An Evolving Global Movement Toward UHC: From Financing to Primary Care-focused Delivery

MSH/Warren Zelman

On this second annual UHC Day, many of us in the global health community are feeling optimistic that key global institutions and many countries around the world – a coalition of 712 partners and 116 countries!—have embraced the goal of universal health coverage (UHC).  Now, as we expand our focus from advocacy to making real progress toward this ambitious goal, we must continue to evolve the concept of UHC and focus on how to achieve it.  In particular, strengthening primary health care (PHC) systems, and better integrating them with effective financing mechanisms, will be crucial and fundamental to achieving UHC. 

When the global health community launched the UHC movement a few years ago, we started from the perspective of financing. A coalition – originally led by the Rockefeller Foundation – called attention to an economic transition occurring in health across the globe – countries as they grow wealthier spend more on health, domestic spending far outstrips donor spending, and much of the new domestic spending often comes in the form of out-of-pocket payment, which is an unfair, inefficient form of payment that pushes people into poverty and leaves the poorest without access to crucial care. 

The World Health Report 2010 crystallized and gave prominence to thinking about financing for universal health coverage.  It encouraged countries to mobilize revenues for health that would have the effect of replacing out-of-pocket payments with pools of funds that then would be used to strategically purchase care for people, especially the poor.  The now famous three-dimensional “UHC cube” illustrated the decisions that countries need to make about how to use those funds—who to cover, what services to cover, and how much of the cost to cover.  Countries around the world—some leaders who had started this trend several decades ago and others inspired by the nascent global movement toward UHC – worked to develop and improve national and state health insurance schemes and other financing programs. 

The early UHC movement shifted global health mindsets by focusing on domestic financing rather than donor financing.  And it promoted integrated financing systems, not just funds for particular diseases.  But a number of valid critiques of UHC emerged. Some critics complained that UHC mainly focused on providing coverage in theory for group of covered individuals or for a set of benefits, but not actually ensuring that people received services—high quality, comprehensive health services that would actually do some good.  Others feared that many countries were following a path-dependent route—building UHC programs by starting with existing insurance programs that covered wealthier formal sector workers, and focusing on hospital care.

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Fast forward five years.  Things have changed.  Now, when people talk about UHC, they talk not just about how to fairly and efficiently finance care for all, but also how to deliver high-quality, comprehensive services to all.  Institutions like the WHO and the World Bank have further clarified this dual-goal and have developed UHC indicators that reflect financial protection and service coverage.   In addition, some low- and middle-income countries moving toward UHC that originally focused their programs on coverage of inpatient services are now engaging in “PHC-led UHC”, expanding benefits to cover primary health care (PHC) services.   For example, PhilHealth in the Philippines introduced the Tsekap program to cover primary care benefits, and Kenya’s National Hospital Insurance Fund recently introduced outpatient benefits.  Many countries now recognize that mobilizing resources, pooling funds and deciding who and what to cover are necessary but insufficient to achieve UHC.  They need to integrate these financing reforms with PHC system strengthening to ensure that people receive high-quality essential services.

Now, at the end of 2015, the UHC movement is changing mindsets about healthcare delivery the way it changed thinking about financing five years ago.  Countries, donors and development partners are increasingly focusing on developing strong integrated delivery systems that can provide high-quality, comprehensive services for many different types of care for different health conditions. And increasingly, PHC -- the bedrock and glue of integrated health systems – is a key area of focus.  This is in part motivated by a desired to ensure prepared and resilient systems the next time an Ebola-type epidemic hits and, in part, motivated to employ cost-effective early detection, prevention, and management of costly emerging chronic conditions that could otherwise break the bank.  Only strong, people-centered integrated health systems that are trusted and used by the people they serve for most of their primary care needs are prepared to react to unexpected epidemics and disasters.  And only strong PHC systems can move beyond just offering access, to proactively ensuring that all people receive the quality services that they need at each phase of life, emphasizing prevention, promotion, early detection, and rehabilitative care, in addition to curative care.

To support this next phase of the movement toward global UHC, a partnership led by the Bill & Melinda Gates Foundation, The World Bank, and the World Health Organization launched the Primary Health Care Performance Initiative (PHCPI). This initiative may not have a cube, but it does have a box – a “black box”!   The initiative, which

Bill & Melinda Gates Foundation/Prashant Panjiar

launched in September with an online tool to enable countries to assess how well their PHC systems perform – is now beginning to support countries in their efforts to unpack the “black box” of service delivery – recognizing that how to convert inputs like money, health workers, facilities, drugs and supplies into high quality coverage outputs -- like fully immunized kids and safe deliveries of newborns -- is challenging and not well-enough understood.  PHCPI is joining forces with the Joint Learning Network for Universal Health Coverage to engage policymakers and practitioners in co-developing practical approaches for assessing root causes for PHC underperformance and identifying promising solutions to improve their PHC systems.

Now we in the UHC community really have our work cut out for us.  Those running national health financing programs need to find practical ways to effectively mobilize domestic revenues, make good decisions about what services and which populations to spend it on, and develop purchasing strategies that provide access to high-quality care, whether delivered through public facilities or purchased from private clinics.  At the same time, people managing primary health care need to develop strong integrated systems that proactively ensure – through competent, available, and motivated health care teams, strong information systems, effective supply chains, and functional facilities -- that all people receive high-quality, coordinated services that they trust. 

As the global health community now makes plans to achieve SDG 3 by 2030, let’s focus on “PHC-led UHC”, building integrated, people-centered delivery systems linked to and supported by comprehensive, efficient, pro-poor financing systems.  Health for all – particularly primary health care for all – is “Right. Smart. Overdue.”   

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Gina Lagomarsino is a Managing Director at Results for Development.