On the Road to Universal Health Coverage: The Vital Role of the Essential Package for Health Impact

On the Road to Universal Health Coverage: The Vital Role of the Essential Package for Health Impact

A Rwandese woman shows her child's community-based health insurance card. {Photo credit: C. T. Ngoc/MSH.}Photo credit: C. T. Ngoc/MSH.

Eugénie, a widow in Rwanda, farms to provide for her children. In January 2012, she had surgery to remove a tumor, a procedure that would have devastated her family economically if she did not have insurance. Rwanda’s health insurance program is the most successful of its kind in sub-Saharan Africa: it supports the health of more than 90 percent of the population, including the most vulnerable, like Eugénie.

Rwanda is one of over 100 countries --- over half of which are low- and middle-income countries --- that have taken steps to provide universal health coverage (UHC). Ghana, India, Rwanda, Thailand, and Turkey are among those countries on the road to realizing the vision of universal health coverage. Each country faces a unique set of challenges demanding vital moral and practical choices. Each is developing different solutions. What they share is the basic goal of better health for their people through UHC.

Universal health coverage has two fundamental goals: maximizing health impact and eliminating --- or at least reducing --- impoverishment and bankruptcy due to healthcare costs. The World Health Organization (WHO) defines universal coverage as: “ensuring that all people can use the promotive, preventive, curative and rehabilitative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”

An essential benefits package is central to achieving both health improvement and financial protection goals. In defining the essential benefits package, UHC programs may be tempted to go straight to the question: What services should be provided? Instead, we propose addressing three questions in sequence:

  1. What is the health impact we aim to achieve and by which we will measure our progress?
  2. What is the essential benefits package of high-impact, high-value services that will achieve this health impact?
  3. How by leveraging synergies through integrated service delivery can make coverage for even high-cost interventions—like Eugénie’s cancer—possible?

Defining Impact

How a program chooses to define and measure health impact will be an important driver of results. Since the Millennium Development Goals were adopted in September 2000, the international development community and many countries have measured success in health by outcome indicators (e.g., maternal deaths) and process indicators (e.g., immunization coverage) associated with the three health goals.

The next generation of development goals, post-2015, undoubtedly will reflect changing global circumstances and priorities. There is a growing view that there will likely be only one health goal and, if this is so, sustaining and building on the health impact of the existing MDGs might best be achieved through the broad, flexible goal of universal health coverage.

The ultimate test of the effectiveness of UHC must be health impact --- not simply coverage and health system performance. The evidence is now clear that UHC actually does improve health outcomes. However, those cautious about UHC as the post-2015 development goal for health, are quick to point out that the relationship is not certain.

Therefore, if universal health coverage becomes the core post-2015 health goal, it is essential that within that goal there are solid indicators and targets for health outcomes as well as coverage and health system performance. In practical terms, this means wrapping in under the UHC goal, key indicators related to child mortality, maternal mortality, and combating HIV/AIDS, TB, and other communicable diseases. At the global or country level, however, it also means wrapping in indicators for chronic diseases such as heart disease, cancer, and diabetes.

Covering the Essentials

Once the health impact goals have been agreed upon, UHC programs can then move to define the essential benefit package of promotive, preventive, therapeutic, and rehabilitative services. The choices are not always easy. Each country will need to determine who is covered, what is covered, and how much is covered. Even the United States, which has by far the highest per capita health spending in the world, has recognized it cannot cover every possible service for every person. This realization is reflected in its 2010 national UHC legislation, which specifically defines an “essential health benefits package” for the United States. Countries must first identify the services that provide the highest impact and value. As their programs achieve stability, they can be expanded.

When Rwanda began its community-based health insurance program (“Mutuelles de Sante”) in 2004, it subsidized the poor at a higher rate than the non-poor and covered a basic package of primary care services as well as a modest complementary package for secondary services. In 2011, Rwanda introduced a sliding-scale contribution system to improve the financial viability and equity of the program. By expanding its database to include socioeconomic information on the vast majority of the population, it was able to determine people’s premiums based on their ability to pay. Contributions from higher-income groups now help to subsidize services for lower-income groups. The reforms have made it possible to cover specialized services like the treatment for Eugénie’s cancer.

Many countries, including fragile states like Afghanistan, have achieved remarkable health impact by implementing a basic package of health services, such as:  maternal and newborn health, child health and immunization, public nutrition, communicable diseases treatment and control, mental health, disability services, and regular supply of essential drugs. A decade ago, Afghan leaders faced some of the world's worst health indicators. Focusing on maternal, newborn, and child health, the country's maternal mortality ratio dropped drastically, and the child mortality ratio also was reduced.

Leveraging Synergies

When we integrate health services, we leverage their synergies for maximum effectiveness and efficiency. Implementing a basic package of health services has worked in many countries not only because those services are fundamental to overall health and well-being, but also because they are closely interrelated. Family planning and reproductive health services can help prevent the spread of HIV & AIDS, for example.

Universal health coverage can work in the same way. We can maximize the affordability of health service delivery when we leverage the synergies of integrated care. This can be as true for low-cost interventions, like assisted birthing, as for high-costs interventions: Just ten years ago, only the wealthiest people had access to treatment for HIV & AIDS. Today 6.6 million people—nearly half of those in need—will take life-saving antiretrovirals. We've also seen a steady decrease in new HIV cases. We’ve achieved this not only by focusing our resources on the HIV epidemic, but also by coordinating and improving the function of health systems overall.

While we should continue to build awareness and set goals for specific health areas, we must integrate financing and service delivery systems to maximize gains in those specific health areas. Rwanda extended insurance coverage to chronic diseases like Eugénie’s cancer by leveraging the integrated health infrastructure of its population database and service delivery platforms. The system efficiencies possible with UHC can bring down the often high cost of services for chronic diseases like cancer—and HIV as a now treatable condition—that are putting new pressures on health systems.

On the Road to Universal Health Coverage

For most countries, achieving universal health coverage will be a lengthy journey along a tortuous road. For nearly every country, defining the essential benefits will be one of the critical milestones along that journey. The essential benefits package should follow from a clear definition of the expected health impact of UHC and it should lead to defining an integrated approach to deliver high-impact, high-value services. Health impact has been the goal for which we’ve worked with the Millennium Development Goals. Should UHC become the post-2015 development goal for health, specific indicators and targets within that goal should still focus on defined health outcomes.

Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.

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Comments

Juliet Siena Ok...
Thank-you for an interesting and thought provoking post on the achievements of Rwanda in Universal Health Coverage. I certainly agree that developing a financing mechanism for healthcare inclusive of public health services is key to making UHC a reality in Low and Middle Income Countries. One of the challenges of implementing international laws and policies is how to hold governments accountable for providing basic health services beyond operational maps and guidelines. Better yet, how do the citizens hold their ministries of health accountable for the social protection plans, cost-sharing,and benefit packages to the level that it guarantees financial-risk protection,improves health outcomes, and leads to greater consumer satisfaction with the quality of healthcare received? How many governments are explicit on what services are provided and what quality is acceptable? Is this information publicly available beyond statements such as "maternal care", "women's health", " preventive services" even "HIV/AIDs care". For example, does women's health exist only in reproductive health? Or is a there a comprehensive commitment to the health and wellbeing of women at various stages of life including adolescent and the elderly? Chronic diseases such as hypertension and diabetes attribute 60% of deaths worldwide and affect women equally: we need to design health systems that are responsible and responsive to the needs of the populations they are designed to cover. I would love to see an explicit commitment by governments to National Health Insurance Schemes that are; 1) Publicly available and include services in the essential benefit packages that are guaranteed as well as an indication of where these services should be provided. 2) Include a commitment to emergency care that is accessible to all citizens implemented through policies similar to the Emergency Medical Treatment and Labor Act of 1986 which ensures that under no circumstances should patient presenting with imminent life threatening conditions be denied medical attention. 3) A mechanism for accountability such as public reporting and to some extent litigation if the citizen's rights to such services are breeched. So far nine LMIC countries including Ghana, India, Kenya, Indonesia etc are currently implementing reform (Jointlearningnetwork.org 2013).Hopefully these governments will make their plans more explicit, responsive, and participatory. Juliet Siena Okoroh is a medical student at UCSD and a recent graduate from the MPH program in Health Policy and Management at the Harvard School of Public Health

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