Setting Priorities, Building Prosperity Through Universal Health Coverage

Keywords:

• universal health coverage
• UHC, priority setting
• Sustainable Development Goals
• SDGs

Since 2000, a growing number of governments around the world have made the political commitment to undertake reforms toward universal health coverage (UHC). According to analysis at the World Bank, UHC efforts in 24 front-runner countries have been massive and transformational.¹ With the recent adoption of UHC as a target in the Global Sustainable Development Goals for 2030, policy makers are more than ever making it a priority to ensure that all of their citizens have access to quality, essential health services and that no one falls into or remains in poverty because of paying for the care they need.

The World Bank Group has embraced the goal of UHC because the links between poverty and poor health are clear. Countries as diverse as Turkey and Thailand have shown that through UHC, not only can they expand life-saving care but they can reduce poverty and drive economic growth and opportunity.

UHC: DRIVEN BY VALUES AND PRIORITIES

The growing global support for UHC is driven first and foremost by the fact that it reflects values related to the right to health and health care, as embodied in the World Health Organization constitution. However, the UHC movement also reflects the values that underpin the World Bank Group's twin goals of ending extreme poverty and boosting shared prosperity by 2030. This focus on the poorest and most vulnerable populations and on achieving equity in health and development should guide the rapid growth of health systems everywhere.

The pursuit of UHC brings into focus the translation of these underlying values of the right to health and equity in the context of finite resources. Through financing reforms that focus on prepayment and pooling, UHC provides an opportunity for policy makers to make informed choices about where to allocate resources to meet the health needs of their population as equitably and efficiently as possible. This contrasts markedly with health systems that have no significant pooling and where priorities reflect the decisions of individuals when they fall sick. Such “pay when you have to” financing systems are both inequitable and inefficient.

PRIORITY SETTING: A RAPIDLY MATURING SCIENCE THAT MUST TACKLE NEW FRONTIERS

Ensuring that resources pooled in UHC are used most effectively points to the need for better criteria to inform allocation. The rapidly growing science related to rational choice and relative cost-effectiveness will help inform better decision making. For example, analysis that proves that a new drug is not cost-effective may lead to a decision not to include it in a universal benefit package and/or help to negotiate a much lower price with the manufacturer.

There is also growing evidence as to how the organization and management of health delivery systems can save—or squander—scarce resources. Examples include effective management of supply chains that prevents stock-outs of life-saving drugs on the front lines or “demand-side” payments to poor mothers to access health-promoting interventions for their children. These results- or performance-based approaches are forcing the science of priority setting to stretch beyond the “what” of single disease interventions and embrace the “how” of health service delivery.

PRIORITIZING PRIORITY SETTING

Of course, priority setting is never easy. Constitutional amendments related to the right to health that often accompany reforms toward UHC can be interpreted in ways that place the right of the individual to health at odds with rational approaches to priority setting for the population. Furthermore, as the recent Ebola crisis in West Africa revealed, health needs are often not predictable and/or do not lend themselves to rational priority setting due to overwhelming uncertainty, a lack of evidence of what works, and a need to respond immediately. Likewise, despite strong evidence of what constitutes “best buys” for a health system, there are a set of de facto realities that can distort priorities. For example, well-staffed institutions like tertiary care hospitals are capable of billing for curative care, procedures, and diagnostics at such high volumes that they can skew allocation priorities away from primary and preventative care. In addition, priority setting—which is often focused on national needs—must be able to reflect diverse contexts such as decentralization and the needs of specific populations, such as those living in urban slums.

BUILDING CAPACITY FOR PRIORITY SETTING IS A TOP PRIORITY

Thus, countries must build their core capacity to enable effective priority setting. Driven by new health technologies, consumer demand, and demographic and epidemiologic transitions toward aging and chronic disease, there will be growing calls for more explicit criteria to justify decisions on the use of scarce resources. Unfortunately, too many health systems lack the requisite reservoir of capacity to meet this fast-growing agenda for evidence-based policymaking.

There are three critical types of investments to build capacity. First, individual capacities must be nurtured through the development of strong cohorts of students well versed in decision sciences. Second, institutional capacities for priority setting must be secured in all countries drawing on leading-edge models, such as England's National Institute for Health and Care Excellence or Thailand's Health Intervention and Technology Assessment Program, and drawing on regional networks for sharing and learning. Third, and too often forgotten, is the need to invest in the information capacities of a country to generate the core demographic, epidemiologic, and economic data required. Good quality and timely data are essential to harnessing the opportunity for evidence-informed priorities that will accelerate progress toward UHC.

Last but not least, development partners also must be on board and ensure that their priorities are well aligned with those of their country partners. This will be increasingly important as countries prepare to transition economically from low- to middle-income status and face a declining share of official development assistance relative to their domestic resources. However, by “prioritizing priority setting,” we can all help countries realize the promise of UHC for their citizens.

DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST

No potential conflicts of interest were disclosed.