Making fair choice^ on the path to universal health coverage Final report of the WHO Consultative Group on Equity and Universal Health Coverage
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Making fair choice^
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Final report of the WHO Consultative Group
on Equity and Universal Health Coverage
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Making fair choice^
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Making fair choices
on the path to universal
health coverage
Final report of the WHO Consultative Group
on Equity and Universal Health Coverage
WHO Library Cataloguing-in-Publication Data
Making fair choices on the path to universal health coverage. Final report of the WHO Consult
ative Group on Equity and Universal Health Coverage
I. World Health Organization.
ISBN 978 92 4 150715 8
Subject headings are available from WHO institutional repository
©World Health Organization 2014
All rights reserved. Publications of the World Health Organization are available on the WHO web
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Requests for permission to reproduce or translate WHO publications -whether for sale or for
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The designations employed and the presentation of the material in this publication do not
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This publication contains the collective views of an international group of experts and does not
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Printed in Geneva.
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Contents
Acknowledgements
Preface
Brief summary ....
vii
ix
Executive summary
List of abbreviations
1 Universal health coverage
2 The critical role of fairness and equity
3 Expanding priority services
4 Including more people ....
5 Reducing out-of-pocket payments
6 Overall strategy and trade-offs
7 Public accountability and participation
8 Indicators of progress
References
24
31
37
42
vi
Authors
Acknowledgements
Members of the WHO Consultative Group:
This work was funded by the Norwegian
Agency for Development Cooperation
(Norad) and the Research Council
of Norway; the Brocher Foundation,
Switzerland; the Harvard University
Program in Ethics and Health; and the
International Development Research
Centre (IDRC), Canada. We extend our
special thanks to Marie-Gloriose Ingabire
and Sharmila Mhatre at the IDRC for
their active engagement throughout
the project. We are also grateful to the
following persons for their valuable
discussions and contributions: Merima
Ali, Dan Brock, David Evans, Raja Khosla,
Theodora Swift Koller, Joseph Kutzin,
Brendan Kwesiga, Jeremy Lauer, Geir
Lie, Calvin Ho Wai Loon, Veronica Magar,
Hannah McLane, Solomon Memire, Oscar
Mujica, Thalia Porteny, Moussa Sacko,
Abha Saxena, Nicole Britt Valentine, and
Jonathan Wolff.
Trygve Ottersen,* Ole F Norheim,* Bona M
Chitah, Richard Cookson, Norman Daniels,
Frehiwot B Defaye, Nir Eyal, Walter Flores,
Axel Gosseries, Daniel Hausman, Sarnia
A Hurst, Lydia Kapiriri, Toby Ord, Shlomi
Segall, Gita Sen, Alex Voorhoeve, Daniel
Wikler, Alicia E Yamin
WHO staff:
TessaTT Edejer, Andreas Reis, Ritu Sadana,
Carla Saenz
* Lead authors
vii
Preface
Universal health coverage (UHC) is at the center of current efforts to strengthen health
systems and improve the level and distribution of health and health services. This
document is the final report of the WHO Consultative Group on Equity and Universal
Health Coverage. The report addresses the key issues of fairness and equity that arise
on the path to UHC. As such, the report is relevant for every actor that affects that path
and governments in particular, as they are in charge of overseeing and guiding the
progress toward UHC.
Background
The goal of UHC has a strong basis, and the underlying aspirations have a long
history. The constitution of the World Health Organization (WHO) asserts that a right
to health is "one of the fundamental rights of every human being without distinction
of race, religion, political belief, economic or social condition."This message has since
been repeatedly reinforced; perhaps most prominently in the 1978 Declaration of
Alma-Ata. Since the turn of the century, the quest for UHC has gained momentum
in numerous countries and in the global health community. In 2005, the member
states of WHO endorsed UHC as a central goal and stated that health systems must"be
further developed in order to guarantee access to necessary services while providing
protection against financial risk."
The World Health Report 2010 followed up by providing practical guidance for how
countries can reform their health financing systems in order to pursue UHC. Since
then, more than seventy countries have requested policy support and technical advice
for such reform from WHO. In 2011, the World Health Assembly responded by calling
on WHO to develop a plan of action for providing such support and advice. One of the
action plan's twelve points is action on equity, a key issue that cuts across most other
components of a health system. Specifically, the WHO Consultative Group on Equity
and Universal Health Coverage was set up to develop guidance on how countries best
can address the central issues of fairness and equity that arise on the path to UHC.
Since 2011, the pressing need to make progress toward UHC has been repeatedly
affirmed, for example, in the Bangkok Statement on Universal Health Coverage and
the Mexico City Political Declaration on Universal Health Coverage. Moreover, in late
2012, the United Nations General Assembly adopted a resolution emphasizing the
responsibility of governments to "urgently and significantly scale up efforts to accel-
viii
Preface
erate the transition towards universal access to affordable and quality health-care
services." Later, WHO published the World Health Report 2013, Research for Universal
Health Coverage, which again emphasized the need to make progress toward UHC
and described several means to that end. Further underscoring WHO's commitment,
advancing UHC has been identified as a leadership priority for WHO in the 12th general
programme of work during the 2014-2019 period. UHC is also a central theme in the
ongoing deliberation over the post-2015 development agenda.
In parallel with the work of WHO and other actors in the multilateral system, many
countries have intensified their efforts in progressing toward UHC. The results have
been encouraging and supported the Director-General's assertion that UHC is "the
single most powerful concept that public health has to offer."
Process
As described, WHO's plan of action motivated the establishment of the Consultative
Group. The group consisted of eighteen ethicists, economists, policy experts, and
clinical doctors, spanning thirteen nationalities. The group worked on the report from
May 2012 until January 2014 and convened three times. The meetings took place in
Stavanger (Norway), Boston (US), and Geneva (Switzerland). At several stages in the
process, drafts were also circulated for external review, including to selected national
ethics committees and to the WHO Collaborating Centers for Bioethics. In addition,
feedback was obtained from numerous other individuals and groups working in
relevant areas.
Content
This report addresses the critical choices of fairness and equity that arise on the path
to UHC. Accordingly, the report is not primarily about why UHC ought to be a goal,
but about the path to that goal. The report may differ from others in the direct way
it addresses fundamental issues and difficult trade-offs. This approach was facilitated
by the involvement of philosophers and ethicists in addition to economists, policy
experts, and clinical doctors.
Target audience
Numerous actors influence the progress toward UHC. Among them are institutions,
groups, and individuals, within and outside government, locally, nationally, and inter
nationally. The issues of fairness and equity addressed in this report are highly relevant
to all of these actors. The report is most relevant, however, for governments in charge
of overseeing and guiding the progress toward UHC. More specifically, the report can
be particularly useful for policy makers and technical advisors in health ministries.
ix
Brief summary
Since 2010, more than seventy countries have requested policy support and technical
advice from the World Health Organization (WHO) for how to move toward universal
health coverage (UHC). As part of the response, WHO set up a Consultative Group on
Equity and Universal Health Coverage.
This final report by the Consultative Group addresses the key issues of fairness and
equity that arise on the path to UHC by clarifying these issues and offering recommen
dations for how countries can manage them.
To achieve UHC, countries must advance in at least three dimensions. Countries must
expand priority services, include more people, and reduce out-of-pocket payments.
However, in each of these dimensions, countries are faced with a critical choice: Which
services to expand first, whom to include first, and how to shift from out-of-pocket
payment toward prepayment? A commitment to fairness—and the overlapping concern
for equity—and a commitment to respecting individuals' rights to health care must
guide countries in making these decisions.
The following three-part strategy can be useful for countries seeking fair progressive
realization of UHC:
• Categorize services into priority classes. Relevant criteria include those related
to cost-effectiveness, priority to the worse off, and financial risk protection.
• First expand coverage for high-priority services to everyone. This includes
eliminating out-of-pocket payments while increasing mandatory, progressive
prepayment with pooling of funds.
• While doing so, ensure that disadvantaged groups are not left behind. These
will often include low-income groups and rural populations.
As part of an overall strategy, countries must carefully make choices within and across
the dimensions of progress. These decisions depend on context, and several different
pathways can be appropriate. Nevertheless, some trade-offs are generally unacceptable.
For example, one generally unacceptable trade-off is expanding coverage for low- or
medium-priority services before there is near-universal coverage for high-priority
services.
When pursuing UHC, reasonable decisions and their enforcement can be facilitated by
robust public accountability and participation mechanisms.These mechanisms should
be institutionalized, for example, through a standing national committee on priority
setting, and the design of legitimate institutions can be informed by the Accounta
bility for Reasonableness framework. A strong system for monitoring and evaluation
is also crucial for promoting accountability and participation and is indispensable for
effectively pursuing UHC.
X
Executive summary
Universal health coverage (UHC) is defined as all people receiving quality health services
that meet their needs without being exposed to financial hardship in paying for the
services. Given resource constraints, this does not entail all possible services, but a
comprehensive range of key services that is well aligned with other social goals. UHC
was firmly endorsed by the World Health Assembly in 2005 and further supported in
the World Health Report 2010. Since then, more than seventy countries have requested
policy support and technical advice for UHC reform from the World Health Organization
(WHO). In response, WHO developed a plan of action that included providing guidance
on how countries can manage the central issues of fairness and equity that arise on the
path to UHC.The WHO Consultative Group on Equity and Universal Health Coverage was
set up to develop this guidance.
This document is the Consultative Group's final report. The report addresses the key
issues of fairness and equity by clarifying these issues and offering recommendations
for how countries can manage them. The report is relevant for a wide range of actors
and particularly for governments in charge of overseeing and guiding the progress
toward UHC.
To achieve UHC, countries must advance in at least three dimensions. Countries must
expand priority services, include more people, and reduce out-of-pocket payments.
However, in each of these dimensions, countries are faced with a critical choice: Which
services to expand first, whom to include first, and how to shift from out-of-pocket
payment toward prepayment? A commitment to fairness—and the overlapping concern
for equity—and a commitment to respecting individuals' rights to health care must
guide countries in making these choices. For fair progressive realization of UHC, the three
critical choices and the trade-offs between the dimensions must be carefully addressed.
Expanding priority services
When expanding services, the crucial question is which services to expand first. Services can
be usefully categorized into three classes: high-priority, medium-priority, and low-priority
services. Relevant criteria for ranking and categorizing services include those related to
cost-effectiveness, priority to the worse off, and financial risk protection.
When selecting which services to expand next, it is often useful to start with cost-effec
tiveness estimates and then integrate the concern for the worse off as well as other
relevant criteria. The specification, balancing, and use of these criteria should take
place in the context of robust public deliberation and participatory procedures. This
will enable a wide range of groups to provide input to the priority-setting process and
xi
Making fair choices on the path to universal health coverage
promote accountability for the decisions made. Countries will also benefit from having
a standing national committee on priority setting to handle particularly difficult cases.
Including more people
When seeking to include more people, an inescapable question is whom to include
first. To include more people fairly, countries should primarily first expand coverage
for low-income groups, rural populations, and other groups disadvantaged in terms
of service coverage, health, or both. This is especially important for high-priority
services. Fair inclusion of more people may call for targeted approaches where these
are effective.
Reducing out-of-pocket payments
Many countries rely heavily on out-of-pocket payments to finance health services. Such
payments represent a barrier to access to health services, especially for the poor. In addition,
forthose who do use the services, out-of-pocket payments are often a substantial financial
burden on them and their families and may even cause financial catastrophe. To improve
access and financial risk protection, countries should therefore shift from out-of-pocket
payment toward mandatory prepayment with pooling of funds. A critical issue is how to
do so. Fairness suggests that out-of-pocket payments should first be reduced for highpriority services and for disadvantaged groups, including the poor. Regarding mandatory
prepayments, fairness suggests that they should generally increase with ability to pay and
that contributions to the system should be progressive. At the same time, the access to
services should be based on need and not ability to pay.
Overall strategy and pathways
A three-part strategy can be useful for countries seeking fair progressive realization of
UHC:
• Categorize services into priority classes. Relevant criteria include those related
to cost-effectiveness, priority to the worse off, and financial risk protection.
• First expand coverage for high-priority services to everyone.This includes
eliminating out-of-pocket payments while increasing mandatory, progressive
prepayment with pooling of funds.
• While doing so, ensure that disadvantaged groups are not left behind. These
will often include low-income groups and rural populations.
As part of an overall strategy, countries must carefully make choices within as well as
across the dimensions of progress. These choices will depend on context, and several
different pathways can be appropriate. However, when pursuing fair progressive reali
zation of UHC, some trade-offs are generally unacceptable:
• Unacceptable trade-offI: To expand coverage for low- or medium-priority services
before there is near universal coverage for high-priority services. This includes
reducing out-of-pocket payments for low- or medium-priority services before
eliminating out-of-pocket payments for high-priority services.
• Unacceptable trade-off II: To give high priority to very costly services whose
coverage will provide substantial financial protection when the health benefits
are very small compared to alternative, less costly services.
xii
Executive summary
• Unacceptable trade-off III: To expand coverage for well-off groups before doing
so for worse-off groups when the costs and benefits are not vastly different. This
includes expanding coverage for those with already high coverage before groups
with lower coverage.
• Unacceptable trade-off IV: To first include in the universal coverage scheme only
those with the ability to pay and not include informal workers and the poor,
even if such an approach would be easier.
• Unacceptable trade-off V: To shift from out-of-pocket payment toward
mandatory prepayment in a way that makes the financing system less
progressive.
Mechanisms and institutions
Fair progressive realization of UHC requires tough policy decisions. Reasonable decisions
and their enforcement can be facilitated by robust public accountability and partici
pation mechanisms. These mechanisms are essential in policy formulation and priority
setting and specifically in addressing the three critical choices on the path to UHC and
the trade-offs between dimensions of progress. These mechanisms are also crucial in
tracking resources and results. To properly play these roles, public accountability and
participation should be institutionalized, and the design of legitimate institutions can be
informed by the Accountability for Reasonableness framework.
A strong system for monitoring and evaluation is also needed to promote account
ability and participation and is indispensable for effectively pursuing UHC in general.
Countries must carefully select a set of indicators, invest in health information systems,
and properly integrate the information into policy making. The selection of indicators
should be closely aligned with the goal of UHC and in most settings include at least four
types of indicators: indicators related to the priority-setting processes and indicators
of coverage, financial risk protection, and health outcomes. The latter three types of
indicators should reflect both average levels and equity in distribution.
xiii
List of abbreviations
AIDS
Cl
ECOSf
GDP
HALE
HIV
HRH
HTA
NCD
PAHO
TB
UHC
WHO
Acquired immunodeficiency syndrome
Concentration index
Equipos Comunitarios de Salud familiar
Gross domestic product
Health-adjusted life expectancy
Human immunodeficiency virus
Human resources for health
Health technology assessment
Noncommunicable disease
Pan American Health Organization
Tuberculosis
Universal health coverage
World Health Organization
xiv
Making fair choices on the path to universal health coverage
1
r
Z1
Universal health coverage
Universal health coverage (UHC) is defined as all people receiving quality health
services that meet their needs without being exposed to financial hardship in paying
for the services.1 Given resource constraints, this does not entail all possible services,
but a comprehensive range of key services that is well aligned with other social goals.
The member states of the World Health Organization (WHO) have endorsed UHC as a
goal and stated that health systems must "be further developed in order to guarantee
access to necessary services while providing protection against financial risk.2 This
report addresses the critical choices regarding fairness and equity that arise on the
path to UHC.
The definition of universal health coverage
As described, UHC has been defined as "all people receiving quality health services that
meet their needs without exposing them to financial hardship in paying for them.
The interpretation of this definition is important. This is especially the case for the
element "services that meet their needs," as the concept of need is ambiguous.5’7 "Need"
can, for example, refer to the shortfall from normal health, the capacity to benefit from
a service, or a combination. Moreover, under most interpretations, available resources
in every country fall short of what is required to meet all needs. Therefore, it is crucial
that resources are concentrated on the most important set of services and that the
resources devoted to the pursuit of UHC do not jeopardize other important social goals.
If UHC is to be achievable, the definition of UHC must be sensitive to these concerns.
Accordingly, this report does not take UHC to require all services that are expected to
be beneficial. Instead, the report takes UHC to require a comprehensive range of key
services that is well aligned with other social goals.
I
Instead of "universal health coverage," the terms "universal coverage," "universal health care," and "universal
access" are sometimes used. Given the understanding of "universal health coverage in this report, universal
access and universal health care can be seen as components of UHC.
II The definitions of "universal health coverage"and"universal coverage"vary.The 2005 58th World Health Assembly
indirectly defined universal coverage as "access to key promotive, preventive, curative and rehabilitative health
interventions for all at an affordable cost."3 Somewhat differently, the World Health Report 2010 specified
"universal coverage" as a goal according to which "all people have access to services and do not suffer financial
hardship paying for them," and the report generally focused on "access to needed services" and "financial risk
protection."4 Since then, most definitions have had a similar structure with some variation in wording. Although
these variations may appear minor, at least four types of variation should be acknowledged. First, some defini
tions assert that everyone must have "access" to services as opposed to "receiving" services. Second, some defini
tions refer to "needed services,""key services," or "necessary services," as opposed to "services that meet [people's]
needs."This is further discussed below. Third, some definitions refer to "financial catastrophe,""financial ruin," or
"poverty" rather than "financial hardship." Fourth, not all definitions explicitly link the financial harm to payment
for services.
2
1 Universal health coverage
The goal of universal health coverage
Although this report is not primarily about why countries should pursue UHC, it is
useful to outline the strong and multifaceted rationale for that goal. First, securing
access to health services is motivated by the individual benefits from service utili
zation. These improvements in health can be seen as an end in themselves as well
as crucial to overall well-being and the related concepts of capabilities and oppor
tunities.5, 8’10 Health can affect overall well-being directly and indirectly, for example,
through income and wealth. Health can also be seen as of great importance due to its
impact on people's range of opportunities—such as their ability to work or pursue an
education—or the range of life plans open to them.5
From the same perspectives, it is also evident why affordable access is so important.
Like poor health, large payments for services can severely limit well-being and
opportunities, not only for the individual who uses the service, but also for his or her
family.11’13 Affordable access across the entire continuum of care also facilitates the
use of preventive services, and these services are often more cost-effective than the
corresponding curative services. Moreover, affordable access confers benefits even to
those who do not eventually need health services. Among other things, knowledge
of affordable access can reduce anxiety and the fear of becoming ill and make people
sleep better at night. Such knowledge can also facilitate planning and productive
use of resources that otherwise would have to be kept in reserve in case the need for
expensive services arises.
Widespread coverage is also beneficial to society at large. Improved coverage
improves population health,14 and health contributes to development directly,10,15 as
indicated by, for example, the Human Development Index (HDI).16 In addition, health
affects development and the overall well-being of society indirectly. Healthy children
are better able to learn,17,18 and a healthy population facilitates economic growth.19,20
According to one study, for every dollar spent on key services, the direct and indirect
economic returns—measured as "full income"—can be multiplied by a factor of 9-20.21
In other words, there can be enormous payoffs from investing in health.
UHC can further be motivated by its distributional effects. Irrespective of the total
benefits to society, universal health coverage can be supported by the idea that
coverage should not be restricted to the better-off part of the population or, more
specifically, by the idea that such a restriction is unfair.5,22 Insofar as it improves
coverage for the worse off, progress toward UHC can also promote fairer distribution
of health and well-being.
UHC is also a way to meet rights to health care and the human right of"the enjoyment
of the highest attainable standard of physical and mental health,"23 which is recog
nized under international law.24 Every country in the world has ratified at least one
treaty that specifies obligations regarding the right to health. Under international law,
states have an obligation to adopt appropriate measures to realize the right to health
or the right to health care on a non-discriminatory basis (as some treaties specify).This
obligation involves a strategy and plan of action for how to achieve that goal as well
as mechanisms for oversight and redress.25 Parties to specific international treaties also
have obligations to allocate sufficient resources to realize the right to health. In other
words, states have an obligation to adopt appropriate measures to realize the right to
3
Making fair choices on the path to universal health coverage
health, and the pursuit of UHC is crucial to this endeavor. Accordingly, many different
approaches, including those based on fairness or rights, can endorse and encourage
the urgent pursuit of UHC.
The scope of universal health coverage
UHC must be understood in a comprehensive way. More specifically, the goal of UHC
calls for quality services of many kinds, for strengthening the entire health system, and
for intersectoral action.
As for services, UHC goes beyond clinical and curative services to include public health
and population measures and promotive, preventive, and rehabilitative services.3,
4 Public health coverage and population measures include, for example, informa
tional campaigns on hygiene and food safety, vector control, and tobacco regulation.
Services, broadly understood, also include the provision of drugs, devices, and other
goods. Especially regarding essential medicines, considerable effort has been exerted
to promote universal access.26,27 For all services, quality, not only quantity, is paramount.
When moving toward UHC, countries must ensure that everyone has access not merely
to services, but to services that are truly effective and of good quality.28,29
UHC is centrally but certainly not exclusively concerned with financing. The financing
function of health systems includes revenue collection, pooling of resources, and
purchasing of services,30 all of which are critical to the pursuit of UHC. However, UHC
and the means necessary to make progress go beyond financing. UHC is concerned
with coverage in general and is thus concerned with all barriers to coverage. Many
of these barriers are primarily nonfinancial—including legal, organizational, techno
logical, informational, geographic, and cultural barriers—and are not necessarily
best addressed through financial means.31’34 Therefore, all functions of the health
system must be strengthened. In addition to financing, the four key functions include
service provision, generation of human and physical resources, and stewardship.35
Stewardship requires that the government oversees and guides those other functions.
The categorization of functions also highlights the importance of human resources in
health system strengthening. 36,37
UHC calls for action going beyond the health sector and the health system, as the means
for improving access to health services and financial protection are not confined to that
sector and system. For example, affordable access may crucially depend on policies
in sectors concerned with transportation, employment, education, and finance. The
pursuit of UHC therefore requires intersectoral action.38,39 In addition, the underlying
objective of improving health—and not only health services—requires approaches that
go beyond the health sector also more generally. Countries must address the broader
determinants of health, including social determinants such as education, employment,
housing, and environment.40,41 Accordingly, any pursuit of UHC must be well aligned
with such endeavors.
Finally, although most UHC initiatives concentrate on domestic health policy, the
broader, ultimate goal of comprehensive coverage for everyone in the world should
be kept in view. Today, differences in health and service coverage are profound both
across and within countries. For example, in 2010, healthy life expectancy at birth for
males ranged from 37.7 healthy life years in the Central African Republic to 70.6 in
4
1 Universal health coverage
Japan.42111 Likewise, under-five mortality rate (U5MR) varied from 180 to 2 per 1,000
live births.43 Differences in service coverage are no less pronounced. For example, the
percentage of one-year-olds who has received the third those of diphtheria-tetanuspertussis vaccine varies (DTPS) from 33 percent to 99 percent, and the percentage of
births attended by skilled health personnel ranges from 9 percent to 100 percent.43
What is particularly troubling is that inequalities in health and inequalities in service
coverage are often correlated, so that coverage is the least where needs are the greatest.
These inequalities and the variation in country capacity to address health needs raise
a number of important issues.44 In particular, there is a question about how capable
countries can and should assist countries that alone are unable to adequately address
domestic needs. Concerns for global justice, global solidarity, and human rights can,
for example, motivate development assistance for health with the aim of closing the
glaring gaps in service coverage.45-46
Dimensions of progress and critical choices
Several countries have recently demonstrated that significant steps toward UHC
can be taken, even in resource-constrained settings.47-48 Among these countries are
Cambodia, Chile, China, Colombia, Ghana, Indonesia, Mexico, the Philippines, Rwanda,
Thailand, and Vietnam.,v
Obviously, no country starts from zero coverage, and there is no single path to UHC
that every country must follow. To achieve UHC, however, every country must make
progress in at least three dimensions. Countries must expand priority services, include
more people, and reduce out-of-pocket payments. These three dimensions closely
correspond to those often emphasized in the context of financing and, more specifi
cally, the dimensions of the now well-known UHC box.4 This box is shown in figure
1.1 .The box illustrates three dimensions to consider when moving toward UHC.These
concern (a) the proportion of the population to be covered, (b) the range of services
to be made available, and (c) the proportion of the total costs to be met. More specifi
cally, the first dimension is linked to the proportion of people covered from pooled
funds, while the third dimension refers to the proportion of total costs to be met by
pooled funds.
As indicated, in this report the three dimensions are interpreted somewhat more
broadly. Although expanding priority services typically requires changes in financing,
expansion can also follow from other changes. For example, coverage for priority
services can be expanded through a change in the use of health personnel or the use
of existing technologies and infrastructure. Moreover, reducing barriers to coverage
requires action on many nonfinancial barriers and the use of nonfinancial means.
These barriers include stigma and cultural norms, for example.
In each dimension, countries moving forward will face at least one critical choice
regarding fairness and equity. When expanding priority services, countries must
decide which services to expand first. When including more people, countries must
decide whom to include first. And when reducing out-of-pocket payments, countries
111
Due to the earthquake, healthy life expectancy in Haiti was as low as 27.8 years in 2010.
iv Many case studies on UHC reforms in these and other countries exist. Useful collections include UHC Forward,49
a WHO compilation of success stories,50 and the World Bank's study series on UHC.51
5
Making fair choices on the path to universal health coverage
Figure 1.1 Three dimensions to consider when moving toward universal health coverage
A
:Reduced
: cost sharing
: and fees
—
'
Extend to
non-coverej
<
Currei
Direct costs:
Include proportion of the
other ; costs covered
“"““z
led fui
__________
Services:
_____________ which services
Population: who is covered?
are covered?
Figure adapted from the World Health Report 20104
must decide how to shift from such payment toward prepayment. The dimensions of
progress and the related choices are summarized in box 1.1.
Box 1.1 Critical dimensions and choices on the path to universal health coverage
Dimension of progress
Critical choice____________
Expanding priority services
Which services to expand first?
Including more people
Whom to include first?
Reducing out-of-pocket payments
How to shift from out-of-pocket payment toward
prepayment?
Expanding priority services
Progress toward UHC can be sought by expanding priority services. However, no
country can cover all services that are expected to be beneficial. For each step toward
UHC, countries must therefore choose among different services that all need to be
expanded. Countries are then faced with the following choice: Which services to
expand first?
Including more people
Progress toward UHC can be sought by including more people. To do so, countries
must seek to reduce all barriers to effective coverage. Among these barriers are prohib
itive payments for services and other financial barriers and many nonfinancial barriers.
The latter include legal, organizational, technological, informational, geographic, and
cultural barriers. Since these barriers cannot be eliminated for everyone immediately,
countries are faced with the following choice: Whom to include first?
Reducing out-of-pocket payments
Progress toward UHC can be sought by reducing out-of-pocket payments while
increasing mandatory prepayment, for example, in the form of taxes or premiums.
When doing so, countries are faced with the following choice: How to shift from out-ofpocket payment toward prepayment?
6
1 Universal health coverage
The context of choice
Numerous actors influence the progress toward UHC. These actors are institutions,
groups, and individuals, within and outside government, locally, nationally, and interna
tionally. Their choices are shaped by multiple considerations, which include economic
and political circumstances and the actors'economic and political interests52’54 as well
as their ideals.55,56 Central among these ideals are those related to fair and equitable
distribution of benefits and burdens in society. This report addresses issues of fairness
and equity arising on the path to UHC. For all actors affecting that path, it is crucial to
be keenly aware of these issues and to make the accompanying decisions with care.
Central among these actors are obviously health workers. This report, however, mainly
addresses the choice situations relevant for governments in charge of overseeing and
guiding the progress toward UHC. In particular, the report can be useful for policy
makers and technical advisors in ministries of health.
7
The critical role of
fairness and equity
Fairness and equity
Fairness and equity are crucial values for public policy, and they are powerful ideas
in public, political, and legal debates.5,8,57 Fairness and equity also have a focal role in
the context of universal health coverage (UHC).31,32,40,58,59 Not only can they motivate
the goal of UHC; they bear on the critical choices on the path to that goal. When UHC
cannot be realized immediately, making progress fairly and equitably becomes imper
ative. More specifically, when countries expand priority services, include more people,
and reduce out-of-pocket payments, they must seek to do so fairly and equitably.
Fairness and equity are fundamentally concerned with the distribution of benefits and
burdens in society. There is no consensus on the precise boundaries of the concepts
of fairness and equity or on their precise content. In this report, we use the two terms
interchangeably. At the same time, a useful distinction between horizontal and vertical
equity can be made. Horizontal equity requires equal treatment of relevantly similar
cases, while vertical equity requires appropriately unequal treatment of dissimilar
cases.'These standards can be applied to the distribution of health benefits and health
service coverage and to the distribution of burdens, including financial contributions
to the health system.
Beyond these general concerns, there may be widespread agreement on more specific
issues. For example, many people find it unfair if some parts of the population do not
have affordable access to even highly cost-effective services targeting very severe
conditions, while other parts of the population are covered for very costly services that
provide only limited benefits. Examples in the former category of services are antibiotics
for pneumonia, skilled birth attendance, malaria treatment, and secondary prevention
of stroke and myocardial infarction. An example in the latter category of services may be
costly, experimental chemotherapy without proven benefits.
Benefit maximization
Alongside fairness, another cardinal objective of public policy is benefit maximization,
that is, the maximization of total benefits across all people in society." With respect to
'
Horizontal and vertical equity have been discussed extensively in the context of health care as well as in many other
settings.6062 The precise definitions used vary and sometimes depart from those used here.
11 This is sometimes framed in terms of efficiency. Strictly speaking, however, efficiency can be defined with
reference to any objective, including fairness and equity objectives.
8
2 The critical role of fairness and equity
health, the relevant benefits can include, for example, additional life years or improve
ments in health-related quality of life. Although fairness is directly concerned with
the distribution of benefits across people, the goal of benefit maximization is directly
concerned only with the total sum of benefits. This goal often motivates a concern for
cost-effectiveness, that is, a concern for the relation between the benefits generated
and the resources used.
In many cases, the demands of fairness and benefit maximization go together. Among
alternative policies, it is not uncommon that the policy which is most fair—under
the relevant interpretation—also generates the greatest sum of benefits.21,63,64 For
example, WHO's "best buys"for maternal, neonatal, and child health services are likely
to benefit those with the worst health and the poorest access to health care and, at the
same time, maximize the sum of health benefits (compared to many other services).65
Similarly, services targeting the poorest and most marginalized parts of the population
can maximize health compared to those services that do not.66 Obviously, it is crucial
that countries manage to identify policies that are optimal both from the perspectives
of fairness and benefit maximization when such policies exist.To do so, countries must
pay close attention to evidence about total benefits as well as their distribution.
In other cases, the policy considered the most fair is not the one that maximizes
benefits.64,67'73 For example, treatmentfor hypertension may be more cost-effective than
pneumococcal vaccine, while the vaccine targets conditions with a larger individual
disease burden.74 Similarly, fairness may recommend that coverage is extended first
to a rural population that has lesser coverage, has worse health, and is poorer than an
urban population.75,76 At the same time, the rural population may be more costly to
reach with a given set of services, the services may be less effective in that population,
or both.63 The objective of benefit maximization may therefore give priority to the
urban population. In situations where the two objectives diverge in what policies they
recommend, it is, again, crucial that countries assess alternative policies with respect
to both objectives. Only then can the objectives be carefully balanced and the best
policy overall be identified. Such balancing acts are further addressed in subsequent
chapters.
Guiding considerations
The objectives outlined above can motivate three more concrete guiding considera
tions for choices on the path to UHC:
• Fair distribution: Coverage and use of services should be based on need and
priority should be given to the policies benefiting the worse off groups;
• Cost-effectiveness: Priority should be given to the most cost-effective policies;
• Fair contribution: Contributions to the health system should be based on ability
to pay and not need.
These considerations are not absolute and must be balanced against each other as
well as against other concerns.
9
Making fair choices on the path to universal health coverage
Fair distribution
There are many reasons why coverage and use of services should be based on need."1
Several central reasons were described in chapter 1 and are related to the importance
of health and health services to individuals and society, the right to health, and the
collective responsibility for affordable access. In particular, no one should be denied
coverage for high-priority services simply because he or she is poor and unable to pay.
More specifically, a fair expansion of coverage gives priority to policies benefiting the
worse off. Individuals or groups can be badly off in different ways, and the many motiva
tions for priority to the worse off partly refer to different aspects of their condition.77*78
First, one may be concerned with the worse off in terms of health, socioeconomic
status, or overall well-being. One motivation can be that the worse off so defined are
at a lower absolute level and typically have a greater need for the benefits that comes
with improved coverage.79*80 Another, related motivation can be the promotion of
equality, including equality of opportunity.5*60*81'84 Moreover, priority to the worse off
can be motivated by the right to health.85 In any case when considering the worse off
in terms of health or well-being, there are good reasons to focus not merely on those
currently worse off, but rather on the people who are expected to be worse off over
their lifetime.81*86 This will be further discussed in subsequent chapters.
Second, one may be concerned about the worse off in terms of service coverage.
Their coverage may be limited for all kinds of reasons, including limited availability
of services, barriers to access to available services, and limited financial protection.
Special attention to people with the least coverage can be motivated in many ways.
For example, those with the least coverage are typically those in the greatest need of
an improvement. Moreover, priority to people with the least coverage can promote
equality in coverage and bring as many people as possible above a certain level of
coverage. Partly through these effects, special attention to people with the least
coverage can also be seen as mandated by the right to health.
Alternatively, one may be more directly concerned with the distribution of coverage
than specifically the worse off. For example, certain distributions better express equal
respect and equal human dignity than other distributions.87 In addition, certain distri
butions of coverage can be motivated by their effects on the distribution of outcomes
in terms of health or overall well-being.5 For example, special attention to people with
the least coverage may promote equality in these outcomes,5 and priority to people
with the least coverage can in many circumstances also maximize total benefits.63*66
Cost-effectiveness
A fair and optimal expansion of coverage gives priority to cost-effective policies and
services. These are the policies and services that generate large total benefits relative
to cost. Many national and international guidelines emphasize cost-effectiveness.19*88
Priority to cost-effective policies is typically motivated by the goal to maximize health
benefits, that is, to obtain as much benefit as possible from the available resources.89'92
111 These reasons will often tell against a "contribution principle," according to which people who contribute the
most to the system should have priority in the distribution of benefits.
10
2 The critical role of fairness and equity
However, special attention to cost-effective policies and services can to some extent
also be motivated by fairness?
Fair contribution
A fair expansion of coverage promotes the separation of use of services from payment
for services. This is especially important for high-priority services. Use and payment of
services can be decoupled by letting need guide the use of services while ability to
pay primarily determines the required payments.4*35 Optimal separation of coverage
and contribution requires a system that relies on mandatory prepayment and pooling
of funds, as described in chapter 5.
The three guiding considerations can help identify critical issues of distribution on
the path to UHC. The guiding considerations also provide direction for how these
issues can be addressed and for fair progressive realization of UHC. However, the three
considerations must always be balanced against each other as well as against other
relevant concerns.
iv Differences in cost-effectiveness can be one among several differences that are relevant for fairness. However,
the policy motivated exclusively by cost-effectiveness considerations can conflict with the policy recommended
by the overall fairness judgment.
11
Expanding priority services
Universal health coverage (UHC) goes beyond a minimum package of health services
and requires progressive expansion of a comprehensive range of key services. At each
point on the path toward UHC, it is important to ensure an appropriate mix of services.To
do so, countries must carefully set priorities and choose which services to expand next.
Whenever service coverage is expanded, priorities must be set among alternative
services. When additional resources become available, countries are faced with a
critical choice: Which services to expand first? Although no country starts from zero,
and there is no single path to UHC that every country must follow, choices of this type
continuously arise for all countries on the path to UHC. In fact every country continu
ously ranks alternative services, implicitly or explicitly. When choosing which services
to expand first, it can be useful to sort services into at least three different classes: highpriority, medium-priority, and low-priority services. Such a simple scheme is illustrated
by figure 3.1.
Broad classes like these can simplify the decision-making process. However, it must
be acknowledged that the boundaries between classes will not always be straight
forward and that there will be significant differences in importance also between
services within each class.
r?
For countries without universal coverage
for all high-priority services, expanding
coverage for these services should be the
first priority. Coverage for low- or medium
priority services should generally not be
expanded before there is near universal
coverage for high-priority services. Similarly,
universal coverage for low-priority services
should generally not be sought before
coverage for medium-priority services is
Ln
fully expanded.
Figure 3.1 Simple classification of services
Highi 1priority
II’
I
I
____
Medium priority
Ln
co
i
Low priority
The ranking and classification of services
should be based on clear and reasonable
selection criteria. Some criteria have a
strong general rationale and are likely to be
12
3 Expanding priority services
found relevant across a wide range of contexts. At the same time, the criteria must be
sensitive to relevant local circumstances and be integrated with public accountability
and participation mechanisms such as those described in chapter 7.
The scope of service selection
When selecting services, a broad range of services must be considered. Attention
must certainly go beyond treatment and curative services to also include prevention,
promotion, rehabilitation, and palliative care. Services for prevention and promotion
must further go beyond personal services to include various population-based inter
ventions.3,4 When different types of services are funded from different budgets, mecha
nisms must be in place to ensure optimal allocation of resources across budgets.
Irrespective of the type of services, UHC requires due consideration of all the most
important causes of morbidity and mortality.This means not only that countries must
firmly address communicable disease and the unfinished agenda of the Millennium
Development Goals (MGDs). UHC also requires services to mount an effective response
to noncommunicable diseases (NCDs)—including mental disorders—and injuries.
If the response to these conditions is concentrated on the most important services,
substantial progress can be made without losing sight of the persisting burden of
communicable disease.93
Explicit service selection must not be misinterpreted as being wedded to vertical
or disease-specific programs. To the contrary, explicit service selection can facilitate
health system strengthening around a comprehensive and well-integrated set of
key services. Moreover, the criteria for selecting services are relevant not only for the
expansion of services when new resources become available. The same criteria can
also inform the displacement of existing, less important services by more important
services within a fixed budget. In addition, similar criteria can be useful for countries
that want to devise an explicit list of included and excluded services. Many countries
explicitly focus on a set of services that targets the entire population or the part that is
likely to have the least coverage.94'96 Irrespective of whether such a list is used, there are
good reasons—including those related to democratic accountability, social learning,
and the prevention of corruption—for any health system to be as explicit as possible
about what services are included and excluded and about what criteria guide service
selection.97
Service selection criteria
There is a range of candidate criteria for selecting priority services and the optimal
mix of services. Several different, yet often overlapping criteria have been set forth in
national guidelines for priority setting. Countries with particularly explicit criteria include
Denmark, the Netherlands, New Zealand, Norway, Sweden, and the United Kingdom
(UK),88 while many other countries lack explicit criteria.94 Common for all of the proposed
criteria is that they can be seen as primarily derived from two pairs of health system
objectives: to improve population health and access to services and to distribute health
and health services fairly. Several sets of relevant or potentially relevant criteria have
also been proposed in the academic literature,70'98'100 and several international initiatives
have been concerned with criteria for service selection.19 One criterion often empha
sized is the cost-effectiveness criterion.
13
Making fair choices on the path to universal health coverage
Priority to cost-effective services
One primary objective of health systems is to improve the health of the population.
The cost-effectiveness criterion is about improving health as much as possible, and
cost-effectiveness as a central guiding consideration was described in chapter 2. In
the context of health systems, it is standard to define the effectiveness of a service in
terms of the total health improvement in the population. However, because different
services may require vastly different resources to be implemented, effectiveness on its
own is not a sensible way to select services. It is better to consider cost-effectiveness,
where benefits are normalized by their costs. Prioritizing services in order of their cost
effectiveness is usually the way to provide the largest possible sum of health benefits
for a given budget. A more efficient system can meet more health needs per dollar
spent, and this is of ethical concern and not simply an economic notion. Accordingly,
an emphasis on cost-effectiveness needs not be motivated by overall cost savings—an
this emphasis needs not even imply cost reduction—and can be solely motivated by
the goal of improving population health.
To use a cost-effectiveness criterion, a measure of health benefits is needed? A
common measure is the number of lives saved. However, one can never really save
someone's life because an individual will always die at some later point. What matters
is how much the individual's life can be extended. A better measure is therefore the
number of life years saved. This still has the problem that it doesn't take into account
the quality of these years at all, and it doesn't take into account services that improve
life without extending it. Many health economists and ethicists therefore support a
method of counting life years weighted by the quality of those years. For example, if
a service provides an extra year of life at full health, the service is said to produce the
same number of healthy life years as a service that improves two years of life from half
quality to full quality. Healthy life years saved as a measure of effectiveness is closely
related to two other commonly used measures: quality-adjusted life years (QALYs)
saved and disability-adjusted life years (DALYs) averted.101'102
Healthy life years is not a perfect measure of health benefits, but it can nevertheless be
very useful in comparing all types of health services. Moreover, the difference between
health services are often so great that even an imperfect measure is highly valuable.103'
104This is illustrated by the WHO-CHOICE data in figure 3.2, which includes a selection
of services targeting high-burden conditions. As is shown in that figure, according to
WHO estimates, some interventions are extremely cost-effective. Fortification of foods
with vitamin A and zinc can avert the loss of almost 60 healthy life years per $1,000
spent. If the same amount were spent on dialysis (not shown in the graph as dialysis
has not yet been included in WHO-CHOICE analysis), it would save just 0.02 healthy
life years—losing 99.97 percent of the total health benefit that could have been
produced.105Taking cost-effectiveness into account is thus extremely important. Other
services listed in figure 3.2 are also highly cost-effective, such as testing and treatment
for tuberculosis, prevention and treatment of malaria, and primary prevention (for
very-high-risk individuals) and treatment of myocardial infarction and stroke. Data on
cost-effectiveness are now becoming increasingly available, for example, through the
WHO-CHOICE project, the Disease Control Priorities (DCP) project, and initiatives in
1
Sometimes, one would like to go beyond health benefits. The resulting type of analysis may be called extended
cost-effectiveness analysis (ECEA) or, when the benefits are monetized, cost-benefit analysis (CBA).
14
3 Expanding priority services
high-income countries such as the National Institute for Health and Care Excellence
(NICE) in the United Kingdom (UK).103,104,106
Figure 3.2 Cost-effectiveness of services targeting high-burden conditions
Cost-effectiveness (healthy life years saved per $1,000)
5.0
60.0
Children under five: Vlt A & zinc fortification
Tuberculosis:Testing and treament
Malaria: Prevention and treatment
Medical treatment of stroke and heart atttack + primary
prevention (>35% absolute risk)
Normal and complicated birth + community newborn
care package + pneumonia treatment
ORT, case management of pneumonia, measles vacci
nation, vit a and zinc suppl.
HIV: Prevention and treatment of HIV including PMTC
Seatbelts, motorcycle helmets, speed cameras,
breath-testing
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polypse,
treatment
Estimates from WHO-CHOICE. $: International US dollars for year 2005. Observe that the x-axis is compressed.
Many national and international initiatives have suggested that health services
should be prioritized primarily based on cost-effectiveness. Among the international
initiatives are the 2001 Commission on Macroeconomics and Health19 and the 2009
Taskforce on Innovative International Financing for Health Systems.107 Many econo
mists and ethicists also support emphasizing cost-effectiveness and find it unethical
to ignore opportunity costs and the size of health benefits.89,91,108 If a health system
covers services that are not cost-effective while people are dying from diseases that
can be treated cheaply and effectively, that will in most circumstances be unfair.
In practice, generating and using cost-effectiveness data can be challenging. However,
as noted, such data are increasingly available,103*104 and several practical guidelines and
tools now exist.92,103 Moreover, even an imperfect application of the cost-effectiveness
criterion—combined with other relevant criteria—is likely to be better than ignoring
cost-effectiveness entirely, as suggested by the huge variation in cost-effectiveness
across services.
Priority to services benefiting the worse off
An exclusive focus on cost-effectiveness is generally found indefensible. Standard cost
effectiveness analysis is concerned solely with the total number of healthy life years.
This analysis thus counts every additional healthy life year as equally important, no
matter whether the additional benefit would accrue to a person with very bad health
or to someone with only a small reduction in health. Fairness, however, suggests that
15
Making fair choices on the path to universal health coverage
providing a health improvement of a fixed size to someone who (without it) would
have less health takes priority over providing that health improvement to someone
who would have more health. In other words, fairness recommends priority to services
benefiting the worse off.
Surveys suggest that the judgment that the worse off should receive some priority
is broadly shared across societies.109’112 Priority to the worse off—as one among
other criteria—also has a firm grounding in the theory of fair distribution.5-71'79'81'113
As for policy, priority to the worse off—often with reference to "need," "severity," or
"urgency"—has also figured centrally in many national guidelines on priority setting,
including those in the Netherlands, Norway, and Sweden.88'114
Although it is not only health that matters, the worse off in terms of health are
generally central to health policy. The worse off in terms of health are also a natural
starting point as available data allow for a reasonably precise characterization of the
worse off in that respect. When focusing on health, however, it is important to focus
not only on those that currently have the worst health. Indeed, there are good reasons
to start with those worse off over their lifetime. There is both empirical and theoretical
support for why one should focus on those worse off thus understood, rather than
those worse off here and now or the worse off only prospectively.81'86,111'112 Consider,
for example, the following two services. One service somewhat improves the sight of
an adult who lost his or her sight at a young age. Another service cures the moderate
mobility impairment of a different adult, who otherwise has good health for a normal
lifespan. Suppose the services are equally costly and yield the same health gain but
that the blind adult has lower lifetime health without the service than the person with
the moderate mobility impairment. Other things being equal, it seems unfair if the
service for the blind adult was not accessible at an affordable cost before the service
for the mobility-impaired adult.
To aid service selection, a measure of the lifetime worse off can be useful. One possi
bility is to specify the worse off as those with the largest individual burden of disease.
More specifically, the worse off can be defined as those with the largest individual
lifetime disease burden without the health service in question. In contrast to the
national burden of disease, individual disease burden is not aggregated across people
and can therefore provide direct information about the burden placed on individuals.
There are several possible ways to calculate individual burden of disease, and one is
described in box 3.1 .The figure in that box also indicates the individual disease burden
for a range of conditions.
16
3 Expanding priority services
Box 3.1 Calculation of individual burden of disease
The individual burden of disease can be estimated in several ways. In the following figure, the
estimation is simplified by considering only life years lost, not healthy life years lost. Mortality
data for Eastern sub-Saharan Africa from the Global Burden of Disease 2010 Study are used.101
The total number of years of life lost due to a certain disease in the region is divided by the
number of deaths from that disease. Years of life lost thus represent the average years of life
lost for those for which the condition is fatal. Accordingly, age of death drives the estimation
of individual disease burden. The estimation of years of life lost in the Global Burden of Disease
2010 Study is based on a reference life table with life expectancy at birth of 86 years. For country
analyses, national life tables could be used.
Ranking of conditions according to individual disease burden
Individual disease burden
Years of life lost
o
20
40
60
80
100
Preterm birth complications
Congenital heart anomalies
Malaria
Obstructed labor
Road traffic injuries
Endocarditis
Leukemia
Tuberculosis
Appendicitis
Asthma
Diabetes mellitus
Ischemic stroke
All the conditions shown in the figure are associated with a large individual disease burden.
Many conditions associated with a much smaller burden are not shown.
As is evident from box 3.1, the individual disease burden associated with different
conditions varies substantially. Individuals about to die from a condition associated
with a very large individual disease burden, such as congenital heart anomalies and
malaria, are generally worse off (in terms of the number of healthy life years enjoyed
during their lives) than individuals about to die from conditions associated with a
smaller individual disease burden, such as ischemic stroke. Similarly, individuals about
to die from ischemic stroke are generally worse off than people with conditions that
are associated with a smaller burden. Priority to services benefiting the worse off thus
characterized captures a widely held idea of fairness, as described. According to this
idea, a healthy life year benefiting someone who otherwise would have few such years
over his or her lifetime has more weight than a healthy life year benefiting someone
who would have many. How much weight remains to be decided in each country,
17
Making fair choices on the path to universal health coverage
and some qualify the general rule by exempting very young children.99'115 In any case,
average estimates for conditions—including the estimates for individual burden of
disease in box 3.1—are primarily relevant at the health program level, as opposed to
the individual level.
As noted, considering the worse off in terms of aspects other than health can also
be relevant. In particular, health systems could consider special priority to services
targeting conditions that disproportionally affect the poor. This is indeed the central
component of one of two "progressive pathways" proposed by the Lancet Commission
on Investing in Health.21 A criterion giving priority to services benefiting the worse off—
broadly understood—can accommodate such an approach. An alternative strategy is
to select services primarily based on health-focused criteria and then give the poor
priority when expanding coverage for these services. Elements of the two strategies
can be combined, and the question of whom to give priority when expanding coverage
is further discussed in chapter 4.
Priority to services whose coverage offers substantial financial risk protection
Financial risk protection is a key rationale for pursuing UHC. As discussed in chapter 5,
large out-of-pocket payments for health services can cause severe financial strain on a
patientandhisorherfamily,and in numerouscountries,the proportion of health service
costs paid out-of-pocket is very high. General reduction in out-of-pocket payments is
therefore critical for progress toward UHC. However, financial risk protection can also
be relevant for the selection of services. Accordingly, one may apply a criterion that
suggests that a service should have priority to the extent that coverage of the service
offers substantial financial risk protection."
Expanding coverage for a given service can provide financial risk protection directly
as well as indirectly. In the former case, coverage provides protection against financial
burdens linked to payment for the service in question. In the latter case, coverage
provides protection against the wider financial burdens that go beyond the service
in question. These burdens include loss of earnings due to an inability to work and
medical expenses for other services in the future.
Several factors increase the amount of direct protection associated with coverage of
a particular service. These factors include high cost and out-of-pocket payments, low
predictability of need, pronounced urgency and severity of the target condition, and
high incidence of the target condition among the poor.62'116’118
Against this background, it is clear that cost may have a complex role in service selection.
Coverage of a high-cost service can in many cases reduce direct financial hardship
more than coverage of a low-cost service. At the same time, high cost will, other things
being equal, imply a higher cost-effectiveness ratio with respect to health benefits.
Accordingly, there may be a conflict between cost-effectiveness and direct financial
risk protection. However, it need not be that way. Especially in resource-poor settings,
11
Economic modeling has shown that if no one buys complementary services beyond a mandatory package of
services or if well-functioning complementary insurance exists, then service selection based on standard cost
effectiveness ratios would tend to maximize expected welfare.116 In low- and middle-income countries, however,
there are substantial out-of-pocket payments for complementary services and no well-functioning insurance of
that kind. In such situations, financial risk protection may become more relevant to the selection of services.
18
3 Expanding priority services
even out-of-pocket payments related to low-cost services may be a significant cause
of financial hardship and financial catastrophe. In such settings, expanding coverage
for low-cost services may actually also be the most efficient way of purchasing direct
financial risk protection.21
It has been suggested that for two services with identical cost-effectiveness ratios, the
most costly service should typically be covered first, because this approach offers a
greater degree of direct financial risk protection.116,117 However, this has to be balanced
against the aggregate financial risk protection that could come with coverage of a
larger number of less costly services. Moreover, when cost-effectiveness ratios differ,
the direct financial benefits must be carefully balanced against the health benefits.
In box 3.2, some possible trade-offs of this kind and how these can be addressed
are described. The analysis in the box also includes a form of indirect financial risk
protection, namely, protection from large out-of-pocket payments for certain services
in the future due to reduced risk of need for these services.
Box 3.2 Trade-offs between health benefits and financial benefits
The figure below shows the results of an analysis of nine services. The figure indicates how
much of each type of benefit that would be produced if we spent $100,000 on each listed
service. A service yields greater health benefit the further to the right it is and more financial
protection the further toward the top it is. The findings demonstrate how the aim of averting
deaths and the aim of averting poverty can conflict."1 For example, the meningococcal (MCV)
vaccine averts more than 300 deaths per $100,000 spent but averts few poverty cases. In
contrast, high blood pressure treatment averts fewer deaths but many more cases of poverty.
Health & financial risk protection benefits afforded, per $ 100,000 spent
o
oi
• RV vaccine
• PCV vaccine
• MCV vaccine
Diarrhea treatment
Pneumonia treatment
• Malaria treatment
•» C-sectlon
a TB treatment
High blood pressure treatment
o
2
s
TO
<u
TO
£o
o
o
o
vg
jD
E
5-
o
0
-i—*--------t—*-------- H—
100
200
300
400
Number of deaths averted
Figure adapted from Jamison et al. 2013?' Indifference curves added.
19
Making fair choices on the path to universal health coverage
Decision makers may disagree on exactly Row to trade off lives saved against cases of poverty
averted, but one can imagine drawing diagonal contour lines in the diagram that connect
points that are equally good overall (known as "indifference curves" in economics). For a given
individual, it is plausibly worse to die than to become impoverished, and this suggests that the
contour lines should be at least as steep as those shown in the figure.
As indicated, even though financial risk protection is very important, one must be
careful not to give too much weight to direct financial risk protection when selecting
services. This is mainly because this approach may involve large sacrifices in terms of
health benefits. This is unfortunate due to the intrinsic value of health benefits, but it
can also be unfortunate from the perspective of financial risk protection. One reason
is that the health benefits may reduce the risk for certain health expenditures in the
future, as discussed. In addition, health benefits may provide financial risk protection
through improved productivity and income-earning potential.19-21
Against this background, some services are so costly that they should probably not be
included among high-priority services in resource-poor settings.To illustrate, consider
some very costly treatments with marginal health benefits for patients with certain
types of advanced cancer.119’123 Even if coverage for these services may offer significant
direct financial risk protection for the patient and his or her family, the resources spent
could—in some contexts—instead save 100 to 300 times as many years of healthy life
if spent on treatment for pneumonia or on tuberculosis control. As described, these
health benefits can also offer considerable financial risk protection at a later date.
Therefore, when selecting services, all these conflicting concerns must be carefully
balanced. Tools are currently being developed to assist in such balancing tasks.124-125
Irrespective of the role that financial risk protection may have in service selection,
financial risk protection has a crucial role in motivating the very goal of UHC and the
general shift from out-of-pocket payment to mandatory prepayment. The latter role
and this general shift are further discussed in chapter 5.
Additional criteria
Several other criteria for priority setting may be relevant." Many of these overlap with
the criteria already outlined and some can even be integral to those criteria. Quality
of services, for example, is a key concern in the pursuit of UHC and may not be fully
captured in cost-effectiveness estimates. To that extent, an additional criterion related
to quality may be needed. Likewise, a criterion related to strength of evidence may be
needed if that concern is not sufficiently taken into account by the other criteria.
Building on a consensus statement developed by a group of ethicists and econo
mists, at least ten priority-setting criteria could be considered in conjunction with cost
effectiveness.108 Several of these criteria are concerned with fairness and equity and
overlap with the criteria outlined or with concerns addressed in subsequent chapters.
The criteria may or may not be relevant for specific decisions about services. Moreover,
the actual use of some of the criteria is controversial, and most ethicists would contest
some of them. The proposed additional criteria fall into three categories: (a) disease
and service criteria, (b) criteria related to characteristics of social groups, and (c) criteria
1,1 The study did not report healthy life years averted, only deaths averted.
20
3 Expanding priority services
related to protection against the financial and social effects of ill health and costly
treatment. The specific criteria are listed in box 3.3.
Box 3.3 Additional criteria that may or may not be relevant
Disease and service criteria: Criteria related to_______________________________________
• severity of disease (present and future health gap);
• realization of potential;
• past health loss.
Criteria related to characteristics of social groups: Criteria related to
• socioeconomic status;
• area of living;
• gender;
• race, ethnicity, religion, and sexual orientation.
Criteria related to protection against the financial and social effects of ill health and costly
treatment. Criteria related to____________________________ _________________________
• economic productivity;______________________________________________________
• care for others;_____________________________________________________________
• catastrophic health expenditures.
Based on Norheim et al. 2014'08
It is also important to keep in mind that some concerns are not easily quantified
or included in standard frameworks. Concerns of this type include those related to
domestic violence against women, palliative and terminal care, social care, infertility,
and abortion.
Combining criteria
Overall, at least three criteria should be considered in service selection.These criteria are
those related to cost-effectiveness, priority to the worse off, and financial risk protection.
Decision makers can use different strategies when addressing a set of criteria. Since
improving health is a primary purpose of the alternative health system, one useful
strategy is to start with cost-effectiveness data to roughly sort services into priority
classes and then make adjustments based on additional criteria. Figure 3.3 illustrates
one schematic way in which this can be done. In that figure, the cost of a healthy life
year is described in fractions or multiples of gross domestic product (GDP) per capita.
While the thresholds linked to different priority classes plausibly vary somewhat with
GDP per capita, this is not to suggest that there is one fixed share of GDP relevant for
all countries. More importantly, the exact cut-offs between classes in the figure are just
for illustration and need to be determined by each country.'7
iv
The relevance of context is even more evident when cost-effectiveness thresholds are meant to apply
more directly to the decision about whether a service should be covered or not.126,127
21
Making fair choices on the path to universal health coverage
Figure 3.3 Framework for integrating cost-effectiveness with other criteria when
selecting services
<■
■>
I
T
T
T
T
T
T
T
0
i
2
3
4
5
6
7
■>
Cost per healthy life year as a multiple of GDP per capita
To determine which services to expand next within this framework, a country first
generates a list of services being considered. Each service can then be put on this scale
according to regional or national cost-effectiveness estimates. Services associated with
only one color are immediately placed in the relevant priority class. Each service located
in the overlapping intervals needs further assessment against other relevant criteria,
for example, those related to priority to the worse off and financial risk protection. If
the service clearly fares well against the additional criteria, it should be placed in the
higher priority class in question. If the service clearly fares badly against those criteria,
it should be placed in the lower priority class in question. The exact location of a service
within overlapping intervals should also be taken into account. The closer to the costeffective end of that region, the less an additional reason is needed. Box 3.4 provides a
practical example of how the framework presented here can be used.
Box 3.4 Application of framework to hypothetical cases in Kenya
The practical use of the framework can be illustrated by applying it to hypothetical cases in
Kenya. Using regional cost-effectiveness data and national income data, four services (A, B, C,
D) have been placed on the scale.*
A
C
B
D
>
*
0
T
1
I
I
I
r
T
i
2
3
4
5
6
7
■>
Cost per healthy life year as a multiple of GDP per capita
If the cut-off values along the scale were to be the relevant ones, the decision maker could
reason as follows:
A: Tuberculosis diagnosis and treatment
Costing less than 10 percent of GDP per capita per healthy life year, this is clearly in the green
category and thus a high-priority service.
B: Traffic safety regulation
At a cost of 80 percent of GDP per capita per healthy life year, this falls in the region where
green and yellow overlap, requiring further assessment against additional criteria. Priority to
the worse off is especially relevant here as traffic accidents often cut down people in their
youth (see box 3.1). We would therefore expect the service to be placed in the high-priority
category.
24
Including more people
The goal of universal health coverage (UHC) gives clear direction for the scope of
coverage: it should be universal. Countries must seek to reduce all barriers to coverage,
for everyone. When coverage cannot be fully extended to everyone immediately,
countries are faced with a critical choice: Whom to include first?
The challenge of coverage gaps
Coverage for specific services varies substantially across services and across countries.
This can be illustrated by coverage indicators that measure how many individuals receive
a health service if they need it.' With coverage thus understood, there are numerous
examples of coverage falling far short of universality, even for high-priority services. For
example, in Ethiopia, the proportion of children under five years with diarrhea who
receive at least oral rehydration therapy or advice about increased fluids is about 30
percent, the proportion of children under five years with suspected pneumonia who
are taken to an appropriate care provider is below 10 percent, and the proportion of
live births attended by skilled health personnel is 10 percent.130 Coverage rates for two
key services in five countries are illustrated in figure 4.1.
Figure 4.1 Coverage rates for two key services in five countries" III
Vaccines
Skilled birth attendance
I
100
w
100
80
80
I 60
£
40
|
|
M H| M
60
#
40
I
<uo>
S
20
20
I
Colombia Ethiopia
India
-—-—0
Rwanda Vietnam
Colombia Ethiopia
India
Rwanda Vietnam
1
Such measures are useful even though they do not fully capture the extent to which services are affordable.
These indicators, often also called utilization rates, do not distinguish between people who have access without
significant out-of-pocket expenditures and people who have access despite facing such expenditures.129
"
Skilled birth attendance coverage is defined as the proportion of women reporting being assisted by a health
professional during delivery. Vaccination coverage is defined as the proportion of children aged 12 to 23 months
who at the time of the survey had received the following vaccines: three doses of diphtheria-tetanus-pertussis
(DTP), three doses of polio, BCG, and measles.
1,1 Data on Colombia, India, Rwanda, and Vietnam are from the World Bank,131 while data on Ethiopia are from the
Ethiopia Demographic and Health Survey (EDHS) 2011 .,3°
25
Making fair choices on the path to universal health coverage
In addition to the general level of coverage, distribution is important. It is well
documented that different groups in society have unequal probabilities of receiving a
given health service if they need it.132 More specifically, this tends to be the case with
groups categorized according to socioeconomic status (income, wealth, occupation,
education), gender, area of living, and health status and sometimes ethnicity, race,
religion, and sexual orientation.
Regarding socioeconomic status, skilled birth attendance in Ethiopia provides one
clear example of a social gradient. In the lowest wealth quintile, 1.7 percent of all births
are attended by a skilled provider, as opposed to 45.6 percent in the highest wealth
quintile.130This inequality is an example of horizontal inequity, which was discussed in
chapter 2. Inequalities in coverage rates, across wealth quintiles, for two key services
in Ethiopia, India, and Colombia are shown in figure 4.2. From the figure, we see that
Ethiopia and Colombia generally have the most and the least pronounced inequal
ities, respectively. Social gradients in effective health care and health outcomes are
also found in the context of noncommunicable diseases.133
Figure 4.2 Socioeconomic inequalities in coverage rates in three countries17
Colombia-Vaccines
-
Ethiopia-Vaccines
-- ------- 1 ■§■
India-Vaccines
§’
mu ...■I .■III
Hill _ _. I ill
8-
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J S-
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J
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Colombia - Skilled birth attendance
Ethiopia - Skilled birth attendance
J
QulnUk.
4
J
j
j
j—
India - Skilled birth attendance
§■
§■
88R-
88R-
u
RR-
J
j
Qu.ntlWt
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&
i
—r
T“
QulntllM
RR2-
3
5
QUnUlei
I
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__T
y
—J
J
J
Quintile.
In many countries, there are also marked geographic variations, across regions and
between urban and rural settings. Inequalities in coverage rates for skilled birth
attendance across the urban-rural divide in Colombia, Ethiopia, and India are shown
in figure 4.3. Again, skilled birth attendance in Ethiopia provides one clear example of
geographic inequality. In the urban population, 50.8 percent of all births are attended
by a skilled provider, while in the rural population, the proportion is 4.0 percent.130
Another challenging inequality is that between genders. Data on coverage across
the gender divide in low- and middle-income countries are scarce. However, figure
4.4 shows gender inequality in under-five mortality in Colombia, Ethiopia, and the
rural and urban populations in India. Although inequalities in health outcomes partly
depend on factors other than coverage, countries must also be sensitive to such
inequalities when expanding coverage.
iv
Data on India and Colombia are from the World Bank,’31 while data on Ethiopia are from the Ethiopia Demographic
and Health Survey (EDHS) 2011 J30
26
4 Including more people
Figure 4.3 Geographic inequalities in coverage rates for skilled birth attendance in
three countries7
Skilled birth attendance
100
80
60
40
£
I
20
Colombia
Ethiopia
India
Figure 4.4 Gender inequalities in under-five mortality in three countries7'
Under-five mortality - by gender
BH Girls
H9I Boys
150
100 |
I8.
50 =1
I
Colombia
Ethiopia
-,-,1—IMu'.a q
India rural India urban
Most, if not all, of the inequalities outlined represent inequities under most inter
pretations of inequity, as discussed in the preceding chapters. For example, these
inequalities are generally considered unacceptable within a right to health framework,
especially when they result from discriminatory practices.136
In many countries, there are also numerous indications of the "inverse care law,"
according to which "the availability of good medical care tends to vary inversely
with the need of the population served."137 Patterns compatible with this "law" are
commonly found, for example, with respect to the groups already discussed.66 As
described, coverage is often more limited for low-income groups and rural popula
tions than for higher income groups and urban populations, although the need for
services is often greater among these groups, as suggested by, among other things,
well-documented inequalities in mortality and morbidity.40 In particular, in countries at
all levels of income, health and illness follow a social gradient: the lower the socioecov
Data on Colombia, India, Rwanda, and Vietnam are from the World Bank,'3’ while data on Ethiopia are from the
Ethiopia Demographic and Health Survey (EDHS) 2011 J30
vi Mortality ratesarecalculated from theColombia Demographicand Health Survey 2010,,34the Ethiopia Demographic
and Health Survey 201 1 ,'30 and the India Demographic and Health Survey 2005-06.135 While the figures for India are
based on the five years preceding the survey, the other figures are based on a ten-year period.
27
Making fair choices on the path to universal health coverage
nomic position, the worse the health. In most cases, the resulting mismatch between
need and coverage is doubly problematic and incompatible with widely held views on
fairness and equity.138
Whom to include first
It is evident that coverage is far from universal in many countries. If coverage cannot
be extended to everybody immediately, countries that want to move toward univer
sality face a critical choice: Whom to include first? To "include" here means to expand
coverage up to a significant level, and this typically presupposes formal affiliation with
a coverage scheme.
The considerations emphasized in the preceding chapters and the inequalities
described above provide guidance. In chapter 2 and 3, it was suggested that a fair
expansion of coverage involves giving priority to the worse off. As indicated, this is
particularly the case for the worse off in terms of service coverage or health. Accord
ingly, in most circumstances, countries should first reduce barriers to coverage for
groups that are disadvantaged in terms of service coverage or health.
Identifying these groups directly is often difficult. However, as illustrated above, certain
more easily identifiable, social groups tend to have poor service coverage, poor health,
or both. These groups include, for example, low-income groups and rural populations.
A more extensive list of potentially relevant social characteristics is shown in box 4.1.
In addition, health state and prognosis are, of course, associated with many medical
characteristics (including diagnosis and risk factor exposure), something which was
discussed in chapter 3.
28
4 Including more people
Box 4.1 Social characteristics often associated with service coverage or health
There are several social characteristics that is often associated with service coverage, health, or
both:
• Income/wealth
• Education
• Occupation
• Ethnicity/race/indigeneity
• Gender
• Area of living
• Refugee/immigrant status
• Religious and political beliefs
• Sexual orientation
This list builds on a framework of the Commission on Social Determinants of Health, linking
social determinants of health and the distribution of health.40
How a given social characteristic is associated with being worse off can vary with context.
For example, how ethnicity/race and religious and political beliefs are associated with health
coverage and health often depend on the national and local setting. This can also be the case
for urban and rural populations. For other characteristics, however, there is little variation
across contexts. For example, the income group that is worst off in terms of service coverage
and health tends to be the one with the lowest income.
The reasons for being concerned with the social characteristics listed may go beyond their role
as indicators of service coverage or health. For one thing, the characteristics may be non-health
components of well-being or indicators of such components. For example, low-income groups
tend to be worse off than high-income groups not only because the former typically have
worse service coverage and worse health than the latter, but also because low-income groups
can also be seen as worse off simply by having lower income.139 However, there is also another
reason for being concerned with the listed social characteristics in a way that goes beyond their
role as indicators of service coverage and health. For some characteristics, their association
with service coverage or health often indicates problematic social practices and associated
vulnerabilities.140 For example, poor service coverage among women, relative to men, may
suggest discriminatory practices in the finance and delivery of health services.
Overall, when expanding coverage, countries should strive to reduce barriers for low-
income groups, rural populations, and other relevant groups to the extent that they
are disadvantaged in terms of service coverage or health. This is especially important
for high-priority services. At the same time, the various considerations of fairness
must be carefully balanced against the concern for benefit maximization. This was
discussed in chapter 2 and is further discussed below.
The role of targeting
As described, fairness considerations motivate special attention to certain groups
when expanding coverage. These include low-income groups, rural populations, and
other relevant groups to the extent that they are disadvantaged in terms of service
coverage or health. At the fundamental level, these groups should be targeted in the
sense that improvements accruing to them should have some extra weight in policy
formulation.
This may further motivate targeting at the practical level, if it can be done effectively.
Many forms of targeting can be useful instruments for moving toward UHC and are
29
Making fair choices on the path to universal health coverage
not in opposition to the goal of universalism in terms of overall coverage. However,
the appropriate forms of targeting at the practical level is an ongoing debate within
the health sector as well as more broadly,21,141-143 and most frequently discussed in
the context of pro-poor policies. Although countries should, if possible, first reduce
barriers to coverage for relevantly disadvantaged groups, the appropriateness of
such a selective approach depends on the type of targeting and the context in which
targeting is applied.
Practical approaches to targeting can be categorized in multiple ways. The most
promising policies are probably those targeting groups, not individuals. One can
further distinguish between approaches that identify the target group directly and
those that do so indirectly, for instance, by area of living.144 In the latter case, the initial
effort to reduce one or more barriers to coverage can be concentrated in a specific
geographic area. An example of such an approach is described in box 4.2.
Box 4.2 Geographic targeting for universal health coverage in El Salvador
40
1.0-
2009
I”’
t
5
0.9-
— 2009
— 2012
0.8-
20"
0.7-
10--
0.6-
poorest
40-
| ..4
median
richest
i IH
2012
i i 0.325.4
0.2-
I
20-
10-
0.0 40.0
poorest
median
richest
In 2009, the Ministry of Health of El Salvador initiated a health sector reform aimed at progres
sively realizing universal health coverage under an integrated national health system based
on the principles and practice of primary health care. A key component of the reform was
the implementation of family health community teams or, in Spanish, Equipos Comunitarios
de Salud familiar (ECOSf). These teams were to be responsible for providing preventative and
curative health care to a territorial jurisdiction comprised of about 600 families. The estab
lishment of and investment in ECOSf were guided by a prioritization process across the 262
municipalities of the country that emphasized levels of extreme poverty and size of the
vulnerable and disadvantaged population.
An exploratory analysis with data from the departmental level (i.e., a spatial aggregate of
municipalities) showed that, three years after the ECOSf strategy was implemented, a non-trivial
decrease in the magnitude of social inequalities in human resources for health (HRH) had taken
place. The bar charts indicate a positive change in the distribution of HRH across subnational
tertiles of wealth from 2009 to 2012, i.e., after ECOSf and the associated geographic targeting
were introduced. More specifically, the range in HRH per 10,000 population between the
poorest and richest 33 percent of the country's population decreased from -23.2 (i.e., 6.8 minus
29.9) to -9.7 (i.e., 15.7 minus 25.4) during that period.
30
4 Including more people
Inequality in HRH can also be measured in terms of the concentration index. This is illustrated
by the concentration curves. Along the x-axis are the departmental populations ranked from
highest to lowest in terms of prevalence of extreme poverty. The corresponding concentration
index decreased from 0.36 to 0.17 during the three-year period assessed, something which
represents a marked reduction in inequality.
Contributed by Dr. Oscar J. Mujica and Dr. Carla Saenz (PAHO/WHO)145'146
There are, of course, many additional ways to target groups. A quite different form
of group-based, equity-promoting targeting relies on service selection. This form
of targeting typically involves giving priority to services addressing conditions that
disproportionally affect disadvantaged groups.21 Conditions of this type include, for
example, infectious diseases and tobacco-related illnesses. Other forms of groupbased targeting include tailored information through public campaigns and the
removal of legal barriers to coverage.147
As noted, delivery mechanisms that target individuals are also available.144 Widely
discussed among these mechanisms are fee exemption schemes, which can be seen
as a form of targeted subsidy. In certain circumstances, such schemes promote UHC; in
other circumstances, they impede that goal.21*144148(149Therefore, the targeting mecha
nisms must be carefully chosen in each particular case. The broader aim of reducing
out-of-pocket payments is discussed in chapter 5.
The advantages of targeting must also more generally be balanced against its disad
vantages. Targeted approaches may sometimes be less efficient in generating health
benefits, as certain populations can be more costly to reach. Other times, however,
targeting of disadvantaged groups goes hand in hand with cost-effectiveness. This
may be the case, for example, when the prevalence of ill health in the targeted group is
higher or when the potential of simple, highly cost-effective services—such as antibi
otics for pneumonia in children—has yet to be realized in that group.139-150The optimal
degree of targeting also depends on public support and financial sustainability. Histor
ically, the move toward universal coverage mobilized support from the majority of
the population, including the middle class.151 If a large scheme becomes too narrowly
focused on a subpopulation, the scheme may lose general support.This is particularly
relevant when considering whom to include in pooled funding arrangements, where
the funding base may depend directly and indirectly on the inclusion of the non-poor.
Conclusion
Inline with the goal of UHC, countries must seek coverage for everyone. When coverage
cannot be fully extended to everyone immediately, countries should strive to first
reduce barriers for the following groups:
• low-income groups;
• rural populations;
• other relevant groups to the extent that they are disadvantaged in terms of
service coverage or health.
This strategy of reducing inequalities in service coverage is integral to the pursuit of
raising the general level toward universality.
31
Reducing
out-of-pocket payments
Universal health coverage (UHC) is centrally concerned with both access to services
and financial risk protection. Large out-of-pocket payments represent financial
risks and barriers to access.' Progress toward UHC therefore requires reform of the
health financing system and a shift from out-of-pocket payment for services toward
prepayment and pooling of funds. Countries are then faced with a critical choice of
how to make such a shift. This choice involves two central questions: When reducing
out-of-pocket payments, for what services and what subpopulations should these
payments be reduced first? And when increasing prepayment and pooling, what
criteria should determine how much money each person must contribute to the pool
and what benefits each person can receive?
The challenge
An increasing body of evidence shows that most health systems fail to adequately
offer financial risk protection and that out-of-pocket payments are a major cause for
this.1391152'153 One common indicator of financial risk and the bad consequences of such
payments is the percentage of the population who experiences catastrophic out-ofpocket expenditures (based on a threshold share of 40 percent of nonfood household
consumption) per year.153 Figure 5.1 illustrates the problem in five countries by way of
such an indicator.
Figure 5.1 Catastrophic out-of-pocket
expenditures in five countries1
As seen from figure 5.1, a substantial
proportion of the population in all of
these countries experiences catastrophic
out-of-pocket expenditures.
Catastrophic out-of-pocket expenditure
Share of nonfood consumption >40%
Kfc
0
As indicated, a key underlying distinction
is that between out-of-pocket payments
and
prepayments.
Out-of-pocket
payments are understood as payments
for services or supplies made by the
recipient at the time of delivery, and
typically after the need for these services
or supplies has become apparent.
30
Bl
fpt
.1 J
Ethiopia
1
1
40
India
20
■
H
■
8
I
ro
(U
X
10
BM
ml IS
L. o
Mexico South Africa Vietnam
The figure is based on data from the World Bank'3’
Access and barriers to access are more directly addressed in chapter 4.
32
5 Reducing out-of-pocket payments
Relevant services and supplies include consultations, tests, procedures, and medica
tions. Out-of-pocket payments can be made to the providers or to some third party,
for example, in the form of coinsurance or deductibles. Prepayments, in contrast, are
made by the potential recipient of the services or supplies before delivery and typically
before the need for a particular service is evident. Such payments include various taxes
and premiums. Every national health system relies on a mix of out-of-pocket payments,
prepayments, and other sources of revenue, but the ratio between out-of-pocket
payments and prepayments varies considerably.
As suggested by figure 5.1, out-of-pocket payments may expose individuals and house
holds to substantial financial risk, and there are many reasons why countries should
reduce their reliance on such payments. One major reason is that such payments often
impede access to needed services. Faced with out-of-pocket payments, many people
have to delay utilization, seek suboptimal alternatives, or go without any service at
all. Moreover, out-of-pocket payments constitute a barrier to access particularly for
low-income groups, something widely considered unfair given the equal or often
greater need and capacity to benefit from services among low-income groups. For
those who do pay, out-of-pocket payments are often sufficiently large and unexpected
to cause severe financial strain on the patient and his or her family. Such expenditures
can be catastrophic and push people into poverty or those already poor into further
destitution. This is illustrated in figure 5.1, and the effects of out-of-pocket payments
are further illustrated in box 5.1.
Box 5.1 Impact of out-of-pocket payments on impoverishment in Uganda
In Uganda, universal health coverage (UHC) is a stated goal in the national Health Sector
Strategic Plan.154The starting point is difficult, however. Although total expenditure on health
represented 9.5 percent of the GDP in 2011, the absolute amount of total expenditure on
health per capita was only $128 (international dollars for 2011). Of this, government and
private expenditure on health represented 26.3 percent and 73.7 percent, respectively. Of the
private expenditures, 64.8 percent was out-of pocket expenditures.155
The figure shows the impact of out-of-pocket payments on impoverishment in Uganda in 2010.
Impact of direct-out-of-pocket payments - impoverishment
The figure illustrates
how out-of-pocket pay
ments increase poverty in
Uganda not only by push
ing previously non-poor
individuals under the
poverty line of $1.25/day,
but also by increasing the
depth and severity of pov
erty among those already
poor. The figure also indi
0T0
cates how out-of-pocket
0.2
0.4
0.6
0.8
payments—as illustrated
Cumulative proportion of population, ranked from poorest to richest
by "paint drips" from the
Figure adapted from Kwesiga et al.156
level of consumption
prior to out-of-pocket payments—were mainly concentrated among the non-poor. However,
the relatively low share of total out-of-pocket payments among the poor—again illustrated by
the "paint drips"—does not imply that the poor are more protected from incurring such pay
ments. Instead, the relatively low share is most likely the result of the poor not utilizing needed
care because they cannot afford it.
8- ------- pre-OOP consumption
-------
I
i
post-OOP consumption
33
Making fair choices on the path to universal health coverage
Reducing reliance on out-of-pocket payments
Only when out-of-pocket payments fall below 15-20 percent of total health expendi
tures does the incidence of financial catastrophe and impoverishment fall to acceptable
levels.4 Fortunately, the proportion of out-of-pocket payments is amendable to policy
intervention. Recent health financing reforms in several countries have demonstrated
how reduction of out-of-pocket payments can reduce financial risk. Thailand provides
a good example. After a UHC scheme was introduced in 2002, impoverishment due to
out-of-pocket payments fell dramatically, as illustrated in box 5.2.
Box 5.2 Number of households impoverished by out-of-pocket payment for health
services in Thailand (1996-2010)
160
Before UCS
140
142.27
o
c>
120
s
131.27^*,^±
123.97
—
■,
X
120.05
If without UCS
'•■•*** 123.24
112.63
118.11
115.82
116.41
100
-E
80
o
«+-
60
-Q
40
□
E
□
z
After UCS
77.23
69.69
58.76
49.00
39.75
20
_
---------------- 1
1996
i
1998
i
2000
i
2002
■
■
2004
2006
2007
2008
2009
Figure adapted from Thailand's Universal Coverage Scheme: Achievement and Challenges’57
In 2002, Thailand introduced the"UC 30 baht scheme," a tax-funded health insurance scheme
designed to cover the approximately 47 million people who were not beneficiaries of the Civil
Servant Medical Benefit Scheme (CSMBS) or the Social Security Scheme (SSS). As shown by the
figure, the number of households impoverished—defined as being pushed under Thailand's
national poverty line—due to out-of-pocket payments fell from about 120,000 in 2002 to
40,000 in 2009.
Several other countries pursuing UHC have experienced trends similar to that in
Thailand.96 Nonetheless, worldwide, an estimated 150 million people still suffer financial
catastrophe each year due to out-of-pocket payments.11 Increased financial protection
through the reduction of such payments is thus both feasible and clearly needed.
Increasing reliance on prepayment
Reduced reliance on out-of-pocket payments must come with increased reliance on
prepayment. If providers cannot increase revenues from other sources, attempts to
regulate out-of-pocket payments downwards can have negative, unintended conse
quences. These consequences include an increase in informal payments, supply-side
shortages, and skimping on the quality of care by diluting, delaying, or removing
services that cost more to produce than providers can recoup.
11' According to the World Health Report 2013.
34
5 Reducing out-of-pocket payments
Prepayment mechanisms have the potential to address many of the shortcomings
associated with out-of-pocket payments, thus promoting both access and financial
risk protection. This is primarily because such mechanisms allow for pooling of
funds and consequently pooling of risk. The pooling of prepayments can take place
in different settings, for example, in private and social insurance schemes, but the
prepayments should be mandatory. Evidence at all national income levels shows that
mandatory contribution mechanisms (taxation or mandatory social health insurance)
are more efficient than voluntary mechanisms.4 This is particularly because voluntary
mechanisms are vulnerable to the problem of "adverse selection," whereby relatively
"high-risk"elderly and sick individuals are more likely to join the pooled scheme than
relatively "low-risk" young and healthy individuals.158 UHC will normally require a
degree of financial subsidy not only from the rich to the poor, but also from the young
and healthy toward the elderly and unhealthy.139 A mandatory system is required to
ensure that the rich, young, and healthy fulfill their obligations of fairness and equity,
since otherwise they may opt out of a pooled scheme that makes them to pay more
than they receive in terms of personal benefits.Therefore, it is generally recommended
that countries move toward mandatory prepayment with pooling.4,116
Countries that want to reduce out-of-pocket payments can raise additional funds
in multiple ways. In particular, additional funds can result from economic growth,
increased mobilization of domestic resources, intersectoral reallocations, efficiency
gains, and more external resources.4,l9'21'107'159These various sources of funds are further
described in box 5.3.
Box 5.3 Sources of additional funds
Additional funds can typically result from economic growth, increased mobilization of domestic
resources, intersectoral reallocations, efficiency gains, and more external resources.4-19'21'107'159
As for economic growth, the Lancet Commission on Investing in Health projected real GDP growth
per year at 4.5 percent for low-income countries, 4.3 percent for lower-middle-income countries,
and 4.2 percent for upper-middle-income countries from 2011 to 2035.21 If these projections
come true and if countries make UHC a national priority, at least middle-income countries can
finance all or most of the required expenditures from domestic resources.
As for increased mobilization of domestic resources, one particularly important option for
countries to consider is increased taxation of tobacco. Such an increase is likely not only to
increase revenue, but also to improve population health. For countries rich in minerals or other
natural resources, increasing government revenue from this source is another opportunity that
should be explored.
Regarding intersectoral reallocations, a related strategy is to reduce or eliminate energy subsidies
and other unwarranted subsidies. This can, among other things, increase the fiscal space for
public spending on high-priority health services.
As for efficiency gains, many promising strategies can be pursued. The Word Health Report 2010
lists ten leading causes of inefficiencies that could be addressed: underuse of generics and higher
than necessary prices for medicines; use of substandard and counterfeit medicines; inappropriate
and ineffective use of medicines; overuse or supply of equipment, investigations, and proce
dures; inappropriate or costly staff mix and unmotivated workers; inappropriate hospital admis
sions and length of stay; inappropriate hospital size (low use of infrastructure); medical errors and
suboptimal quality of care; waste, corruption, and fraud; and inefficient mix or inappropriate level
of strategies.4
Finally, as for external resources, many low-income countries will, in the foreseeable future, continue
to need development assistance for health (DAH) to supplement domestic resources.21'107'159
35
Making fair choices on the path to universal health coverage
Exactly what combination of financing mechanisms best facilitates the shift from
out-of-pocket payment toward prepayment and thus progress toward UHC depends
on a range of country-specific factors. Across these factors, however, research has
clearly demonstrated, as described, that extensive reliance on out-of-pocket payment
is a major obstacle to both access to services and financial risk protection.
Making the shift fairly
For countries seeking to shift from out-of-pocket payment toward prepayment with
pooling, a critical issue is how to do so fairly. Central to this issue are questions related
to priority when reducing out-of-pocket payments and to the criteria for the pool of
funds.
Priority when reducing out-of-pocket payments
When reducing out-of-pocket payments, a crucial question is for what services and
what subpopulations these payments should be reduced first.
For services, out-of-pocket payments should, if possible, first be eliminated for highpriority services. The rationale for such an approach was discussed for barriers to
coverage in general in chapter 4. Criteria for high-priority services were addressed in
chapters and are related, among otherthings, to cost-effectiveness, priority to the worst
off, and financial protection. Fairness suggests that out-of-pocket payments should
at least not be a barrier to coverage for these most important services as coverage
of these services should be truly universal.111 Services of somewhat lower priority, but
still important for people, could—on the path to UHC—be financed through a greater
range of financing mechanisms, including general taxation, voluntary, supplementary
insurance, and out-of-pocket payments.
For subpopulations, fairness considerations motivate special attention to certain groups
when expanding coverage, as suggested in chapter 4. More specifically, these groups
include low-income groups, rural populations, and other relevant groups to the extent
that they are disadvantaged in terms of service coverage or health and sometimes
more generally. Regarding out-of-pocket payments, there is even a particular reason
to first reduce such payments for low-income groups, since a given fee represents a
greater barrier to access and a greater financial burden to these groups. In addition,
such a policy response will reduce the extent to which out-of-pocket payments are
regressive with respect to income.
In practice, decades of experimentation have shown that it is often difficult to effectively
and efficiently exempt poor individuals from out-of-pocket payments.4,149 Part of the
explanation is that differentiated copayment and exemption schemes typically involve
difficult means testing and high transaction costs.21,149 Seeking financing mechanisms
based on prepayment should therefore be the first priority, but these efforts can be
combined with other ways of targeting disadvantaged groups, as described in chapter 4.
In addition, issues of demand must be taken into account when considering the level of out-of-pocket payments.
For some high-priority services, and especially preventive services, demand does not properly reflect their
importance from a public health perspective. For these services, there is an extra reason to eliminate out-ofpocket payments.
36
5 Reducing out-of-pocket payments
Criteria for the pool of funds
When increasing prepayment and pooling, a crucial question is what criteria should
determine how much money each person must contribute to the pool and what
benefits each person can receive.
Generally, the criteria for contribution and benefits should be devised to separate use
of services from payment for services.4,35 This is especially important for high-priority
services. Use and payment can be decoupled in various ways.61 One particularly
attractive combination of criteria, in line with the guiding considerations discussed in
chapter 2, is to have mandatory payments generally increase with ability to pay while
benefits received are primarily based on need.
Regarding the benefit criterion, there are several reasons why this should be primarily
based on need. As discussed in previous chapters, central reasons relate to the impor
tance of health and health services to individuals and society, the right to health, and
the collective responsibility for affordable access.
In particular, there are good reasons for why use of services should not primarily
depend on ability to pay. It is not fair that the poor are denied access to high-priority
services simply because they are poor.
Regarding the contribution criterion, contribution according to ability to pay finds
support in the 2000 and 2010 World Health Reports4,35 and in many theories of
distributive justice in health care.5,160 Many further argue that contributions should be
progressive with respect to income; that is, the rich should pay proportionately more
than the poor.
Conclusion
Progress toward UHC requires a shift from out-of-pocket payment toward mandatory
prepayment with pooling of funds. When making such a shift, countries should seek
to do the following:
• first eliminate out-of-pocket payments for high-priority services;
• first eliminate out-of-pocket payments for low-income groups and other
disadvantaged groups, if this can be done effectively;
• make contributions to the pool of funds generally depend on ability to pay and
make use of services primarily depend on need.
This approach will promote fairer distribution of benefits and burdens, across highand low-income groups, across the young and the elderly, and across the healthy and
the sick.
37
Overall strategy and trade-offs
Each of the three preceding chapters addressed one central dimension of progress in
the pursuit of universal health coverage (UHC). Against that background, an overall
strategy for fair progressive realization of UHC can be outlined. This general strategy
leaves room for several different pathways to UHC, but it also suggests that some
trade-offs are unacceptable in most circumstances.'
Overall strategy
A three-part strategy can be useful for countries seeking fair progressive realization of
UHC. Countries can do the following:
(a) Categorize services into priority classes. Relevant criteria include those related
to cost-effectiveness, priority to the worse off, and financial risk protection;
(b) First expand coverage for high-priority services to everyone. This includes
eliminating out-of-pocket payments while increasing mandatory, progressive
prepayment with pooling of funds;
(c) While doing so, ensure that disadvantaged groups are not left behind. These
will often include low-income groups and rural populations.
When high-priority services have been covered for everyone or all reasonable measures
to that end have been taken, steps (b) and (c) can be repeated for medium-priority
services and thereafter for low-priority services.
The overall strategy makes clear that systematic priority setting and service selection
are front and center in the pursuit of UHC. It is not only the total number of services
that matters; it is crucial what those services are. The more important a service, the
more important it is that the service is universally covered. Another central feature of
the overall strategy is that it privileges the inclusion dimension, that is, the"people"axis
of the UHC box illustrated in chapter 1. Countries should take all reasonable measures
to include everyone as quickly as possible and not try to cover a very expansive set
1
There may be certain circumstances in which the generally unacceptable trade-offs are acceptable. First, there
may be circumstances in which a policy involving a generally unacceptable trade-off will yield vastly greater
total benefits, in terms of coverage or health improvement, than any other alternative policy. Second, there may
be circumstances in which the worse off will be better off in absolute terms from a policy involving a generally
unacceptable trade-off than from any other alternative policy. It is sometimes argued, for example, that certain
policies involving generally unacceptable trade-offs best ensure sustainability of the financing system in the
long run. However, such claims must be very carefully assessed. In particular, it must be ascertained that all other
feasible steps have been taken, and the evidence should be very strong and unambiguously suggest that those
policies are best overall.
38
6 Overall strategy and trade-offs
of services from the outset if this would impede that goal. The general strategy also
provides guidance for how to pursue universalism. It recommends that countries
include disadvantaged groups from the outset and make sure that these groups are
not left behind. Since the poor represent one such group, this approach overlaps with
"progressive universalism."21-143
As part ofthis or any other overall strategy, countries must carefully make choices within
and across dimensions of progress. These decisions depend on context, and several
different pathways can be appropriate. However, when pursuing fair progressive reali
zation of UHC, some trade-offs are generally unacceptable.
Trade-offs
A trade-off can be seen as a compromise between two desirable but competing
considerations. It thus involves a sacrifice made in one dimension to obtain benefits
in another. Ethical theory is not always fine-grained enough to specify which trade
offs are acceptable and which are not. However, the considerations outlined in the
preceding chapters point toward some unacceptable trade-offs, within and across
dimensions. More specifically, at least the following five trade-offs can be considered
generally unacceptable and incompatible with fair progressive realization of UHC in
most circumstances. In addition, the same considerations that rule out certain trade
offs suggest that certain other trade-offs are acceptable.
Unacceptable trade-offI: To expand coverage for low- or medium-priority services before
there is near universal coverage for high-priority services. This includes reducing out-ofpocket payments for low- or medium-priority services before eliminating out-of-pocket
payments for high-priority services.
High-priority services are the most important services, partly because they tend to be
the most cost-effective and to benefit the worse off. It is therefore generally unfair to
expand coverage for low- or medium-priority services before there is universal coverage
for high-priority services or all reasonable measures to that end have been taken. For
example, it would be unacceptable to expand coverage for coronary bypass surgery
(plausibly not a high-priority service in low-income countries) before securing universal
coverage for skilled birth attendance and services for easily preventable or easily
treatable, fatal childhood diseases. Services of the latter kind include oral rehydration
therapy for children with diarrhea and antibiotics for children with pneumonia.
Lack of coverage for high-priority services tends to be concentrated among disadvan
taged groups. To first expand low- and medium-priority services in such situations is
particularly problematic and unfair. High-priority services are also those for which it
is most important that out-of-pocket payments are reduced. In most circumstances,
out-of-pocket payments for those services should therefore be eliminated before such
payments are reduced for other services.
The considerations that lead to the judgment that trade-off is unacceptable suggest
that certain other, important trade-offs are acceptable. Specifically, they suggest that
it is acceptable not to first address coverage gaps or inequalities in coverage for lowand medium-priority services if that would undermine efforts to expand coverage
of high-priority services or to reduce inequalities in coverage of such services. For
39
Making fair choices on the path to universal health coverage
example, less than universal coverage of certain advanced cancer treatments with
marginal health benefits—and associated inequalities in access to those treatments—
can be acceptable if necessary for securing universal coverage of highly effective HIV
treatment. The unacceptability of trade-off I further indicates that it is acceptable not
to reduce out-of-pocket payment for low- and medium-priority services if that would
undermine efforts to reduce out-of-pocket payments for high-priority services. For
example, out-of-pocket payments for open-heart surgery can be acceptable if they
are necessary for removing out-of-pocket payments for cesarean sections.
Unacceptable trade-off II: To give high priority to very costly services whose coverage will
provide substantial financial protection when the health benefits are very small compared
to alternative, less costly services.
Coverage of very costly services can often offer substantial financial risk protection
by reducing out-of-pocket payments. However, when the health benefits are very
small compared to alternative, less costly services, there are at least two reasons why it
would be generally unacceptable to give high priority to the very costly services. First,
by so doing, one would sacrifice many health benefits that could otherwise have been
secured with the same resources.This is unfortunate because health benefits are highly
valuable by themselves, but it is also unfortunate from the perspective of financial risk
protection because health benefits tend to provide such protection indirectly. Health
improvements can prevent certain out-of-pocket payments downstream and can
increase productivity and the income-earning potential in the beneficiaries and their
families.21 Second, even immediate financial risk protection can often be secured more
cheaply and fairly than through coverage of very costly services with limited health
benefits. One reason is that even small out-of-pocket payments for non-costly services
can be a significant financial burden on the poor, and more of these services can be
covered within a fixed budget.21 In addition, it is also fairer to purchase financial risk
protection for the poor and disadvantaged. These points were discussed in greater
detail in chapter 3.
As indicated, there are several reasons why financial risk protection must be carefully
balanced against other concerns in the selection of services. Financial risk protection
can play many different roles in this context, while, at the same time, persistently
motivating UHC and the reduction of out-of-pocket payments more generally.
The reasons why trade-off II is unacceptable suggest that certain other, important
trade-offs are acceptable. Specifically, in many circumstances it can be acceptable
not to cover very cost-inefficient services even when such coverage would provide
substantial financial risk protection.
Unacceptable trade-off III: To expand coverage for well-off groups before doing so for
worse-offgroups when the costs and benefits are not vastly different. This includes expanding
coverage for those with already high coverage before groups with lower coverage.
It is difficult to justify expanding coverage for well-off groups before worse-off groups
if the policies are largely similar in other respects. This is especially the case if the
services in question are high-priority services, if the worse-off group is very badly off,
or both. As discussed in previous chapters, to expand coverage for well-off groups first
would typically conflict with ideals of equality and a special concern for the worse off.
40
6 Overall strategy and trade-offs
These considerations suggest that certain other trade-offs are acceptable. For one, it is
acceptable not to expand coverage for well-off groups if that would undermine efforts
to expand coverage for worse-off groups. Moreover, the argument indicates that it
could be acceptable to expand coverage for well-off groups before worse-off groups
if the costs or benefits are vastly different. For example, expanding coverage for a
given service from 90 to 100 percent in certain heard-to-reach areas can sometimes be
extraordinary difficult and costly. If the resources involved could produce vastly larger
improvements in coverage and health outcomes in areas that are only somewhat
better off, that may be acceptable. However, it must be ascertained that all other
feasible steps have been taken and that the evidence strongly and unambiguously
suggests that those policies are the best overall.
Unacceptable trade-off IV: To first include in the universal coverage scheme only those
with the ability to pay and not include informal workers and the poor, even if such an
approach would be easier.
Not only the total number of people included in a scheme matters. Who those people
are and who is left behind also matter. It would generally be unacceptable to include
only formal workers and the non-poor in the early stages of the pursuit of universal
coverage. Instead, as discussed, there are many reasons why informal workers and
the poor should have priority in the early stages, to the extent that this does not
jeopardize the financial sustainability of the scheme. One is the ideal that coverage
and use of services should be primarily based on need and not on ability to pay or
political power. More specifically, including informal workers and the poor from the
outset can counteract "the inverse equity hypothesis."This hypothesis suggests that a
new health intervention tends to increase inequities because it initially reaches those
who are already better off.161
Unacceptable trade-off V: To shift from out-of-pocket payment toward mandatory
prepayment in a way that makes the financing system less progressive.
One of the problems with out-of-pocket payments is that they tend to be regressive
with respect to income; that is, the poor pay proportionately more than the rich.
This was discussed in chapter 5. When shifting from out-of-pocket payment toward
mandatory prepayment with pooling of funds, this shift should therefore be done in a
way that does not make the overall financing system less progressive.This is supported
by the ideal that contributions to the system should increase with ability to pay.
Beyond the generally unacceptable trade-offs, there are several constraints on the
pursuit of UHC that do not involve a compromise between two desirable ends and
thus are not trade-offs. Central among these constraints is the prohibition on discrim
ination based on race, ethnicity, religion, gender, political beliefs, and sexual orien
tation. Discriminatory practices of these types are morally and legally indefensible, as
suggested by widely accepted ethical theories, human rights frameworks, and many
bodies of law.85'162'163 For example, it is impermissible to deny access to HIV treatment
simply due to sexual orientation.
41
Making fair choices on the path to universal health coverage
Conclusion
A three-part, overall strategy can be useful when countries are seeking fair progressive
realization of UHC. More specifically, countries can categorize services into priority
classes, first expand coverage for high-priority services to everyone, and, while doing
so, ensure that disadvantaged groups are not left behind. As part of this or any other
overall strategy, countries must carefully make choices within as well as across dimen
sions of progress. These decisions will partly depend on context, and several different
pathways can be appropriate. However, when pursuing fair progressive realization of
UHC, some trade-offs are generally unacceptable. Robust public accountability and
participation mechanisms are essential when deciding on the overall strategy, specific
pathways, and the appropriateness of central trade-offs.
42
Public accountability
and participation
1
People should be at the center of the health system in all respects. This implies that
people should be not only recipients of services, but also agents that actively shape
the system and how services are financed and delivered. The preceding chapters
addressed several substantive considerations regarding the critical choices on the
path to universal health coverage (UHC). Although such considerations do inform fair
progressive realization of UHC, the processes of choice and implementation are also
crucial. Specifically, fair progressive realization of UHC requires robust public account
ability and public participation.
The importance of public accountability and participation has long been appreciated.
The WHO 1948 constitution states that "[informed opinion and active co-operation on
the part of the public are of the utmost importance in the improvement of the health
of the people,"164 and the 1978 Declaration of Alma-Ata asserts that "[t]he people have
the right and duty to participate individually and collectively in the planning and
implementation of their health care."165 Accountability and participation have recently
attracted renewed international attention and now figure prominently in numerous
health initiatives and in the shaping of the post-2015 development agenda.166
Basic ideas
Accountability involves answerability and enforceability.167 Individuals and institutions
that are held accountable must give information about their decisions and actions,
justify them, and face some type of sanctions in the event of misconduct. All actors
that influence the health system and the pursuit of UHC should be accountable to the
public in a meaningful way, but this is particularly important for national and local
governments and service providers. The public's role is to actively hold the relevant
actors accountable.
Public participation is the practice of involving members of the public in the agenda
setting, decision-making, and policy-forming activities of institutions responsible for
policy development.168 True public participation involves interaction and dialogue. It
thus goes beyond situations in which institutions simply provide information to the
public or simply obtain information from the public.
Public accountability and participation can each take numerous forms.168’174They can
also be related in several ways and tend to reinforce each other: robust accountability
can strengthen participation and robust participation can strengthen accountability.
43
Making fair choices on the path to universal health coverage
Moreover, governments and other relevant institutions can be held accountable for
ensuring that proper participatory processes are in place.25'175 Public accountability and
participation are also related to—and partly overlap with—several other important
ideas, including transparency, voice, inclusion, empowerment, and responsiveness.
Motivations
Strengthened public accountability and participation can facilitate fair progressive
realization of UHC and benefit society more generally in basically three ways. These
are through better policy decisions, more effective implementation of these decisions,
and supplementary benefits from an improved process.5-176178 As for the quality of
decisions, strengthened public accountability and participation in policy formulation
can improve policy decisions by making decision-makers more careful and disciplined,
by making decisions sensitive to a wider range of needs and values, and by promoting
consistency across decisions. Strengthened public accountability and participation
can also make the implementation of decisions more efficient by addressing disagree
ments at an earlier stage and by facilitating ownership. Strengthened public accounta
bility and participation in the implementation phase itself can further make the imple
mentation of decisions more efficient by discouraging fraud, corruption, and waste
and by promoting collaboration within the community.
Strengthened public accountability and participation are also valuable beyond
the immediate quality of the decisions and the effectiveness of the implemen
tation. Meaningful accountability and participation are crucial for fair and legitimate
processes, can promote democratic values, and are key components of a human rights
framework. Accountability and participation can also help build trust and facilitate
public deliberation, education, and learning. In the longer run, these benefits also
affect the quality of the choices and the effectiveness of implementation. Moreover,
there is also evidence for a positive impact of participation on health and healthrelated outcomes.136 However, across all these roles of public accountability and partic
ipation, it is important who the accountees and participants are. In particular, for fair
progressive realization of UHC, efforts to strengthen accountability and participation
should pay special attention to marginalized groups.
A human rights framework puts special emphasis on accountability and participation,
both in the context of health and more broadly.25-175-179'181 For accountability, a human
rights framework requires that the state should be held accountable for what it does,
how much effort it is expending (in terms of resources, for example), and how it is
going about the process.175 Since, in a human rights framework, the state is primarily
accountable to its subjects (rather than to donors, for example), requiring policy
decisions that affect people's rights to be justified and subjecting those justifications
to public scrutiny is fundamental. Under human rights law, there should be account
ability for the process through which health policy goals are reached. Therefore, there
needs to be adequate monitoring and oversight, transparency, access to information,
and meaningful public participation.179 From this perspective, meaningful participation
implies processes that empower and mobilize ordinary people to become engaged in
political and social action that promotes realization of the right to health as well as
other human rights.25-182
44
7 Public accountability and participation
Public accountability and participation are important throughout the health system
and throughout the policy-making process. To illustrate how accountability and
participation can be strengthened and facilitate fair progressive realization of UHC, it
is useful to emphasize three parts of that process: policy formulation, policy commu
nication, and monitoring and evaluation. In each stage, numerous accountability and
participation mechanisms can be used. Some of these may require institutional reform
or even new institutions.
Policy formulation
The previous chapters highlighted critical choices on the path toward UHC. Robust
public accountability and participation are crucial when such choices are made and
when policy are formulated. This requires that stakeholders can influence what is
"up for contention" and not merely respond to a pre-set agenda.180 Public account
ability and participation in policy formulation can be promoted in numerous ways.
One group of participatory procedures include citizens'jury, citizens' panel, consensus
conferences, deliberative polling, and town meetings with voting.168* 173,174These proce
dures are typically linked to one specific decision or a small set of related decisions
and are often transitory. However, these procedures can also be integrated into
more continuous decision-making processes and be used on a regular basis. Other
permanent and institutionalized mechanisms for strengthening accountability and
participation should also be considered. One type of such mechanisms is the formal
or semi-formal integration of entirely civic entities into the decision-making process.
Another mechanism is citizen or lay representation in regular committees, boards, or
other decision-making bodies. Examples of these mechanisms are provided below.
At the overarching level, public accountability and participation are promoted by
strengthening democratic governance, including general elections. However, robust
accountability and participation also at this overarching level, require much more than
elections. In particular, vigorous public debate and deliberation over policy formu
lation are critical.5*183 Accountability and participation can also be promoted in several
more indirect ways, such as through strengthening legal rights and strengthening
marginalized groups and civil society.40
The various mechanisms can be used to address the critical choices within and across
the dimensions outlined in the preceding chapters. In particular, robust account
ability and participation are important with respect to decisions over both financing
and service selection. These decisions pertain to the distribution of contributions,
including the role of out-of-pocket payments, and the distribution of resources from
pooled funds. A proper approach to these issues can be facilitated by the many
mechanisms outlined above. Among the more integrated approaches is, for example,
participatory budgeting.40*184 186 Typically, such budgeting involves a process by which
citizens, either as individuals or through civic associations, can regularly contribute to
decision making over at least part of a public budget through a series of meetings
with government authorities.187 Among countries with substantial experience with
participatory budgeting are Brazil, Cameroon, Peru, and Sri Lanka.186 In Porto Alegre in
Brazil, for example, one study reports that more than 100,000 people (8 percent of the
population) were involved in the 1996 budget process.184
45
Making fair choices on the path to universal health coverage
Regarding service selection, priorities must be set based on scientific evidence, ethical
arguments, and public values. To properly integrate these elements, it is important
to have explicit, systematic, and continuous processes for priority setting and health
technology assessment (HTA). Many countries now have formal processes in which
experts assess evidence for health interventions—often including evidence on clinical
effectiveness and cost-effectiveness—in a way that promotes scientific accountability.
These countries include Australia, Colombia, Denmark, Finland, Germany, Mexico,
the Netherlands, New Zealand, Norway, Sweden, Thailand, the United Kingdom (UK),
and the United Stated (US).88<941188(189 Some countries have also sought to integrate
elements of direct public participation into the process.88,94,190 Among these countries
is Thailand, whose priority-setting process is further described in box 7.1.
Box 7.1 Stakeholder involvement in health technology assessment (HTA) in Thailand
The Health Intervention and Technology Assessment Program in Thailand makes recommen
dations about which services to include in the benefit package. Among the criteria considered
are the following: (a) size of population affected, (b) severity of disease, (c) effectiveness of
health Intervention, (d) variation in practice, (e) economic impact on household expenditure;
and (f) equity/ethical and social implications.94
Building on well-established practices of health technology assessment (HTA) used
worldwide,191 several groups of stakeholders are involved in assessing evidence against prede
termined criteria. In Thailand, four groups of stakeholders are involved: health professionals,
academics, patient groups, and civil society organizations.These stakeholders are involved in .
all phases of the HTAs, including nomination of services for assessment, selection of services
for assessment, and appraisal of services.*
A scoring approach—based on multi-criteria decision analysis (MCDA)—with well-defined
parameters and thresholds is used to assess the service(s) in question against each criterion.192
The rank order of services can be adjusted through deliberation among the panelists. This
method has been used to assess, for example, interventions related to alcohol regulation,
prevention of cervical cancer, prevention of maternal-to-child transmission of HIV, and retro
peritoneal hemodialysis for end-stage renal disease and to decide what drugs to include on the
essential medicines list.94
*VirojTangcharoensathien (Personal communication, interview with Thalia Porteny, June, 2013).
Policy communication
Another, related way for enhancing public accountability and participation, with
respect to policy decisions and their implementation, is to provide clear information
about approved policies to the public.97'193 This is particularly important for policies
related to basic rights and entitlements, public services including health services, and
public expenditure budgets. Obviously, only if people know what policies have been
approved can there be genuine public debate. Clear communication of policy decisions
is also important for monitoring and evaluation, as discussed below. However, such
communication is valuable also in a third, more direct way. Clear information is critical
to the full use of services and for citizens' ability to claim their rights and entitlements.
This is especially the case for poor and vulnerable groups, which often lack information
about policies that are vital to their lives.
Regarding UHC, it is critical that all important aspects of UHC reforms and policies
are clearly communicated to the public. Against the background of the preceding
chapters, one particularly important aspect relate to service selection and out-ofpocket payments. People need to know what services they are entitled to and at what
46
7 Public accountability and participation
level of out-of-pocket payments. Only then can services be used to the full extent and
true coverage be obtained.
One way to facilitate policy communication with respectto service selection and out-of
pocket-payments is to devise a list of services included and excluded and to make that
list publicly available. Examples of countries that have defined priority services as part
of UHC reform include Chile, Ghana, Mexico, Nigeria, Rwanda,Thailand, and Vietnam.94'
95 For explicit lists to be valuable, however, it is important that priority services are well
defined, justified, and repeatedly reexamined and updated in light of new arguments
and evidence.
Another important aspect of health-system policies about which public information
is essential is the approved health expenditure budgets. These budgets, with descrip
tions of budgeted allocations atthe national, district, and local levels, should be widely
disseminated. This will enable citizens to claim the services for which resources have
been allocated.
Monitoring and evaluation
It is necessary but not sufficient to formulate good policies and to communicate them
clearly. Robust public accountability and participation also require careful monitoring and
evaluation of the implementation stage and the effects of the approved policies. Specifi
cally, fair progressive realization of UHC requires monitoring and evaluation of resources,
coverage, and health outcomes. In addition, the process of policy formulation itself can be
monitored and evaluated, something which is further described in chapter 8.
Resources
With respect to resources for health services, it is important to monitor both how
funds are generated and how they are used. Information about the current state of
affairs and change over time can facilitate comparison with stated policy and inform
public debate and future policy making. For example, the WHO Commission on Infor
mation and Accountability for Women's and Children's Health has recommended that,
by 2015, countries should track and report, at a minimum, two aggregate resource
indicators: total health expenditure by financing source and total reproductive,
maternal, newborn, and child health (RMNCH) expenditure by financing source.194
To gather information, the System of Health Accounts (SHA) can be used.195 The SHA is
now the internationally accepted methodology for tracking contributions to the health
system and health spending within countries. For example, the pattern and total amount
of out-of-pocket expenditure can be monitored. Health accounts can also be used to
gather information about the flow of resources across health-system levels, geographic
areas, and types of services, such as drugs, public health interventions, diagnostic and
curative services, and rehabilitation. Moreover, condition-specific allocations can be
tracked, such as the proportion of resources going to HIV,TB, immunization, malaria, and
chronic conditions. Overall, with a good, comprehensive system of health accounts in
place, civil society can more easily follow, criticize, and challenge the patterns of revenue
generation and resource allocation. Accordingly, such a system can strengthen public
accountability and participation in health sector reform.
47
Making fair choices on the path to universal health coverage
Coverage
Monitoring and evaluation of service coverage are obviously essential to account
ability and participation in the specific context of UHC and to the pursuit of UHC
more generally. The use of a comprehensive set of indicators enables the public to
hold decision makers accountable for taking the right steps toward UHC. Indicators of
service coverage and financial risk protection are needed, and the selection of specific
indicators is an important, nontrivial task which is addressed in chapter 8. For most
indicators, not only average levels, but also the distribution across relevant groups
must be measured and reported.
Health outcomes
Among the chief motivations for UHC are the improvement of population health and the
promotion of a fair distribution of health in society. Decision makers should therefore
be held accountable for health outcomes, and accountability in this respect will be
strengthened by thorough monitoring and evaluation of highly relevant outcomes.
These are further discussed in chapter 8. Information on health outcomes constitute,
of course, critical input to policy formulation also more directly. Again, both average
levels and the distribution across relevant groups must be measured and reported.
For example, information about profound health inequalities across socioeconomic
groups or geographic areas can form the basis for civil society pressure for reform.
The role of institutions
To ensure robust accountability and participation, accountability and participation
mechanisms must be institutionalized.196'197 Many countries that have succeeded
in moving toward UHC—such as Mexico, Rwanda, Thailand, and Turkey—have
created innovative institutions that promote accountability and participation.47'48 94'
198 Moreover, some high-income countries have established national committees for
priority setting in order to make the priority-setting process more transparent and
more explicit and to better engage the public.88
As described, accountability and participation are highly relevant for several issues and
several types of institutions. Although these issues and institutions are diverse, general
frameworks exist that can be relevant for most, or all, of these. One widely accepted
framework for legitimate decision making is Accountability for Reasonableness (A4R).5'97
This framework takes seriously thefactthatthere is often reasonable disagreement about
values and their relative importance. People differ in their views about which values are
important, how they should be interpreted, and how they should be balanced, and such
reasonable disagreement exists within and across countries. Divergent views of this
kind may underlie, for example, disagreements about how to best trade off different
service selection criteria against each other. Key policy decisions on the path to UHC
should therefore be made through a process that all citizens see as legitimate. Such a
process should be transparent, the decisions and their reasons should be made public,
and the public—through participation—should have ample opportunity to influence
the outcomes of the process. More specifically, the Accountability for Reasonableness
framework lays out four conditions that should be met and these are described in box
7.2. The framework has been explored in a range of contexts5'97 and can be crucial in
facilitating fair and legitimate decisions on the path to UHC.
48
7 Public accountability and participation
Box 7.2 The four conditions in the Accountability for Reasonableness framework97
•
Publicity Condition'. Decisions regarding both direct and Indirect limits to care and their
rationales must be publicly accessible.
•
Relevance Condition: The rationales for limit-setting decisions should aim to provide
a reasonable explanation of how the organization seeks to provide "value for money"
in meeting the varied health needs of a defined population under reasonable resource
constraints. Specifically, a rationale will be reasonable if it appeals to evidence, reasons,
and principles that are accepted as relevant by fair-minded people who are disposed to
finding mutually justifiable terms of cooperation.
•
Revision and Appeals Condition: There must be mechanisms for challenge and dispute
resolution regarding limit-setting decisions, and, more broadly, opportunities for revision
and improvement of policies in the light of new evidence or arguments.
•
Regulative ConditiomThere is either voluntary or public regulation of the process to ensure
that conditions 1-3 are met.
Conclusion
Fair progressive realization of UHC requires tough policy decisions. Reasonable
decisions and their implementation can be facilitated by robust public accountability
and participation mechanisms. Such mechanisms are essential in policy formulation
and priority setting and specifically in addressing the three critical choices on the path
to UHC and the trade-offs between dimensions of progress. Public accountability and
participation are also closely linked to policy communication and monitoring and
evaluation. To be truly robust, accountability and participation mechanisms must be
institutionalized, and the design of legitimate institutions can be informed by the
Accountability for Reasonableness framework.
49
Indicators of progress
For all countries, it is crucial to have information on health system performance.
Specifically, such information is indispensable for making progress toward universal
health coverage (UHC). Although it is impossible to capture the full complexity of
coverage, a good set of indicators can guide policy and facilitate fair progressive reali
zation of UHC. To this end, countries must carefully select a set of indicators, invest in
the necessary information systems, and then properly integrate the information into
policy making.199
Several recent and ongoing efforts attempt to delineate an optimal framework for
monitoring and evaluation in the context of UHC.129'200'202 To promote fair progress,
however, concerns for fairness and equity must be centrally positioned in these frame
works, especially in the selection of indicators? Against the background of the preceding
chapters, it is possible to give some direction for how this can be done.
Selection of indicators
In designing a framework for monitoring and evaluation, countries should select the
set of indicators that can best facilitate fair progressive realization of UHC. When doing
so, there are at least four central considerations:
• The purpose of monitoring and evaluation: Investing in health information
systems is only valuable if monitoring and evaluation can guide local, regional,
and national policy making, inform public debate, and help countries compare
performance within their health system and against other countries at a similar
level of development.
• The goal of universal health coverage and beyond: Indicators should be closely
aligned with the goal of UHC. The set of indicators should reflect the degree
of access to a comprehensive range of key, quality health services and the
degree of financial protection related to these services. However, focusing too
narrowly on the health sector may hamper the wider goals related to the level
and distribution of health outcomes. Outcome indicators are therefore also
needed.
1
Work is under way in WHO, in collaboration with the Rockefeller Foundation, to identify a set of indicators on
social determinants related to health, gender, and human rights for monitoring equitable progress toward
UHC. The project specifically looks at monitoring barriers to UHC and determinants of health that have differ
ential impact across populations. The project also focuses on areas for intersectoral action that support the
advancement of progressive universalism; that is, reforms toward UHC that benefit disadvantaged populations
at least as much as they benefit better-off populations
50
8 Indicators of progress
• Data availability and quality.The glaring lack of data in many countries and
rapid changes in coverage necessitate a broad set of indicators that goes
beyond the data currently available. For many low- and middle-income
countries, the Demographic and Health Surveys (DHS) and the now outdated
World Health Survey (WHS) are the main sources of data. Investments in more
comprehensive, high-quality data collection systems are clearly needed.
• Types of indicators: The means and ends of UHC can be monitored and evaluated.
A broad approach calls for at least four types of indicators: indicators related to
the priority-setting processes and indicators ofcoverage, financial risk protection,
and health outcomes. For the last three types, it is indispensable that not only
average level is measured, but also the distribution across relevant groups.
Process indicators
As described in previous chapters, careful priority setting is crucial for fair progressive
realization of UHC.The priority-setting process is hard to measure quantitatively, but a
set of qualitative indicators can be useful.34'192,203'204 Among these indicators are those
that reflect the existence of the following:
• an institution or entity within an institution (such as within the Ministry of
Health) responsible for assessing and evaluating scientific evidence relevant for
priority setting;
• procedures or decision-making bodies that involve citizens and key
stakeholders in priority setting and provide reasons for priority-setting
decisions;
• publicly available criteria for priority setting;
• publicly available descriptions of the high-priority services that people are
entitled to and information about how these services are financed (with special
emphasis on out-of-pocket payments).
This set of process indicators can be useful for strengthening public accountability and
public debate, something which was discussed in chapter 7.
Indicators of coverage
Availabledata do not permit countriesto fully monitorservicecoverageforall important
services. Countries therefore have to select which services their indicators should be
related to. To facilitate this task, countries can categorize services into priority classes,
as described in chapter 3. Given the service selection criteria outlined in that chapter,
a certain set of prevention and care services is likely to be among the high-priority
services in most countries.This set covers services addressing communicable diseases,
reproductive health, and nutrition and other noncommunicable diseases (NCDs)—
including mental disorders—and injuries.
WHO and the World BankGroup(WBG) have developed a jointframeworkfor monitoring
progress toward UHC at country and global levels.202 Building on this framework, a
list of primary coverage indicators and a list of supplementary coverage indicators
are outlined for illustrative purposes. Exactly what services the coverage indicators
should relate to is an issue of considerable controversy, and the final selection must be
sensitive to country context. Table 8.1 provides an illustrative list of primary coverage
indicators that together target a wide range of conditions.
51
Making fair choices on the path to universal health coverage
Table 8.1 Illustrative list of primary coverage indicators
77
Conditions
Jitions
Indicators related to
Level/distribution
Communicable
1. Immunization
diseases and repro
ductive, maternal,
2. Antibiotic treatment for suspected pneumonia
neonatal, and child
3. Met need for contraceptives
health conditions
Noncommunicable
diseases
+/+
+/+
+/+
4. Basic obstetric and neonatal care with skilled
birth attendance
+/+
5. Comprehensive emergency obstetric and
neonatal care
+/+
6. Prevention of mother to child transmission
(PMTCT)
+/+
7. Antiretrovirals for HIV/AIDS
+/+
8. Diagnosis and treatment for tuberculosis
+/+
9. Insecticide-treated mosquito nets (where
relevant)
+/+
10. Prevention of malnutrition
+/+
11. Care and treatment for schizophrenia and
depression
+/+
12. Primary medical prevention of CVD (risk > 35%)
+/+
13. Implemented tobacco and alcohol regulation/
taxation/campaigns
14. Screening for cervical cancer
Injuries
+/+
15. Road traffic regulation and legislation
As can be seen from table 8.1, the conditions emphasized go beyond communi
cable diseases and conditions related to reproductive, maternal, newborn, and child
health (RMNCH) to also include noncommunicable diseases (NCDs) and injuries.21-202
The services for which universal coverage is sought plausibly target all these kinds of
conditions. However, it is important to note that relevant data on NCDs and injuries are
generally lacking.
ZX^CPHE - S0CHAiiA>^
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52
8 Indicators of progress
Countries further down the path to UHC may find a list of supplementary coverage
indicators equally relevant for policy making. One such list is illustrated in table 8.2.
Table 8.2 Illustrative list of supplementary coverage indicators
Conditions
Indicators related to
Level/distribution
Communicable
diseases and repro
ductive, maternal,
neonatal, and child
health conditions
1. Hospitalization for severe birth
complications, sepsis, pneumonia, malaria,
and other infections
+/+
Noncommunicable
diseases
2. Treatment for type 1 diabetes
+/+
3. Preventive treatment for type 2 diabetes
+/+
4. Hospitalization for myocardial infarction
+/+
5. Acute medical treatment for stroke
+/+
6. Treatment of epilepsy
+/+
7. Treatment of acute renal failure
+/+
8. Treatment of cervical cancer
+/+
9. Treatment of breast cancer
+/+
10. Treatment of stomach cancer
+/+
11 .Treatment of leukemia (adults and children)
+/+
12. Palliative care
Injuries
13. Prevention of injuries
+/+
14. Essential surgery
+/+
15. Intensive care for severe injuries
+/+
Information on each service, if available, is typically reported as overall coverage
rates, i.e., the proportion of the total population covered for the service in question.
As suggested, countries should also collect disaggregated data that show the distri
bution of coverage across relevant groups, including across wealth quintiles.200 Such
data are illustrated in table 8.3. Here, the coverage rates for skilled birth attendance
for every quintile are shown for five countries. The variation across wealth quintiles
is pronounced. In Ethiopia, for example, coverage for skilled birth attendance is 46
percent in the highest quintile and only 2 percent in the lowest quintile.
Table 8.3 Distribution of skilled birth attendance in five countries131
Ethiopia
India
Rwanda
Colombia
Vietnam
Quintile
1
Quintile
2
Quintile
3
Quintile
4
Quintile
5
Inequality
(Cl)*
Average
1.7
19.6
61.2
84.4
2.9
32.4
63.5
3.2
49.7
66.7
7.4
67.5
72.6
99.4
45.6
89.1
85.9
99.5
0.607
0.293
0.067
10.0
47.3
69.0
(%)
0.036
94.9
98.8
96.8
85.2
0.101
99.7
97.1
86.2
95.1
58.2
* Cl = Concentration index (range 0-1). With perfect equality, Cl takes the value of 0.
Inequalityadjusted
coverage
3.9
33.4
64.4
91.5
76.6
53
Making fair choices on the path to universal health coverage
The concentration index (Cl) is a widely used indicator of distribution. It is analogous
to the Gini index but uses a measure of socioeconomic status for ranking of groups.
The Cl is related to the concentration curve, which plots the cumulative proportion
of the outcome variable against the cumulative proportion of the population ranked
by a measure of socioeconomic status, and the Cl equals twice the area between the
concentration curve and the diagonal line of equality.205'206
Data on average level and distribution of a service or set of services can also be combined
into a summary indicator.207 One such indicator, representing inequality-adjusted
coverage, can be calculated as follows: inequality-adjusted coverage = m(1 -Cl), where m
is the average service coverage rate for the population as a whole and Cl is the concen
tration index. Inequality-adjusted coverage can differ significantly from non-adjusted
coverage rates as the former is directly sensitive to the distribution of coverage. Such
indicators can therefore help facilitate fair progressive realization of UHC.
It is important to note, however, that it is not only distribution across socioeconomic
groups that matters. The distribution of service coverage across other characteristics,
such as gender and area of living, should also be monitored.
Indicators of financial protection
The goal of UHC pertains not only to access; UHC is also centrally concerned with
affordability and financial protection beyond their role as barriers to access. It is
therefore crucial to monitor and evaluate the extent to which the health system offers
such protection.4'14,129-200'201'205 The following three measures are found particularly
relevant and are strong indicators of financial risk linked to out-of-pocket payments:202
• Percentage of the total population that faces catastrophic health expenditure
due to out-of-pocket payments: Health expenditures are typically considered
catastrophic for a household if they exceed a certain threshold, for example,
40 percent of nonfood household expenditures in a year.200 In many countries,
the relevant information is available from household expenditure surveys. Both
level and distribution across groups should be monitored;
• Percentage of the total population impoverished due to out-of-pocket payments:
This is defined as the proportion of the population, over a year, that is pushed
below the poverty line due to out-of-pocket payments. In many countries, the
relevant information is available from household expenditure surveys. Again,
both level and distribution across groups should be monitored;
• Proportion of out-of-pocket payments: This is defined as the proportion of
out-of-pocket payments relative to the total health expenditure. In many
countries, the relevant information is available from national health accounts.
The proportion of out-of-pocket payments is primarily linked to financial
risk protection by a known high correlation between that proportion and
catastrophic health expenditure and impoverishment. Evidence suggests
that out-of-pocket payments typically have to represent less than 15 to 20
percent of total health expenditure before the incidence of catastrophic health
expenditures and impoverishment falls to negligible levels.4
54
8 Indicators of progress
All these measures can be useful indicators of financial risk protection in monitoring
and evaluating the progress toward UHC."
Health outcome indicators
Among the chief motivations for UHC are the improvement of population health and the
promotion of a fair distribution of health in society. This suggests that health outcome
indicators also provide relevant information for fair progressive realization of UHC.
The value of such indicators is further underlined by the fact that many determinants
of health are found outside the health system, including various social determinants.
Health outcome indicators can reflect the level and distribution of such determinants
and may also reflect imbalances in country efforts to address the various types of deter
minants. For example, imbalances between the efforts to improve the health system and
the efforts to improve women's education or infrastructure to provide clean water may
be reflected in overall health outcomes, at least in the long term.
At the macro level, the most relevant summary measures of health outcomes are life
expectancy and health-adjusted life expectancy (HALE). Other important outcome
measures include maternal mortality, under-five mortality, and stunting rates or other
measures of malnutrition. As suggested in the preceding chapters, distribution is crucial
also with respect to such outcomes. Accordingly, if a health outcome indicator such as
HALE is used, the distribution of HALE should also be reported. Possible methods for
reporting distribution of this outcome include bivariate and univariate measures of
health inequality.208 Some of these have, for example, been developed and discussed
in the context of the Human Development Reports.209’210
Conclusion
Monitoring and evaluation are essential for fair progressive realization of UHC. To this
end, countries must carefully select a set of indicators, invest in health information
systems, and properly integrate the information into policy making. The selection of
indicators should be closely aligned with the goal of UHC and in most settings include
at least four types of indicators: indicators related to the priority-setting processes and
indicators of access, financial risk protection, and population health. The last three
types of indicators should reflect not only average or aggregate levels but also the
distribution.
11
Notice that these indicators have some limitations. For example, especially the first two indicators are not directly
sensitive to under-consumption of health services due to lack of affordability.
55
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World Health
Organization
Making fair choices
on the path to universal
health coverage
Final report of the WHO Consultative Group
on Equity and Universal Health Coverage
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