Policy brief Access to care and financial protection for all The challenge of scaling up towards universal coverage b Many Respect basic principles of prepayment and pooling> Pre-payment countries are far from achieving universal coverage because there is for health care can be organized by collecting health revenues through still a large supply gap, financial barriers may deter families from the general taxation, social health insurance schemes or mixed systems uptake of services, or there is no system offering financial protection. The Whichever way financing is organized, two design features are especially magnitude of the challenge of scaling up and financing health services so important for governments striving for universal access with financial as to establish universal coverage should not be underestimated. There is protection. First, no population groups should be excluded. Second, ma- a long way to go. For example, in the 75 countries in which almost all of the ternal, newborn and child health services should be part of the set of worlds burden of maternal, newborn and child ill-health are concentrated, core services that are covered in the benefit package; policies to move 7% of mothers and children do not have access to the care they need, towards universal coverage are just empty shells if they do not have the because of insufficient supply, because of financial barriers to access, whole range of MNCH interventions at the core of the package of guar- or for other reasons. The remaining 43% currently do receive care, but anteed benefits. If these two conditions are met, whether best usually not the full range of what they need. They often spend be provided through public employees, or purchased from non-for-profit considerable amounts of money to get care; their expenditure on health NGOs or private entrepreneurs, is a matter of what is most effective and care may be high enough to push them into poverty efficient in a given context. Organizing the financing of the health sector for universal Rapidly achieve universal coverage in countries where dense health care coverage p The organization of the financing of the health sector must networks already exist To organize universal coverage it is necessary to combine three key concerns: first, ensuring that there is a sufficient supply consider all sources of funding in a country: public, private, external and of service networks to respond to the need and demand for care of all moth- domestic. Sometimes the political and economic context allows for a ers and children; second, keeping financial barriers to service uptake low very rapid combination and extension of pre-payment schemes. Some enough as not to exclude any mother or child in need; and third, protecting low-middle income countries have made a quantum leap in extending all mothers and children against the financial hardship that results from entitlements to the whole population and achieving near-universal paying for care. coverage. This is possible in conditions where the health care network is already well developed and political will can be mobilized to commit the additional public funds necessary for health care to include all citizens TAKING THE LEAD: POLICY RECOMMENDATIONS Phase out user fees In many places the lack of serv- Start early> In many countries, it may take many years before access ices is the immediate impediment to universal access. and financial protection are available for all. The road ahead may seem Filling the supply gap is then the first priority. To help them do this many very long indeed, particularly for the poorest countries, where health care countries have tumed to user fees. In the countries where the health of networks are sparsely developed, financial protection schemes hardly mothers and children is worst out-of-pocket payments for user fees can exist and health financing is highly dependent on external funds. It is be two to three times the combined expenditure of governments and important, particularly for the poorest countries, to move towards prepay- honors. Out of pocket payments occur in many settings: to private ment systems from a very early stage and to resist the temptation to rely providers and drug sellers; as official user fees in public facilities; and on user fees. This builds the institutional capacity to manage the financing as informal payments' in supposedly free public facilities. Experience of the system along with the extension of supply. It is also important that suggests that even where official user fees are well-regulated and help international funding, which often has a strategic role in these countries, revitalise previously moribund services, the drawbacks for the poorest be channeled through such nascent pre-payment and pooling schemes usually exceed the benefits By and large, the introduction of user fees is and institutions rather than through project or programme funding not a viable answer to the under funding of the health sector and the need This channeling must be done for two reasons. First, it helps build the to expand supply; it institutionalizes exclusion of the poor and does not institutional capacity to develop and extend supply, access and financial accelerate progress towards universal coverage. Nevertheless, abolishing protection in a balanced way. Second, it makes external funding more user fees where they exist is not a panacea. It needs to be accompanied, stable and predictable -an essential condition to become more effective from the very day they are brought to an end, by structural changes and a in tackling major system constraints such as the human resource crisis refinancing of the health services Combine schemes There is no single road map for acie Shift from out of pocket payments to pre-payment and ing universal coverage. As countries expand their health care ooling Rather than relying on collectinguserfeesfrom sickindividuals, itis networks, and simultaneously try to move away from user fees and possible to organize systems of prepayment. Collecting funds ahead provide financial protection, they often also supplement the limited of time has several advantages. It means individuals do not have high coverage of public tax-based financing or social health insurance schemes expenses when sick- when their income may be lower than usual. It through a multitude of voluntary insurance schemes: community, allows for pooling of funds so that there can be cross subsidies between cooperative, employer-based and other private schemes. It requires a the rich and the poor, and the healthy and the sick. These pooled funds great deal of political savoir-faire to creatively combine all these schemes can then be used to pay for services, available when people need them, in view of moving towards universal coverage. Where the voluntary that significantly increase protection against the financial consequences private prepayment schemes protect middle or higher income groups from of ill-health. There is a wealth of evidence that financial protection is financial catastrophe, limited public resources are earmarked for the greater in those countries in which there is more pre-payment for health poorest Where social health insurance covers workers in the formal are and less out-of-pocket payment. Studies suggest that if out-of- sector, it may be possible to extend coverage to dependents and the pocket spending could be reduced to levels lower than 15% of total self-employed, using general tax revenue to pay insurance contributions health spending very few households would be affected by catastrophic for the poor. Various routes are possible, but during such a transition, payments. There is a strong case for replacing out-of-pocket payment of population coverage is by definition incomplete. a major concen is how user fees by pooled prepayment systemsPolicy brief Access to care and financial protection for all The challenge of scaling up towards universal coverage ► Many countries are far from achieving universal coverage because there is still a large supply gap, financial barriers may deter families from the uptake of services, or there is no system offering financial protection. The magnitude of the challenge of scaling up and financing health services so as to establish universal coverage should not be underestimated. There is a long way to go. For example, in the 75 countries in which almost all of the world’s burden of maternal, newborn and child ill-health are concentrated, 57% of mothers and children do not have access to the care they need, because of insufficient supply, because of financial barriers to access, or for other reasons. The remaining 43% currently do receive care, but usually not the full range of what they need. They often spend considerable amounts of money to get care; their expenditure on health care may be high enough to push them into poverty. Organizing the financing of the health sector for universal coverage ► The organization of the financing of the health sector must combine three key concerns: first, ensuring that there is a sufficient supply of service networks to respond to the need and demand for care of all moth￾ers and children; second, keeping financial barriers to service uptake low enough as not to exclude any mother or child in need; and third, protecting all mothers and children against the financial hardship that results from paying for care. TAKING THE LEAD: POLICY RECOMMENDATIONS Phase out user fees ► In many places the lack of serv￾ices is the immediate impediment to universal access. Filling the supply gap is then the first priority. To help them do this many countries have turned to user fees. In the countries where the health of mothers and children is worst out-of-pocket payments for user fees can be two to three times the combined expenditure of governments and donors. Out of pocket payments occur in many settings: to private providers and drug sellers; as official user fees in public facilities; and as ‘informal payments’ in supposedly free public facilities. Experience suggests that even where official user fees are well-regulated and help revitalise previously moribund services, the drawbacks for the poorest usually exceed the benefits. By and large, the introduction of user fees is not a viable answer to the under funding of the health sector and the need to expand supply; it institutionalizes exclusion of the poor and does not accelerate progress towards universal coverage. Nevertheless, abolishing user fees where they exist is not a panacea. It needs to be accompanied, from the very day they are brought to an end, by structural changes and a refinancing of the health services. Shif t from out of pocket payments to pre-payment and pooling► Rather than relying on collecting user fees from sick individuals, it is possible to organize systems of prepayment. Collecting funds ahead of time has several advantages. It means individuals do not have high expenses when sick - when their income may be lower than usual. It allows for pooling of funds so that there can be cross subsidies between the rich and the poor, and the healthy and the sick. These pooled funds can then be used to pay for services, available when people need them, that significantly increase protection against the financial consequences of ill-health. There is a wealth of evidence that financial protection is greater in those countries in which there is more pre-payment for health care and less out-of-pocket payment. Studies suggest that if out-of￾pocket spending could be reduced to levels lower than 15% of total health spending very few households would be affected by catastrophic payments. There is a strong case for replacing out-of-pocket payment of user fees by pooled prepayment systems. Respect basic principles of prepayment and pooling ► Pre-payment for health care can be organized by collecting health revenues through general taxation, social health insurance schemes or mixed systems. Whichever way financing is organized, two design features are especially important for governments striving for universal access with financial protection. First, no population groups should be excluded. Second, ma￾ternal, newborn and child health services should be part of the set of core services that are covered in the benefit package; policies to move towards universal coverage are just empty shells if they do not have the whole range of MNCH interventions at the core of the package of guar￾anteed benefits. If these two conditions are met, whether care can best be provided through public employees, or purchased from non-for-profit NGOs or private entrepreneurs, is a matter of what is most effective and efficient in a given context. Rapidly achieve universal coverage in countries where dense health care networks already exist ► To organize universal coverage it is necessary to consider all sources of funding in a country: public, private, external and domestic. Sometimes the political and economic context allows for a very rapid combination and extension of pre-payment schemes. Some low-middle income countries have made a quantum leap in extending entitlements to the whole population and achieving near-universal coverage. This is possible in conditions where the health care network is already well developed and political will can be mobilized to commit the additional public funds necessary for health care to include all citizens. Start early ► In many countries, it may take many years before access and financial protection are available for all. The road ahead may seem very long indeed, particularly for the poorest countries, where health care networks are sparsely developed, financial protection schemes hardly exist and health financing is highly dependent on external funds. It is important, particularly for the poorest countries, to move towards prepay￾ment systems from a very early stage and to resist the temptation to rely on user fees. This builds the institutional capacity to manage the financing of the system along with the extension of supply. It is also important that international funding, which often has a strategic role in these countries, be channeled through such nascent pre-payment and pooling schemes and institutions rather than through project or programme funding. This channeling must be done for two reasons. First, it helps build the institutional capacity to develop and extend supply, access and financial protection in a balanced way. Second, it makes external funding more stable and predictable – an essential condition to become more effective in tackling major system constraints such as the human resource crisis. Combine schemes ► There is no single road map for aciev￾ing universal coverage. As countries expand their health care networks, and simultaneously try to move away from user fees and provide financial protection, they often also supplement the limited coverage of public tax-based financing or social health insurance schemes through a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes. It requires a great deal of political savoir-faire to creatively combine all these schemes in view of moving towards universal coverage. Where the voluntary private prepayment schemes protect middle or higher income groups from financial catastrophe, limited public resources are earmarked for the poorest. Where social health insurance covers workers in the formal sector, it may be possible to extend coverage to dependents and the self-employed, using general tax revenue to pay insurance contributions for the poor. Various routes are possible, but during such a transition, population coverage is by definition incomplete. A major concern is how 3_universal_rsvd 1.indd 2 2005-03-24 18:42:19