to point out that in a sense everyone already has coverage. China’s rural health facilities continued to receive subsidies even after 1978. Thailand already had a network of government facilities even before it launched its UC scheme. Mexican families without a social security member already had access to the network of government facilities run by the ministry of health even before the Seguro Popular scheme was launched.
Coverage was already universal. That wasn’t the issue. Rather the issue was that not everyone enjoyed the same depth of coverage: people outside a “scheme” (often the less well off) were liable for higher out-of-pocket payments than those inside a “scheme” (often the better off). So what was needed was not universal coverage (which existed already) but rather “deep coverage for everyone” (or DCFE). The argument was accepted, but the acronym DCFE was horrible. Adding a D to make UDHC didn’t get any support either so it was decided to stick with UHC but add a second dimension to coverage—depth.
Soon there was another complaint. We were focusing on the financial side of coverage and ignoring the issue of what health benefits countries would get by expanding and deepening coverage. If the focus was on reducing out-of-pocket payments, might not coverage expansion initiatives be skewed against low-cost but highly effective interventions in favor of costly inpatient and pharmaceutical-based interventions with limited effectiveness? In short, shouldn’t we be thinking about what is covered and not just who is covered and how deeply. There was of course some debate. There were those who accepted that publicly-financed coverage expansion initiatives needed to have an eye to the health impacts, but that wasn’t the only goal of public policy: financial protection mattered too. But it was conceded that there needed to be a third dimension to UHC reflecting what is covered.
A cube is born
And so the famous WHO UHC cube was born. This helped for sure. But since the adjective “universal” captures only one of the three dimensions, and since all countries afford some coverage to everyone, the concept underlying UHC would always be hard to get across: “Well yes actually it’s not so much who has coverage we’re talking about so the ‘universal’ bit is indeed a bit misleading; it’s more about the depth of people’s (financial) coverage and what (services) they’re covered for.”
It didn’t take long after the cube’s birth before people started asking awkward questions about the three dimensions.
Are we talking about coverage on paper on paper (de jure) or coverage in practice (de facto). What if a country promises but doesn’t actually deliver coverage? After all one of the complaints with government facilities has been that people don’t always get the services they think they’re entitled to. There’s plenty of evidence on health worker absenteeism, drugs being unavailable, and so on.
And what of providers failing to deliver the correct care? We know many fail to make the correct diagnosis, and even when they get the correct diagnosis often fail to prescribe the right treatment. This isn’t always due to ignorance. Often providers make the wrong diagnosis because they fail to do everything they know they should do.
It soon became clear that when thinking about the “service coverage” dimension of UHC, we need to look beyond what services people are entitled to. Service coverage is about people getting the care they need. We can’t get at this by looking at the number of contacts with a provider.We need to look at what happens during the contact, comparing the services the person gets (or doesn’t get) to what’s needed. In some cases, this is straightforward. A child of a certain age requires a specific set of vaccinations, and one can verify whether they’ve been received. In most cases, though, establishing what’s needed and what’s received during the contact is much harder—if not impossible beyond a detailed case study. But if we don’t try, and instead focus on what services people are entitled to or the number of contacts, we could go badly wrong.
The de jure and de facto distinction matters too for the financial coverage dimension. We need to look beyond the payments people should make on paper. Financial coverage is about what people pay in practice, and how affordable these payments are. Patients may end up paying considerably more out-of-pocket than they expect to on the basis of what’s written on paper. Providers may deliberately overprescribe to make money. They may do this even more when they know a patient is in a “scheme”. Or providers may deliberately switch to a more resource-intensive style of care. Paradoxically we may find that expanding coverage may lead to larger out-of-pocket payments and hence shallower coverage.
So what exactly is UHC?
As each layer of argument has been added, UHC has thus morphed from a straightforward notion of making sure everyone has coverage to something much more complex and useful.
Yes universalism is still there. But UHC isn’t about getting everyone coverage, since everyone already has it.
So what exactly is UHC? I think it means that that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result.
UHC is about equity: linking care to need, not to ability pay. UHC is also about financial protection: making sure that people’s use of needed care doesn’t leave their family in poverty. And UHC is about quality of care: making sure providers make the right diagnosis, and prescribe a treatment that is appropriate and affordable.
New labels aren’t always bad
Are these new ideas? No. They’ve been around for a long time. Countries have been pursuing these goals for ages, and scholars have been studying these issues for ages. It’s just that it hasn’t been called UHC. UHC is indeed old wine in a new bottle. We’ve all been working on UHC all along; we just didn’t know it!
And yes the term UHC doesn’t capture the richness of the agenda we’ve been working on very well. There is indeed a risk that it draws people’s attention toward the rather empty question of who has coverage—the dimension of UHC that gave its name, but the one that turned out to the least useful.
But if we can manage this risk, UHC may yet serve as a useful rallying cry for the goals of equity, financial protection, and quality of care. We just have to downplay the original concept and explain that despite its name UHC isn’t just about giving everyone coverage. It’s about ensuring that in practice everyone—whether rich or poor—gets the care they need without suffering undue financial hardship as a result.
If by slapping the UHC label on the bottle, we get people more interested in the wine—even if the label is a bit misleading—that’s surely a good thing. After all the wine’s not a bad one. Far from it.