WHO Director-General addresses the economic dimensions of universal health coverage
Dr Margaret Chan
Director-General of the World Health Organization
UN Secretary-General Ban Ki-moon, honourable ministers, distinguished participants, our good friends from the World Bank and the International Monetary Fund, ladies and gentlemen,
The Lancet Commission on Investing in Health reaches some very welcome conclusions. Advances in health economics allow better quantification of the gains from investing in health. These gains are even higher than previously calculated.
In the allocation of finite budgetary resources, making the right investments in health improves social welfare and stimulates economic growth. If investments continue in smart, strategic, and selective ways, dramatic gains in health outcomes are predicted.
These gains include a grand convergence, within a generation, with mortality rates in mothers and children in low- and middle-income countries dropping to levels seen in high-performing middle-income countries, which took much longer to achieve such results.
Reforms that move health systems towards universal coverage are put forward as a route to this convergence.
I warmly welcome this ambitious investment framework, the firm emphasis on equity that comes with support for universal coverage, and the optimistic outlook for the future of global health.
In a significant departure from the 1993 World Development Report, the Commission recognizes the instrumental role of public financing in realizing the goals of increased service coverage and improved financial protection.
As clearly stated, universal coverage cannot be achieved through private market-based systems of user fees and private insurance, or through voluntary community-based schemes.
The Commission is optimistic that funds for public financing will increase as economies grow and tax administration improves.
Recommendations for investing in health are centred around two broad objectives: to maintain the momentum to reach the health-related MDGs, and to address newer challenges associated with modernization, urbanization, and motorization, namely chronic conditions and injuries.
In a particularly useful analysis, the report takes forward policy options set out in the 2010 World Health Report on health systems financing. These options respond to a central question. Why do some countries achieve better health outcomes with the same resources?
Proposed options address the main barriers to equitable and cost-effective care, including waste and inefficiency, perverse provider incentives, underinvestment in preventive services, and insufficient attention to the root causes of ill health that reside in non-health sectors.
Special attention is given to strategies for avoiding unproductive cost increases, especially costs associated with new technologies. Clear policy objectives call for minimizing fee-for-service payments to providers and the reduction or elimination of user fees, especially for the poor.
As noted, an insurance scheme that covers the entire population, as opposed to focusing exclusively on the poor, promotes broader acceptance among populations and providers, as it benefits the middle classes. It also tends to drive up the quality of care.
For noncommunicable diseases, the Commission singles out taxes and subsidies, laws and regulations as efficient ways to achieve population-wide risk reduction. For clinical care, it recommends that countries initially aim for universal coverage with WHO “best buy” interventions, then choose among several pathways for expanding access.
Ladies and gentlemen,
During this meeting, you will be considering a joint WHO/World Bank framework for monitoring progress towards universal health coverage. The framework has two main components: level of coverage for health interventions, and financial risk protection, with a focus on equity.
The discussion paper notes the need to adapt the framework to each country’s context, including its unique epidemiological and demographic profile, the expectations of its population, the existing health system, and the level of economic development.
At the same time, three common domains for monitoring should be used in all countries. Namely: access to essential quality services, financial protection, and the population covered.
For service coverage, the aim is to monitor progress for the full spectrum of services, including health promotion, prevention, treatment, rehabilitation, and palliative care.
This range of services is simplified into two broad categories covering services for promotion and prevention, and services for treatment and care. Half a dozen coverage indicators are proposed to monitor each of the two categories, to be tracked individually and as a composite measure.
The services include interventions for infectious diseases, reproductive health, and maternal and child health, and interventions for the prevention of risk factors and the treatment of chronic conditions, across all age groups. Countries can also use a broader set of service coverage indicators, in line with their own situation.
Internationally standardized indicators should be used for both categories, although more work is needed to identify reliable and comparable indicators for treatment and care.
Two measures are proposed to monitor coverage with financial protection: the incidence of catastrophic expenditures, and the incidence of impoverishment associated with out-of-pocket health care expenditure. Catastrophic expenditures would also be disaggregated by wealth quintile, gender, and place of residence.
The proposed framework has some strengths but also faces some challenges. I look forward to your discussions on this issue and the other items on our agenda.