Universal Health Coverage (UHC) has gained great attention among policymakers and academics since the publication of the World Health Organization’s (WHO) World Health Report in 2010 (WHO, 2010a). A right to health or health care is reflected in the text of the WHO Constitution (WHO, 1948) and the Universal Declaration of Human Rights (United Nations, 1948). It is also reflected in many national constitutions, for example, the constitutions of South Africa (1996) and Mexico (2013) declare that everyone has the right to access to health care services.
Many countries have identified Universal Health Coverage (UHC) as the goal for their health systems, and health financing reforms are at the core of strategies to move in this direction. UHC is however, not a new concept, the literature shows that it emerged after the Second World War, underpinned in many countries by a broad value consensus such as social cohesion in European countries and human security in Japan.
The advent of UHC has marked a change in the underlying rationale for public policy on health service coverage. Prior to this, beginning in 1883 with Bismarck in Germany, followed by several other European countries and Japan over the next 40 years, the motivation was different. These countries sought to support industrial development through a healthier workforce with a concern to mitigate growing political pressures from labor unions (Saltman and Dubois, 2004, Ikegami et al., 2011) submitted.
The coverage policies introduced health insurance for workers in the formal sector of the economy funded by mandatory contributions of employers and employees were consistent with these underlying motivations. It meant, however, that large shares of the population, particularly those working in agriculture or otherwise outside of the formal/industrial economy, did not have any explicit form of entitlement the shift from “workers” to “people” as those entitled to coverage after the Second World War had important implications for health financing policy. In particular, it meant that there had to be a shift away from a purely contributory, funding
mechanism and basis for entitlement. More specifically, the use of revenues from general public budgets were needed to provide all or nearly all of the funds, as is the case in the British National Health Services (NHS) established in 1946 (Abel-Smith, 1987), or to supplement compulsory health insurance contributions to ensure coverage for the poor and others outside of the formal sector of the economy, as in Japan, which achieved universal population affiliation with its health insurance system in 1951 (Ikegami et al., 2011).
Much of the advice provided to Low-to-Middle-Income Countries (LMICs) in the 1980s and 1990s on health financing encouraged them to initiate compulsory health insurance for formal sector workers. Such recommendations according to various scholars were implicitly based on (or at least consistent with) the pre-war rationale for public policy on health coverage, combined with a politically hopeful (or naïve) expectation that such coverage programs would be fully self-funding and thus enable public subsidies for health services to be captured by the poor. Unfortunately, this approach tended to concentrate even greater shares of public subsidies on the formal sector population.
Definition of financing for UHC is derived from the World Health Report (WHO, 2010, p. 6), which state that: “Financing systems need to be specifically designed to: Provide all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to be effective; ensure that the use of these services does not expose the user to financial risks. These conditions cannot be fully achieved anywhere, even where all people are protected from financial hardships, there is always some gap between the need for and use of services, and quality often varies. To transform UHC from a mere aspiration to a practical concept requires identifying the specific goals embedded within the definition and orienting policy toward progress on these goals.
Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda. The literature however indicates that whether it is a means to an end or an end in itself and whether it is measurable are subjects of heated debate. Universal health coverage not only leads to better health and to financial protection for households, it is valuable for its own sake. More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access.
Universal health coverage is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments, it has been presented by various scholars and the WHO. It involves coverage with good health services from health promotion to prevention, treatment, rehabilitation and palliation as well as coverage with a form of financial risk protection. Universal coverage should be for everyone. Although many countries are far from attaining universal health coverage, all countries can take steps in this direction Improving access is one such step with Botswana not being an exception.
Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things. Hence, universal health coverage is not possible without universal access, but the two are not the same. According to the WHO Framework on this aspect, it states has “Access “has three dimensions: These three dimensions can be adopted as a form of policy transfers from WHO “Best buys” for policy development at the national level. This may also inform agenda setting in health care reforms in Botswana aligned to the HE Masisi “Re Set Agenda”. It can also serve as guide in the development of the National Strategic Framework on health care financing adopting the UN 2030 Agenda, Agreement on the Addis Ababa on health care reforms and financing as well as Botswana VISION 2036 -Achieving Prosperity for all.
Physical accessibility. This is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them.
Financial affordability. This is a measure of people’s ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g., the costs of transportation to and from facilities and of taking time away from work). Affordability is influenced by the wider health financing system and by household income.
Acceptability. This captures people’s willingness to seek services. Acceptability is low when patients perceive services to be ineffective or when social and cultural factors such as language or the age, sex, ethnicity or religion of the health provider discourage them from seeking services.
Services must be physically accessible, financially affordable and acceptable to patients if universal health coverage is to be attained. The requirement that services be physically accessible is fulfilled when these are available, of good quality and located close to people. Service readiness is said to exist when the inputs required to produce the services (e.g., buildings, equipment, health personnel, health products, technologies) are also available and of good quality.
Financial affordability can be improved by reducing direct, out-of-pocket payments through insurance prepayments and pooling, for example, the collection of government revenues and/or health insurance contributions to fund health services or through demand-side stimuli such as conditional cash transfers and vouchers. Social and cultural accessibility can be enhanced by ensuring that health workers and the health system more generally treat all patients and their families with dignity and respect. Addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities.
Improvements in education will raise the average income, make health services more affordable and equip people with the awareness needed to demand and obtain the health services they need. Efforts to address these social determinants will help to reduce inequalities in income, service affordability and access to services, and this, in turn, will help to attenuate differences in health service coverage and in financial risk protection. In addition to the specification of goals and intermediate objectives, as well as the functional approach to understanding health financing arrangements in any country, policy analyses and recommendations need to be guided by an approach to applying the following concepts. These may assist in the design and the development of the National Strategic Framework in Health Care Financing and or in the development of a working paper in Botswana. These three factors need to be considered that, broadly, address the following questions:
(1) Where are we going?
(2) From where are we starting?
(3) How far and how fast can we go
The first issue is to orient the direction of reforms to specific policy objectives. The second question is grounded in a fundamental policy reality, the starting point for any reform is the system that currently exists in the country. the third question speaks to the context the factors largely outside the control of health policymakers that have implications for both what can be implemented and what can be attained in terms of progress towards UHC.
Thabo Lucas Seleke is a Researcher & Scholar, Global Health Policy (LSHTM)
