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Addressing health inequities through Universal Health Coverage

Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to drive countries to implement equitable pathways towards UHC by including appropriate targets and metrics in the post-2015 development framework. These are the main messages of Universal Health Coverage: A commitment to close the gap – a joint report launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO. Research commissioned for the report includes a structured literature review, a Lives Saved Tool (LiST) [1] analysis, an econometric analysis and key informant interviews.

Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. As the LiST analysis reveals, the deaths of 1.8 million children under-five and 100,000 mothers could be averted each year by eliminating within-country wealth inequities in coverage of essential maternal and child health interventions in 47 of the 75 Countdown to 2015 countries [2]. This would reduce maternal and child mortality by almost one-third and one-fifth respectively [3].

The econometric analysis demonstrates that more equitable health financing saves lives. If the share that is pooled funding were to increase by 10 percentage points while keeping total health expenditure constant, it is estimated that 15 fewer deaths would occur per 1,000 live births in the under-five mortality rate of an average country. This could enable 13 countries that are currently off-track to achieve their MDG 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, this effect is amplified [4].

Despite huge improvements in health outcomes and access to health care – for instance the reduction by almost half in the number of children who die each year from 1990 rates – too many people are denied their right to health. For instance, 6.6 million children still died before the age of five last year, and most of these deaths could have been prevented. Overreliance on out-of-pocket payments for health care both deters the poor from accessing care and exacerbates poverty, with 150 million people estimated to incur catastrophic expenditures for health care each year. This is a scandal that must be addressed.

The health system’s response to this challenge must be Universal Health Coverage – defined as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement policy reforms.

The report identifies emerging policy lessons for equitable pathways towards UHC in low- and middle-income countries, focusing primarily on health financing. It reinforces the importance of increased equitable funding for health through mandatory, progressive prepayment mechanisms including revenues from taxation and the elimination of out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. And a universal benefit package should be designed to meet the needs of the poorest and most vulnerable first through strategic purchasing, while aligning provider incentives to promote quality of care. The report also calls for a whole-system approach to UHC, acknowledging the importance of coordinated reforms across health system building blocks. Overcoming pervasive inequities in the coverage of quality health services and financial risk protection will also require concurrent efforts on the wider social determinants of health. And enabling factors, notably political will and strong mechanisms for effective accountability, are also critical to the implementation of equitable pathways towards UHC.

As the Millennium Development Goals have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, embedded through clear targets and indicators that strengthen health systems and close the equity gap.

A presentation of the report followed by a panel discussion will take place in New York on the 23rd September from 18.00-20.00 at the Rockefeller Foundation 420 Fifth Avenue (between 37th and 38th Streets). For more information and to RSVP, please contact: health@rockfound.org.

Lara Brearley is a Senior Health Policy & Research Adviser at Save the Children UK

[1] The Lives Saved Tool is a computer-based tool that combines information about effectiveness of interventions for maternal, neonatal and child health with information about cause of death and current coverage of interventions. It permits an estimation of the differences in impact across different scenarios as intervention packages and coverage levels are varied. See http://www.jhsph.edu/departments/international-health/centers-and-institutes/institute-for-international-programs/list/
[2] Countdown to 2015 is a multi-disciplinary, multi-institutional collaboration using country-specific data to stimulate and support country progress towards achieving the health-related MDGs. Countdown tracks progress in the 75 countries where more than 95% of all maternal and child deaths occur, including the 49 lowest-income countries. See http://www.countdown2015mnch.org/
[3] In this analysis, the major assumptions made include: that the national coverage is scaled up to its target coverage of the highest wealth quintile linearly in their period of 2013 to 2015; that target coverage of vaccines modelled in the analysis – Hib, PCV, Rotavirus – will reach the DTP coverage of the richest quintile; that interventions coverage did not change between the estimates abstracted from the most recent DHS / MICS and our base year of analysis of 2013.
[4] MDG 4 achievements are based on the key following assumptions: (1) The increase in the pooled share of spending is assumed to be achieved by replacing previous OOPS with pooled spending (ie, keeping total national health spending unchanged); (2) The count of countries that could reach MDG targets by 2015 is based on projected changes in under-five mortality rates from 2012-2015, calculated using the average annual reduction rate from 1990-2011, and the difference between projected and target (based on a two-thirds reduction) rates for 2015; (3) The calculations of MDG progress and achievement are for the 75 Countdown countries. The countries that could reach MDG targets by 2015 are based on projected changes in U5MR from 2012-2015, calculated using the average annual reduction rate from 1990-2011, and the difference between projected and target (based on a 2/3 reduction) rates for 2015.

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni