Sustainability of Funding Universal Health Coverage

Our thanks to all the contributors to this Health Hub discussion. Each of the contributions will be included in a synthesised final report, which will be circulated and made available on the Health Hub. If you would like to contribute further to this topic, please email the Health Hub Facilitation team at healthhub@commonwealth.int.


Achieving Universal health coverage is a key objective for advancing the Sustainable Development Goals (SGDs), however a big challenge in achieving this is how best to afford good health services for the whole population.

Funding public services will always be a matter of prioritising limited resources. Continuing the theme of the previous discussion on Global Health Security (GHS), estimates of the cost of delivering even basic health protection services are significantly more than many countries are able to afford.

UHC is about more than just health protection, with issues such as the rising costs of Non-Communicable Diseases (NCDs) putting an ever increasing burden on national health budgets

Where should the balance lie between investment in primary healthcare and prevention measures versus hospitals and treatment services to find the most cost-effective and sustainable approach to maintain the health and wellbeing of the population?

Do any countries have examples of challenges, solutions or good examples related to these issues they would like to share?

To sign up for the Community of Practice, please click here: Sign Up Form

Discussion Themes:

As the discussion progresses it will develop its own themes which will eventually feed into a final document summarising the conversation. At present these themes are developing along the following lines:

Global Consensus
With Universal Health Coverage (UHC) enshrined into the SDGs, and with its own UN General Assembly Resolution, the debate over how to finance health and public health services is largely over. What is needed now is a similar global consensus on how to reach and sustain UHC.
Do the experiences in some countries suggest there are still significant barriers to health financing reform?

Access to healthcare
Health care financing impacts the accessibility of care for people in need influencing the cut-off point between winners and losers.

Quality and governance of UHC
Improving not just the extent but also the quality of health services and interventions is key. One example of a key strategy to move toward UHC is by extending social protection in health.

Have others followed a similar strategy to improve quality? What other approaches have, and have not, been found to work in others experience?

Simply allocating more money will not necessarily translate into increased access to and use of high quality health services for all and improved health outcomes without efficiency in public financial management. Country resources should be judiciously used through an inclusive, transparent budget process with increased citizen and community engagement at all levels of governance.

Learning from experience
Eastern European countries in the 1990s and then South Eastern European countries have experienced major changes and reforms to their health systems. This experience provides a valuable resource to be further researched and drawn upon.
Do others have examples they would like to share?

Domestic resource Mobilisation (DRM)
DRM is key to sustainably financing universal health coverage particularly in low and middle income countries. Despite global consensus on public financing for UHC, current fiscal and economic realities in many countries limit the capacity of governments to mobilize adequate resources for this noble aspiration with significant investment returns.

There are a number of opportunities to scale up DRM including:
1. Strengthened tax administration capacity
2. Increased diaspora remittance
3. Repatriation of looted funds
4. Innovative financing mechanisms

Previous Contributions:

27/5/16

Professor Tony Nelson
Department of Paediatrics
The Chinese University of Hong Kong
Hong Kong
Secretary of Commonwealth Health Professionals Alliance

Hybrid Funding Model of UHC

It is self-evident that universal health coverage (UHC) would be best achieved by providing evidenced-based health interventions in the most cost-effective way. It is also self-evident that delivering health interventions through a “private-for-profit” provider is likely to be a more costly to society as whole than delivering these through a “public-not-for-profit” provider.

Dr Ravindra Rannan-Eliya, Director, Institute of Health Policy, Sri Lanka presented at the Commonwealth Civil Society Forum prior the 2016 Commonwealth Health Ministers Meeting. His presentation was based on a review of some Commonwealth health systems that have achieved UHC at very low cost (the full review will be available on the Health Hub in due course). Despite their success, these predominantly Commonwealth funding systems have received little global attention.

UHC requires a level of healthcare that reduces disparities between rich and poor and ensures financial risk protection. Two main routes to achieve UHC are typically recommended to low income countries, namely: 1) The Beveridge Model which uses tax to pay for most health services in the country e.g. UK, New Zealand; 2) The modernized Bismarck Model which combines taxation with Social Health Insurance e.g. Korea, Germany. Unfortunately both of these systems require more taxes than are available in many low income countries.

Thailand is typically held up as the role model for achieving UHC in the Asian region but spends 3-4% of GDP in public money. Yet Sri Lanka and Malaysia not only do better across most health indicators, but spend 2% or less of GDP in public money. The latter two countries achieve this success by using a “hybrid funding model”. These countries combine limited public money with private funding to achieve not only good health outcomes but both good health coverage and better than average financial risk protection. How is this done?

This hybrid funding model requires a difference in “consumer quality” that encourages the more affluent to “go private” leaving more public resources to provide UHC of good “clinical quality” for the poor. Poor consumer quality in the public system includes: congestion at health care delivery sites; longer waiting times for health care; limited choice of doctors; and poorer quality of amenities, such as cleanliness and size of waiting areas and wash-rooms and availability of private inpatient rooms. At the same time, these systems can combine the inferior consumer quality with equal or better clinical quality in the public sector as compared to the private sector. This further minimizing inequality in access to effective medical care between different income groups. The main downside of this hybrid system is that the inferior consumer quality in the public system creates dissatisfaction among the non-poor patients and although they can and do “go private”, the costs can impose a burden particularly on middle-income patients. This leads to discontent and can create pressure for “the government” to “provide better services” despite what are usually good clinical outcomes. It is therefore not surprising that governments using these hybrid funding models may feel the need to explore ways to encourage a greater proportion of the population to obtain health insurance and leave the public system.

This hybrid funding model needs further study and discussion as a route for other low-income countries to achieve UHC with good health outcomes at low cost. To understand this hybrid funding better it will be necessary to improve measures that can monitor both “consumer quality” and “clinical quality” .

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to all the contributors to this the second Health Hub discussion. As the discussion closes today, all any further contributions will be added to the final report but will not be able to be circulated as an individual post. Each of the contributions over the whole of this discussion will be included in a synthesised final report, which will be circulated next week and made available on the Health Hub.

This second discussion spanned the 2016 Commonwealth Health Ministers meeting held on the 22nd May in Geneva. The theme of the meeting was ‘Health Security and Access to Universal Health Coverage’ noting the overarching Agenda 2030 for Sustainable Development and Heads’ collective commitment to deliver Goal 3: Ensure healthy lives and promote well-being for all at all ages. Ministers acknowledged the Commonwealth Heads of Government priority areas, including security, climate change and migration, and health protection, including the control of communicable diseases, emergency preparedness and the role of health systems to enhance resilience, and a call for collective Commonwealth action for global health security and the reduction of all public health threats, including the global imperative of addressing antimicrobial resistance. Additionally, Heads of Government encouraged action for the final eradication of Polio, and to continue to address the challenges for non-communicable diseases.

The full text of the statement which was read out by Malta on the first day of the World Health Assembly is available here. The theme for the 2017 CHMM will be ‘Sustainable Financing of UHC as an Essential Component for Global Security Including the Reduction of All Forms of Violence’

The next discussion will be chosen from the list currently on the hub discussion main page. This will be announced next week. The hub wishes you a happy healthy weekend and look forward to the start of the next discussion.

20/5/16

Denis Gilhooly
United Nations Digital He@lth Initiative
2030 Innovation Task Force

In the wake of Ebola, critical policy and finance questions remain to be addressed in parallel with those in the technology and innovation space. For example, is there an inherent conflict between the International Health Regulations (IHR) and health emergency action? How can emergency funding be made available without delay? Health emergencies know no borders, so how can a regional approach be ensured by organizations like the Commonwealth?

Fundamentally, why was US$4 billion spent on Ebola, when experts say that $500 million of timely funding would have been sufficient? Have these funds led to any kind of breakthrough or systemic change in health systems policy and practice in Guinea, Liberia or Sierra Leone? It is still the case that 53 countries fall below the minimum required for maintaining a basic health system of US$60/capita/year, and 40 countries are below US$40/capita/year. So where are we in ensuring finance of basic health infrastructure, from international and domestic sources?

These complex and vexed questions are compounded in health emergencies. Emergencies require surge. But surge should not lead to critical depletion of vital health services in other sectors. How can surge be managed? Are the human resources efficiently mobilized from outside the affected countries? A health emergency affects markets, transport and travel, water and sanitation, food and nutrition. How can multi-sector capacities be brought into play? Who calls the shots in a major health emergency, and, perhaps most difficult, how is a sovereign country supposed to manage the external actors coming in to help?

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Denis Gilhooly for his contribution, which nicely bridges the topics of the current discussion regarding sustainable funding for UHC and the previous discussion which focused on Global Health Security.

Together these discussion topics speak to the theme of the upcoming Commonwealth Health Ministers Meeting (CHMM) this Sunday in Geneva. The theme of the meeting is Health Security and access to Universal Health Coverage.

19/5/16

Jack Woodall PhD
Co-founder & Assoc. Ed.
ProMED
One Health Initiative Autonomous pro bono Team

I should have thought it is self-evident that there is enough money in all countries for basic health care, it is just impossible to allocate it because of mind-sets focused on military strength, and corrupt leaders. As a dual citizen of the UK & USA, two countries wildly overspending on their militaries (depending on your mind-set) and not free from corruption themselves, I can point the finger at most of the world, where health, sanitation and education are always at the end of the line at budget time with their begging bowls. Governments cannot allocate what money they have to counter epidemics at the source, which is more effective by far from tackling imported cases, until they have at least one and the media go mad – the public would not stand for it. Even when the aid belatedly starts to flow, corrupt administrators might skim it.

I realise that human nature being what it is, this is what will inevitably occur. The best we concerned public health people can do is to acknowledge there is no treatment and try to alleviate the symptoms.

Onwards & upwards!

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Jack Woodall for his contribution.

Sustainable funding for UHC will by definition require commitments by governments to finance health at a sufficient scale both in terms of size as well as the duration of the funding allocated. Governments will always have to balance many different competing priorities for scarce resources.

Is simply taking an evidence based approach to making the case for investments in health and wellbeing whilst being sympathetic to political pressures?

Is it naïve to think evidence speaks for itself?

How can we help governments prioritise allocation of resources to achieve the most gains for health and well-being for all?

18/5/16

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Geziena Kruger-Swanepoel for this very detailed contribution from the frontline of healthcare delivery. Geziena makes the point that it is not just the good intentions and planning at national levels which need to be considered, just as important (perhaps more so) is implementation on the frontline.

Understanding how strategies, action plans and road maps are received and implemented by health professionals is an important consideration. Do others think this receives enough attention? How can policy makers and planners better connect with the frontline? What are the barriers to understanding how to tackle this issue ? How can technology assist in this? How do others see digital initiatives such as the Commonwealth Health Hub facilitate this through eHealth and mHealth?

Geziena also comments on observations of workforce mix, with nursing staff making up the bulk of the roles in her experience. What are the workforce implications of a move to UHC? Thinking from a global health security perspective, how much spare capacity does there need to be in the system to reduce risk? Perhaps more importantly, how much ‘slack’ can countries afford?

Geziena Kruger-Swanepoel
Pharmacist
Jan Kempdorp CHC

Dear colleagues,

Here is some insight as to how the primary healthcare system in South Africa functions in a rural town, this might not be true for all facilities in South Africa but this is typically how healthcare is provided in this specific province in the rural areas.

South Africa currently has a relatively good healthcare system on paper. The problem is that most of what is on paper in the policies, procedures and laws, is not always practical to implement and adhere to at ground level.

Most towns have a primary healthcare clinic or access to a mobile primary healthcare clinic. With regards to coverage it is my opinion that South Africa is not too far behind in reaching most of its citizens with basic healthcare.

The current healthcare system is based on nursing staff. Nurses are the backbone of the South African healthcare system. There is a definite shortage of medical doctors and pharmacist in the public sector.

In the rural town I live and work in, the public health services available consist of the following:
A Community Healthcare Centre (CHC) open 24 hours a day with emergency care and maternity care available.
This was previously a fully functioning hospital, but had to be downgraded to a community healthcare centre due to the unavailability of a permanent doctor.

The CHC has up until last month been without a doctor since December 2014 and is fully run by nursing staff. Some of the doctors who have private practices in town do sessions at the CHC after hours.
The pharmaceutical services is supplied by the supervising pharmacist of the CHC main pharmacy, this includes medication ordering for the facility and supplying the ward with medication and surgical items.

The services of the following allied health workers are also available:

• Radiographer
• Dietician
• Occupational Therapist
• Environmental Health Professional
• Social Worker

These allied health workers are required to do weekly visits at all the surrounding clinics.

3 Primary Healthcare Clinics.

The first clinic was about 20km out of town, but during some political protests in 2014 the clinic was burned down, and not yet replaced. The staff and salvaged patient records were moved to the CHC building in town. The community must then come into town to receive healthcare. Medication is ordered via the supervisor pharmacist at the CHC pharmacy. Prescriptions are also done by the main pharmacy of the CHC. The clinic is open from 07H30 to 16H00 Monday to Friday

The second clinic is about 5km from the CHC and service the informal settlement community. The clinic has the services of one of the private doctors doing a session for 1 hour each week. This clinic has the services available of a permanent post-basic pharmacy assistant under the direct supervision of the supervisor pharmacist of the main pharmacy at the CHC. The clinic is open from 07H30 to 16H00 Monday to Friday.

The third clinic is situated within the CHC building and services both the community living in the town as well as the community living in the informal settlement. The clinic also has the services of one of the private doctors doing a session for 1 hour each week. This clinic is serviced by the satellite pharmacy of the CHC where I am currently working as a production pharmacist. The clinic is open from 07H30 to 16H00 Monday to Friday.

1 Mobile Clinic vehicle that service the farming communities and the villages surrounding the town.

Most of the services rendered at the health facilities is preventative in nature and special care is given to maternal and child health.

Here are some services that are available:

• Vaccinations and catch up vaccinations to all children attending the clinic.
• De-worming and vitamin A supplementation to all children <5 years given every 6 months.
• Free PAP-smears for women,
• Contraceptives are available to women, to name but a few.

All the services at the PHC are free. For some services rendered at the CHC there is a fee to be paid, but all services given to women and children are free.

In the PHC where I am working there are 4 permanent professional nurses appointed, 1 permanent assistant nurse, 1 permanent pharmacist, 1 community service pharmacist, 2 permanent admin clerks, 7 contract based counsellors working for a NGO company. I unfortunately don’t have any statistics available as to how many patients the clinic service per month. There are 2 days set out as ‘chronic days’ when all patients receiving chronic medication come to the clinic to collect their medication. The approximate amount of chronic prescriptions dispensed on one such a day can be between 150 to 200 prescriptions. I have worked out that if I am working alone which is often the case, I have 2 minutes per prescription. During this time I need to read and interpret the prescription, compile the prescription, write/print the labels and council the patient on the correct use of the medication issued.

The patient waiting times are quite long and are one of the biggest complaints received from the community.

When a chronic patient visits the clinic the process is as follow:

• Retrieve the patient file from reception.
• Sit in line to see the assistant nurse, who is responsible for taking blood pressure, blood glucose levels, urine test if applicable, HIV testing, TB sputum collection and temperature if necessary.
• After this the patient must see the professional nurse who will then write him/her a prescription for the chronic medication, do adjustment to the medication if necessary.
• Once the patient is finished he/she must then give the file in at the pharmacy to receive the medication prescribed. (In a clinic with no pharmacist available one of the professional nurses will also dispense the medication.)

Currently although the service is sometimes not up to standard and the waiting times are long, it is still patient centred. Patient screening and care is the most important part of the service when visiting the clinic.

At the moment in South Africa there are proposed changes to the public healthcare system such as the National Health Insurance that is based on the current health system of the UK. There is still a lot of debate about this topic in the news and private healthcare sector and I am not going to comment much about this now.

One change that is directly affecting the PHC where I am working is the implementation of and “ideal clinic”. The communication with regards to this change has not properly reached the healthcare worker rendering the service directly to the community but is just a list of paperwork that must be implemented regardless if it does or does not make any practical sense. Not one of the superiors can tell me why, the only explanation on questioning this is that it must be done. Judging from the response of the community we are servicing, they have also not been informed as to what is changing at the clinic and why.

As far as I can understand the “ideal clinic” wants to reduce the amount of patients visiting the clinic by pre-packing their prescriptions for collection only at the facility.

There are quite a few problems I am foreseeing by this change.

• Firstly the fact that more than 50% of the patients I issue medication to, are illiterate. They can’t read or write. If I am only sticking a label onto a box of medicine stating ‘take 1 tablet 2 times a day’, they can by no means understand the directions. This can, and in my experience has, led to over and under dosing with severe consequences. Most of the illiterate patients attending the clinic rely on what directions I give them verbally in order for them to take their medications correctly.
• Secondly the pharmacy law and good pharmacy practice in South Africa state that there are 3 phases of dispensing, interpreting of the prescription, compounding the prescription and patient counselling with regards to correct use of the prescription. By prepacking the medication, you are omitting the 3rd phase, thus breaking the law.
• Thirdly the patient will omit being screened by the nurses, and preventable and treatable conditions will be missed.

The current primary healthcare system in South Africa does not need to be changed for it to be improved. The existing system must be improved by computerising systems, more trained staff to be appointed and less double paperwork that increases the employee work load. Preventing by vaccinating and screening is always better than treating. If the current system can be improved more quality health coverage will be available in the rural areas of South Africa.

11/5/16

Dr ‘Kunle ADESINA MB(Lagos) MD(Lyon) FRCP(Lond.)
Consultant Physician/Nephrologist NHS England
Finishing M.Sc (Oxon) in Global Health at Oxford University 2016
Founder/Director, Healthworks International Support Systems (HISS), London
Founding member & Conference Delegate of Better Health for Africa (BH4A), London

Thank you very much for your sterling initiative in making available this discussion platform.

As an African observer, I have always been intrigued that much of the debate on Healthcare for our people have always tended to be skewed towards mainly methods and mechanisms, as though the change we all want to see will come about once we get these right. However, may I suggest that addressing both of these by whatever means we have may yet remain futile if we disregard the central importance of MIND-SETS – crucially, of the leaders, but also the led. In other words, how much of the alarming gaps, insufficiencies and inequities we see are actually due to wrong methods rather than warped mind-sets? How much of it is due to absence of wherewithal rather than WILL?

For instance, on a very basic level, is the absence of reliable basic public health data on vital statistics (i.e. how many in the populations are being born and dying each year) in Africa and other low and middle income countries (LMICs) really due to so-called ‘lack of infrastructure’ or sheer lack of political and collective will? How can we truly hope to ever overcome the life-threatening diseases and risk to health if there is not the most elementary framework for collecting data on cause-specific mortality let alone morbidity?

Can we seriously and constructively address a sincere shifting of mind-sets about the universal right of citizens to quality health care (curative and preventative)?

To my mind, lasting political commitment to UHC, when it is driven by genuine political will, commitment matched by the desire, and the expectation and unrelenting demand of resident populations, is key to achieving this goal.

Thank you all.

Dr ‘Kunle ADESINA, FRCP

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Dr Adesina for their contribution focused on mind sets and political will. Success in achieving the UHC goal is dependent on many factors including having an engaged and motivated workforce, high profile and visible political will and perhaps most importantly support from the wider population.

What methods work in advocating to health leaders, including ministers and others, that the goal of UHC is something Commonwealth state citizens support?

9/5/16

Dr. Abiodun Awosusi MD, MCert
Advisor, Africa Platform for Universal Health Coverage
Advocacy and Partnerships Manager, Action against Hunger (ACF International)
Abuja

Domestic resource mobilization (DRM) is key to sustainably financing universal health coverage (UHC) particularly in low and middle income countries. Despite global consensus on public financing for UHC, current fiscal and economic realities in many countries limit the capacity of governments to mobilize adequate resources for this noble aspiration with significant investment returns. There is, however, ample opportunity to scale up DRM through (but not limited to) the following means:

1. Strengthened tax administration capacity
2. Increased diaspora remittance
3. Repatriation of looted funds
4. Innovative financing mechanisms

Raising more money will not necessarily translate into increased access to and use of high quality health services for all, nor improved health outcomes without efficiency in public financial management. Country resources should be judiciously used through an inclusive, transparent budget process with increased citizen and community engagement at all levels of governance.

It is commendable that the UK government devotes 0.7% of its Gross National Income as official development assistance. Other developed nations can emulate this example not just to fund specific development programmes in least developed countries but to deploy aid in a catalytic way that unlocks sustainable domestic resources for health. The Commonwealth is well positioned to support countries to enhance DRM capacity to strengthen health systems and ensure healthy lives.

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Dr Abiodun Awosusi for his contribution to the discussion bringing up the issue of Domestic Resource Mobilisation (DRM).

Would others like to comment on means for scaling up DRM? Would you add anything further to the list presented in the contribution?

6/5/16

Raghavendra Guru Srinivasan
Chartered Accountant
Institute of Chartered Accountants of India
(Author’s contribution is an independent work and not the view of the Institute)

Please find below the Global framework for health related food taxation (Tax based domestic health financing).

Foundations of tax policy: Health related food tax (especially fat tax) was conceptualized for developed countries. Current health related food tax is a product of both medical science (Allopathy/western medicine) and economics. With obesity and non-communicable diseases (NCDs) being one of the biggest market failures, there is an urgent need to look at healthy people like yoga (Indian medicine) practitioners for lessons in management of food consumption and for taxation.

Innovation: The Governments around the world have proposed to tax various food products to stop obesity, diabetes and other NCDs, and they include soda tax, candy tax, sugar tax, high salt and high sugar tax, junk food tax, pastry tax, etc. Even after taxing food products there is still discussion on food supplied in large quantities, and on promotions to children in the form of gifts and toys. There is a need for a comprehensive global framework for health related food taxation and it is addressed by my work.

Behavioural insight: This effort has also brought out the business behaviour of food consumption in individuals. Market mechanisms reward the business behaviour food consumption as higher sales translates into higher profits. Governments in developed countries have set up a team to nudge people’s behaviour for improving health especially in the area of obesity and NCDs. The business behaviour of food consumption generates or increases the need for governance efforts like behaviour change interventions, and regulating behaviour will reduce the burden of governance.

The above framework will be a single basic document for Overeating behaviour/Tax based financing for health/ Behavioural insight efforts.

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Raghavendra Guru Srinivasan for the contribution focused on taxation and its effects on health behaviours. This hub discussion looks at the sustainability of funding Universal Health Coverage. Reducing the burden of disease through measures to improve health behaviours is of course an important, but allied issue to be discussed in achieving this.

What do others think and the impact of funding prevention versus treatment services in achieving sustainable UHC?

21/4/16

Prof. Dr. med. Ulrich Laaser DTM&H, MPH
Section of International Public Health (S-IPH)
Faculty of Health Sciences
University of Bielefeld

Dear colleagues,

To explore the historical chain of thinking about financing health care in transition countries the following resources might be of interest:

Laaser U, Radermacher R (Eds.): Financing Health Care – A Dialogue between South Eastern Europe and Germany. Series International Public Health, Vol. 18, Hans Jacobs Editing Company, Lage, Germany 2006: 334 pages
Chapter on The Benefits and Challenges of Social Health Insurance for Developing and Transitional Countries available here: http://www.who.int/health_financing/issues/shi-doetinchemschrammschmidt.pdf

‘The health care financing system has direct impact on the accessibility of care for people in need. Poor access to health services rapidly leads to poverty and smaller future chances for a decent standard of living. In short, the way health care is financed has a strong influence where in society the cut-off point is that divides the winners and losers.

These implications of a health care financing system had to be born in mind by eastern European transition economies facing the extraordinary challenges of redesigning a health care system in a short time frame since the 1990s. More than a decade later, experiences of south-eastern European countries in financing the health system are available for research, but remained in many cases not well analysed.’

and,

Laaser, U: Challenging Developments in Universal Insurance Coverage (editorial).
Journal of Public Health Policy 02 (2007): 281-283
Available here: http://www.palgrave-journals.com/jphp/journal/v28/n2/full/3200133a.html

‘One of the crucial factors for achieving effective universal coverage is to improve the quality of health services and interventions. Extension of social protection in health is a key strategy to remove financial barriers to health services and to protect people from the impoverishing effects of catastrophic health expenditures, thereby reducing poverty.’

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Prof. Dr.Ulrich Laaser for signposting to two resources, freely available excerpts of which we have provided above.

These resources make the case that access and quality are key when considering strategies to move toward Universal Health Coverage. They also direct to examples from Europe where many countries have experience of major changes to their health systems provides a valuable resource to be further researched and drawn upon.

Do other have examples of major changes to their own Health Systems or other Commonwealth countries which they would like to signpost as examples we can learn from?

What views or examples do others have about the experience of private and social insurance funding approaches and how these impact on cost?

20/4/16

Rob Yates
Senior Fellow
Chatham House

For decades the issue of how countries should finance their health systems was one of the most contentious topics in international development. This was particularly the case in the 1980s and 1990s when battles raged between agencies (e.g. The World Bank) promoting a greater role for private financing mechanisms (for example user fees) and those who argued that health services should be publicly financed.

But now, with Universal Health Coverage (UHC) enshrined in the Sustainable Development Goals, and with its own UN General Assembly Resolution, these rows are largely over. Instead there is a global consensus that the only way to reach and sustain UHC is through public financing mechanisms. This is because from the definition of UHC (everyone receives the health services they need without suffering financial hardship) it is obvious that this goal can only be achieved by ensuring that wealthy and healthy members of society cross-subsidise services for the sick and the poor. As a private financing system based on voluntary insurance and fees will never deliver this outcome (as the US demonstrates) it is necessary for the state to intervene to organise an efficient and fair financing system, with contributions made according to one’s ability to pay and services allocated according to need.

All the major recent international reports on health financing from the likes of WHO, the World Bank, OECD and Chatham House support this consensus and even people who advocated a significant role for private financing in the 1990s have changed their tunes: http://www.theguardian.com/society/sarah-boseley-global-health/2012/oct/01/worldbank-healthinsurance and http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62613-6/fulltext?rss=yes.

Now health systems debates have shifted to new topics like the pros and cons of private versus public provision of services and is it better to adopt broad health systems reforms or scale up vertical interventions tackling specific diseases?

But at least the debate about how one should finance UHC has been put to bed: public financing is the key to UHC.

Moderator’s Note [Stephen Dorey, The Commonwealth Secretariat]

Our thanks to Rob Yates, from Chatham House for the first contribution to the hub discussion.

Rob makes the case that there is a global consensus that public financing is the approach to take to achieve Universal Health Coverage (UHC) and that the debate is now shifting to how these services should be provided.

Does the example of the US suggest there are still significant barriers to change in some countries and a need for more work to be done to advocate for sustainable health financing?

Do others have a view on this from their national or regional perspectives across the Commonwealth?