The Ebola crisis exposed the weaknesses of healthcare systems in low- and middle-income countries created mainly by insufficient funding. Given the global community’s commitment to universal health coverage (UHC), the Ebola outbreak has prompted serious reflection among health policy decision-makers. One of the central features of this debate is financing: how can relatively poor countries find the money to pay for universal health coverage? To date, low- and middle-income countries have been growing toward UHC through social health insurance systems funded through employment. Yet, progress has been slow and uneven leaving people in the informal sector, who are the majority of the population, out was insurance schemes. Rather than seeking innovative solutions to this old problem, what is needed is a renewed commitment to an old solution: tax-based financing.
Taxation has sometimes been overlooked in debates around financing UHC. The Lancet’s recent Global Health 2035 commission only discussed taxation in the context of specific consumption taxes on risky behaviours, such as tobacco and alcohol. These so-called “sin taxes” are important public health measures but they are unlikely to generate sufficient revenue to finance UHC. Instead, low- and middle-income countries should look to translate economic growth into healthcare spending through general taxation.
Using data from low- and middle-income countries my colleagues and I examined the association between tax revenues and health spending. We found that tax revenue was a major statistical determinant of progress towards UHC. Each $10 per-capita increase in tax revenue was associated with an additional $1 of public health spending per capita. Whereas each $10 increase in GDP per capita was associated with an increase of $0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax financing is an efficient way of translating economic growth into health spending.
Countries with more tax revenues have also made more progress on other indicators of UHC, even after adjusting for economic activity in the country. Among tax poor countries, greater tax revenues are associated with more women being attended by a skilled healthcare worker during pregnancy and greater access to healthcare for all people.
How taxes are collected is also important. Governments can choose how they collect tax revenues. The IMF and World Bank traditionally split these modes of taxation into three types: 1) Taxes on income, profits, and capital gains, which tend to be progressive because the poor pay a smaller proportion of their income; 2) Taxes on goods and services, which tend to be regressive because the poor pay a larger share of their income; and 3) Other taxes, such as property taxes. In recent years, low- and middle-income countries have tended to rely more heavily on taxes on goods and services because they are easier to collect. However, they can also increase the cost of staple foods and healthcare, unless these specific goods and services are exempt from such taxation. Because taxes on goods and services can increase the cost of food and healthcare they may also reduce access to these necessities among economically deprived households and communities.
With the same tax data described above, we examined whether changes in taxation within a country over time was associated with changes in infant mortality. The results were clear. Where taxes on goods and services increase (thereby increasing the cost of food and healthcare) infant mortality also increased. However, where taxes on income, profits, and capital gains increase (progressive taxation) we do not find this same relationship.
Expanding the tax base in low- and middle-income countries can be difficult, especially if governments are going to rely on income, profits, and capital gains. This is because there is a very large informal economy in many of these countries, tax revenues from income can be unstable. Yet, the UK government has shown how some countries can increase revenues through reducing corporate tax evasion. Under the direction of DFID, tax accountants worked with two developing countries (Ethiopia and Tanzania) to reduce tax evasion, increasing tax revenues by 40% in 3 years. This type of intervention is especially important because before the Ebola outbreak in Sierra Leone, only one in five leading mining companies had paid any corporate income tax. If they had been adopted sooner, such interventions could have strengthened the health systems in Sierra Leona and other Ebola-hit countries.
Tax is not sexy. Tax is not necessarily innovative. But, tax is the cornerstone on which we can achieve UHC.
This post is based on: Reeves A., Gourtsoyannis Y., Basu S., McCoy D., McKee M., Stuckler D., 2015, Financing universal health coverage: effects of alternative tax structures on public health systems in 89 low- and middle-income countries. The Lancet, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60574-8/abstract
As the Government of Ghana gears up its plans to celebrate the 10th anniversary of its now internationally famed National Health Insurance Scheme, Ghana’s Universal Access to Healthcare Campaign today launch our own assessment of progress to date. Our new paper explains how 65% of the population is still paying out-of-pocket in the old ‘cash and carry’ system and that at the current rate of progress UHC will not be achieved until at least the year 2076. Our campaign argues that progress will continue to stall as long as the NHIS structure excludes the very people it seeks to protect through overly-burdensome and unworkable insurance premiums.
Next week Ghana’s National Health Insurance Authority (NHIA) will host a three day International conference in Accra with the theme: “Towards Universal Health Coverage: Increasing Enrolment whilst Ensuring Sustainability”. The conference will attract Universal Health Coverage (UHC) practitioners, academia, policy makers, NGOs and CSOs in their numbers, and seeks to examine the successes and challenges of the NHIS, and elicit feedback and proposals for reform.
While the Universal Access to Healthcare Campaign (UAHCC ) welcomes the anniversary event, we are concerned that inherent pitfalls of the NHIS have been consistently left on the sideline over the past decade and if unadressed will stifle any prospect the NHIS has of achieving UHC in the near future. The UAHCC will convey this position at the anniversary conference, where we have been invited to participate in a panel discussion, but also in our own civil society forum today to which government officials and donor agency staff have been invited.
The paper launched today acknowledges some strengths of the scheme including its generous benefits package, comprehensive level of care and treatment coverage and relatively broad range of exemption categories. However, these strengths are only relevant to NHIS active members. The UAHCC calls on the Government of Ghana to act on the glaring short falls of the scheme including:
Sidua Hor is coordinator for the Ghana Universal Access to Healthcare Campaign Coalition
“We must be the generation that delivers universal health coverage.” – WBG President Jim Yong Kim in a speech to the World Health Assembly, May 2013
As the World Bank Group’s Annual Meetings come to Washington this weekend, there is much talk of President Jim Yong Kim’s new strategy to achieve the institution’s updated vision: to end extreme poverty by 2030 and promote “shared prosperity,” Bank-speak for reducing inequality.
We would argue that pursuing Universal Health Coverage (UHC) – alongside robust investments in other aspects of human development – must be utterly central to the Bank’s strategy to achieve its two goals. While Dr. Kim’s Annual Meetings opener speech last week touched on the importance of health (and education) in achieving its goals, human development is not articulated as a central component of the Bank’s new strategy to achieve the goals, which its Board will be approving on Saturday.
The Bank says this is because the strategy is meant to describe an overall approach rather than privileging any particular sector. That may be, but it is hard to see how the Bank’s two goals can be met without a clear vision for how the fruits of economic growth can be equitably shared through transformative essential public services. We hope to see this change as the implementation details of the strategy become clearer.
Nevertheless, President Kim’s recent speeches and writing provide clues to his vision of the importance of health in reducing poverty and inequality. In a recent article he wrote that “to free the world from extreme poverty by 2030, countries must ensure that all their citizens have access to quality, affordable health services.” At the World Health Assembly in May, he pointed to a hopeful new direction for the Bank by committing to help countries work towards UHC and stating that point-of-service fees are “both unjust and unnecessary.” But will these high level statements really translate to a change in the way the Bank works in countries?
We hope so. The Bank’s expertise in building health systems can be powerfully harnessed for the cause of UHC, but this means a break from business as usual. Building health systems isn’t enough; they must be the right kinds of systems — systems that are equitable and truly universal.
Oxfam’s new paper, “Universal Health Coverage: Why health insurance schemes are leaving the poor behind,” examines the conditions necessary for health systems to be equitable and universal. The paper looks at four key ingredients to successful financing for UHC: removal of direct payments and other financial barriers, compulsory pre-payment, large risk pools, and financing from general revenues to cover the uncovered. In our analysis, conventional insurance schemes – whether private, community-based or European-style social health insurance – come up short when measured against these criteria.
Since UHC is about access to quality care for everyone regardless of ability to pay, governments must move away from relying on employment-based and contributory insurance models. Instead, health care must become a right of citizenship (or residency), financed in large part through general government revenues. As the diverse but successful UHC experiences of Mexico, Thailand, Sri Lanka, Brazil and Kyrgyzstan show, equity must be designed into the system from the beginning, rather than starting with the easiest to reach in the formal sector.
The World Bank Group has a history of promoting health insurance as a financing mechanism to generate revenues in the health sector in environments of fiscal constraints. Some examples include a recent policy series on private health insurance, previous work in countries such as Ghana, and IFC investments to support insurance schemes in Africa.
But things may be changing at the Bank. In a series of 22 recently released case studies on UHC, the Bank finds that, across countries, the use of financing from general taxation to expand coverage is an important commonality, and that prioritizing equity is a key lesson. We also hear the Bank is playing a more constructive role in certain countries to encourage universal system design. And new leadership in the health sector and from the President should be cause for optimism.
A real test of the potency of the new World Bank strategy will be whether the World Bank Group throws its full weight behind equitable, universal health systems – systems that are financed largely through tax-based general revenues and which include all members of society – through its global knowledge products, its policy advice and technical assistance, and through its lending choices.
In a new report published today, Oxfam is warning that health insurance schemes introduced in the name of universal health coverage (UHC) are excluding the majority of people and leaving the poor behind.
While the new growing momentum for UHC is welcome there is a concern that the mistakes of history could be repeated. The optimism in 1978 following the Alma Ata ‘Health for All’ declaration was quickly replaced by disillusionment as influential donors failed to act on the shared vision of comprehensive universal primary health care. They financed low cost selective interventions instead. Today, a similar danger exists as we witness a wide range of ‘business as usual’ interventions being rebranded as ‘UHC’ despite them bearing little resemblance to the World Health Organisation’s UHC principles.
This is certainly the case for health financing. Our new report takes a critical look at the almost exclusive focus of some donors and low and middle income countries on contributory insurance schemes as the way to achieve UHC. Such schemes fail to provide coverage for the majority of citizens and serve to divert attention away from needed reforms to national and international tax systems that could raise significant additional revenues for health.
Voluntary insurance – private and community-based – has never worked to achieve UHC yet is still being widely promoted. India’s voluntary RSBY insurance scheme for people below the poverty line is widely praised as a success but offers limited financial protection and has skewed public resources to curative rather than preventative care.
For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries, but attempts to replicate in poorer countries have proved unsuccessful. In practice SHI schemes usually start with the small number of easy-to-reach formally employed and then struggle to scale up beyond. Premiums are too expensive for most and schemes become de facto voluntary, leading to large scale exclusion. Ten year old national insurance schemes in Tanzania and Ghana cover only 17% and 36% of citizens respectively. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans.
Hopes that insurance contributions from those outside of formal employment would raise significant additional revenue have also not been realised. In Ghana, premiums paid by the informal sector contribute just five per cent towards the cost of the national scheme. Governments also face huge bills to cover the SHI contributions of their workers. The Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.
Instead of importing inappropriate health financing models from high-income countries, our paper recommends that developing country governments look to learn from the increasing number of home-grown UHC success stories in other, more comparable countries.
The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency (not employment status or financial contribution) and while specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population. According to WHO, only eight of 49 low-income countries will be in a position to fully finance UHC from domestic resources in 2015 so international aid will continue to play a crucial role.
The focus on health insurance seems to have served as a distraction for the international health community from the key ingredient for all UHC success stories – public financing. Rather than focus efforts on collecting contributions from people who are too poor to pay, governments and donors should look to reform national and international tax systems in order to generate significant and urgently needed revenue for health. Oxfam estimates that strengthening tax administration alone could raise an additional 31 per cent of tax revenue across 52 developing countries, amounting to $269bn in increased domestic resources. Enough to double health budgets in these countries.
The growing momentum for UHC is welcome, exciting, and challenging. However, if we are to heed World Bank President Jim Kim’s warning that UHC could easily become a ‘toothless slogan’, then UHC advocates must stand true to the WHO UHC principles to reduce out of pocket payments, introduce mandatory pre-payment, create large risk pools and scale up public financing to cover those who cannot afford to contribute. To these we add that entitlement to health coverage should be based on citizenship and/or residence, and that progress can only be considered progress if women and men living in poverty benefit at least as much as the better off at every step of the way towards UHC.
Oxfam’s report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ is available to download from www.oxfam.org/uhc
Anna Marriott is a Health Policy Advisor for Oxfam and editor of Global Health Check
About a year ago, at the AIDS 2012 conference in Washington DC, I wondered why the theme universal health coverage was virtually absent from the conference. It looked as if UNAIDS’ universal test-and-treat strategy and WHO’s universal health coverage plan were designed for two different worlds, as I argued in a blog post then. Such a division of global health advocates was bad news for global health, in my opinion, especially in light of the coming MDG negotiations. We should not count on three or more health-focused MDGs this time.
But I also understood why the AIDS activists at the conference were wary about supporting universal health coverage. The key UN resolutions about universal health coverage – the 2005 World Health Assembly resolution and the 2012 UN General Assembly resolution – hardly mention international responsibility or solidarity. The 2005 WHA Resolution mentions international assistance in its preamble – “Noting that some countries have recently been recipients of large inflows of external funding for health” – while the 2012 UNGA Resolution mentions “universal health coverage on the basis of solidarity at national and international levels”, but none of them admit that real universal health coverage will require considerable levels of international assistance during decades to come. With real universal health coverage, I mean “that people should have access to all the services they need”.
Universal health coverage “developed within the particular epidemiological, economic, socio-cultural, political and structural context of each country in accordance with the principle of national ownership”, as it is formulated in the 2012 UN General Assembly resolution, could mean anything and everything. In low-income countries, it could mean something that looks a lot like selective primary health care, excluding antiretroviral treatment. For AIDS activists, universal health coverage could mean a giant step backwards, so even if I deplored the lack of support for universal health coverage by many of them, I didn’t expect them to change their position.
But I was proven wrong by the International HIV/AIDS Alliance that came out with a statement in support of “universal health coverage, including universal access to HIV prevention, treatment, care and support and universal access to sexual and reproductive health services via a rights-based approach” first, and for universal health coverage as a “key mechanism for achieving the health goal” more recently. The words that matter are “rights-based approach”, as universal health coverage anchored in the right to health requires at least comprehensive primary health care, with duty-based international assistance to countries that are unable to provide comprehensive primary health care without assistance.
Wishful thinking? The UN Sustainable Development Solutions Network (UNSDSN) doesn’t think so. A few days ago, it presented a draft report on health financing in the sustainable development framework, inviting everyone to comment before October 15, 2013. There’s a comment form to be used, but the UNSDSN will forgive me for using a different channel. The draft report proposes targets for “Public health care expenditure as a percent of GDP (Gross Domestic Product)” – 3% of GDP in low income countries; 3.5% in lower middle income countries; 4% in upper middle income countries; 5% in high income countries – and also for “ODA (Official Development Assistance) for health as percent of GNI (Gross National Income) – Minimum of 0.1% of GNI in high-income countries. When these percentages are applied to present GDP levels of all countries of the world, allocating international assistance on the basis of ‘poorest countries first’, universal health coverage at a minimum value of 50 US dollars per person per year becomes possible. That is still cheap, but it should allow financing comprehensive primary health care, including antiretroviral treatment.
The UNSDSN proposal will meet resistance, and not only from high-income countries, which are being expected to double their international assistance for health – from about 0.05% to 0.1% of GDP (from 5 cent to 10 cent out of every 100 dollars). The net ‘cost’ of this proposal will be higher for low income countries, which are being expected to increase their public health care expenditure from domestic resources with at least 1% of GDP – from the present level of 2% of GDP to 3% of GDP, see World Health Statistics 2013, page 140.*
Not feasible? Well, that was also said when antiretroviral treatment was started in low income countries, or when user fees were removed. If all global health advocates unite, it is possible.
You have until October 15 to express your support for #RealUHC here. And on Twitter, of course. And elsewhere.
* If you want to look it up, don’t get confused by the ‘total expenditure on health as percentage of GDP’ column. Total health expenditure combines government and private (including out of pocket expenditure), but the UNSDSN proposal of 3% of GDP for low income countries is about government health expenditure only. In low income countries, the average total health expenditure amounted to 5.3% of GDP (in 2010). Government expenditure made up only 38.5% of this figure in the same year meaning that government expenditure on health, on average, amounted to 2% of GDP – the UNSDSN wants that to increase to 3% of GDP.
Gorik is a human rights lawyer, researcher at the Institute of Tropical Medicine, Antwerp, and adjunct professor of law at Georgetown University, Washington DC.