Year : 2018 | Volume
: 7 | Issue : 1 | Page : 1--4
Universal health coverage in the World Health Organization South-East Asia Region: how can we make it “business unusual”?
Poonam Khetrapal Singh1, Phyllida Travis2,
1 World Health Organization Regional Director for South-East Asia, New Delhi, India
2 Director, Department of Health System Development World Health Organization Regional Office for South-East Asia, New Delhi, India
Director, Department of Health System Development World Health Organization Regional Office for South-East Asia, New Delhi
|How to cite this article:|
Singh PK, Travis P. Universal health coverage in the World Health Organization South-East Asia Region: how can we make it “business unusual”?.WHO South-East Asia J Public Health 2018;7:1-4
|How to cite this URL:|
Singh PK, Travis P. Universal health coverage in the World Health Organization South-East Asia Region: how can we make it “business unusual”?. WHO South-East Asia J Public Health [serial online] 2018 [cited 2020 Feb 27 ];7:1-4
Available from: http://www.who-seajph.org/text.asp?2018/7/1/1/228420
This issue of the WHO South-East Asia Journal of Public Health coincides with World Health Day, which this year focuses on universal health coverage (UHC). UHC means all people get the health care they need, without suffering financial hardship. Member States of the World Health Organization (WHO) South-East Asia Region are at very different stages along the path towards UHC, but no country is starting from zero. Even so, the challenge is formidable, and there is growing recognition that “business as usual” is not an option.
An increasing unity of purpose for universal health coverage
There is currently a “grand convergence” of global attention to accelerate progress towards UHC. Within the Sustainable Development Goal (SDG) for health, there is a strong focus on UHC, with a specific target (3.8) to “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The wide range of development actors – countries, international agencies and civil society organizations – that met in December 2017 at the UHC 2030 Forum in Japan re-emphasized the need for more collective and more urgent action. The resulting Tokyo Declaration on Universal Health Coverage  underscored that UHC is not only important in its own right but also central to achieving health for all, health security, and the SDG for health. By definition, UHC is about equity and “leaving no one behind”. For WHO, it is one of three strategic priorities in its new Global Programme of Work, where there is an ambitious global target for a billion more people with UHC by 2023, the mid-point to 2030.
Available data suggest that to achieve this global target, much of the additional services coverage needs to come from the WHO South-East Asia Region, given its large population and current health service coverage: at least 300 million of the “billion more” people are in this region. In parallel, much of the global progress in reducing financial hardship because of health spending also depends on progress in this region. The most recent WHO South-East Asia Regional Office estimate, based on national household income and expenditure surveys, is that at least 65 million people in the region are impoverished as a result of health-care spending.
Regional political commitment, with progress on measurement
UHC is not a new regional priority. A regional UHC strategy was adopted in 2012, and since 2014 UHC has been a regional priority area, or “flagship”. Health services cannot be delivered without health workers and medicines, and in the region these have been judged to be particularly big obstacles to progress on UHC. The regional UHC flagship therefore has a special focus on strengthening human resources for health and improving access to quality medicines.
In 2014, WHO South-East Asia Member States committed to a Decade for Strengthening Human Resources for Health from 2015 to 2024, as they recognized that sustained support was needed to achieve changes in the health workforce. UHC is also now reflected in national health policies and strategies across the region. There is also agreement that regular tracking of progress is needed to maintain the momentum. Last year, the WHO South-East Asia Regional Committee decided to review progress on UHC, along with SDG 3, every year until 2030. Progress on the Decade for Strengthening Human Resources for Health is reviewed every 2 years: the first review took place in 2016, and there will be a new report later in 2018. All this suggests political commitment to UHC exists, with some definite priorities.
Tools for monitoring UHC have also been developed, and are being used. A preliminary assessment of the extent to which people are receiving care according to need in this region, using a new essential health services coverage index developed by WHO, was published in 2016 and will be updated annually. Analysis of the level of financial protection is available from a growing number of countries in the region. Altogether, the questions being asked today are less to do with “whether UHC”, but more how to make progress towards it, and – with the SDG target 3.8 for UHC – how to do it more quickly.
Can the region make faster progress on universal health coverage?
International experience shows that progress will be gradual, and will require hard decisions on priorities. Experience also shows that a country does not have to be rich: progress can be made from any starting point. In this region, Thailand has gradually moved towards UHC over the last three decades, starting with the launch of free medical care for the poor in 1975, when the gross domestic product (GDP) per capita was only US$ 390. In 2002, only a few years after the 1997 Asian financial crisis, full population coverage was implemented, when the GDP per capita was still relatively low at US$ 1900. Given that all countries face changing health needs resulting from epidemiological and demographic transitions, there are arguments that countries cannot afford to not take a more holistic approach, as health interventions all use the same limited resources, and UHC provides a platform to do this more efficiently.
It is frequently said that there will be no real and sustained progress on UHC without progress on care for noncommunicable diseases. What is increasingly clear is that today's health systems need to adapt the way health services are staffed, organized and paid for – sometimes significantly. This is becoming more pressing with the growing numbers of people aged over 65 years, who more commonly have chronic and often multiple heath conditions at the same time. Service delivery models originally designed for acute and time-limited health conditions are no longer sufficiently fit for purpose.
Health services in the region are already beginning to change. There is a growing focus on front-line services, recognizing that many cost-effective health interventions can be safely delivered at this level of care, and they are generally closer to vulnerable populations. The private sector is a major source of ambulatory health care – up to 70% of all consultations in some countries in this region. There is a need to explore new approaches to harness the potential of this large, diverse and growing sector, in ways that benefit public health and advance UHC. The history of low utilization and frequent bypassing of public front-line health services also raises many challenges, including how to revitalize these services such that they are more trusted, used by more people, and more responsive to new health needs and expectations.
The central role of health workers in delivering progress towards universal health coverage
What do changing health service needs mean for ensuring the health workforce is fit for purpose? There are several key questions. How many health workers are needed, and with what skill-mix? What type of education do they need? What policies will improve their distribution and retention? Can we afford to pay for these changes? Can we afford not to? Whose support do we need to implement these policies? How do we manage change? What do we need to do first, second and third? Guidance on effective workforce strategies is accumulating. Regional priorities for strengthening the health workforce are shown in [Box 1].[INLINE:2]
Regional data show that increased numbers of health workers have been trained in recent years. However, health workers remain in short supply in many Member States of the region when compared with the WHO SDG index threshold of 4.45 physicians, nurses and midwives per 1000 population. There remain inefficient imbalances in skill-mix – for example, several countries still report having as many doctors as nurses. Doctors and nurses remain concentrated in urban areas in many countries, and almost all health workers are expected to carry out different tasks from those they were originally trained to do. There remain limited data and evidence from within the region on the effectiveness of human resources for health strategies. The good news is that a set of indicators on human resources for health was agreed globally in 2016, and tools to improve data have been developed., The second WHO South-East Asia review of progress on the Decade for Strengthening Human Resources for Health, to be reported later this year, uses a subset of these indicators.
Of course, a sufficient and well-performing health workforce alone is not enough to ensure all people get the care they need. They need the tools of their trade: guidelines, diagnostics, medicines, information and clean, safe workplaces. National health workforce strategies have to be linked to changing service delivery models, and backed up by effective financing strategies.
The other side of the universal health coverage coin: financial protection
Access to needed health care is one side of the UHC coin. The other side of the coin is protection from financial hardship due to health-care costs. The main driver of financial hardship is out-of-pocket payment for care, and the main component of out-of-pocket payment is medicines.
Current evidence suggests that out-of-pocket payment below 20% of total health expenditure is a good indication of reduced risk of impoverishment from health spending. There has been a small but welcome downward trend in the region in the last 10 years, but out-of-pocket payments are still more than 30% in seven Member States. Inadequate public investment is largely responsible. This is unfortunate, given that evidence strongly suggests that increased public spending is a precondition for improved financial protection. Across the region, increasing health budgets is both necessary and possible, even if it is challenging. Since the year 2000, five countries have managed to do so – Bhutan, Indonesia, Maldives, Myanmar and Thailand. Though some – such as Myanmar – had a low starting point, they have made significant progress.
There are also opportunities to make better use of existing funds. The World health report 2010 identified 10 leading causes of inefficiency, of which the top three were related to medicines management. This reinforces the focus on medicines within the region. Access to medicines will be the theme of an upcoming issue of the WHO South-East Asia Journal of Public Health.
The regional agenda for universal health coverage is evolving
There are some old and sound priorities and some new ones: all will benefit from better data and evidence
There are three groups of priorities. First, we should continue to regularly track progress towards UHC as part of the SDGs, and understand who is benefiting and who is not. The increased attention by countries in the region to better monitoring of equity trends is welcome. Second, we should maintain the regional UHC focus on strengthening the health workforce and access to medicines. These are complex problems that are central to improved access to needed health care, and require both political and technical interventions. Third, we should encourage experimentation with new ways to organize, manage and pay for the increasing range of front-line services required to address today's health needs. Policy-makers and managers can look for opportunities to make services more responsive, equitable and efficient. They can look for opportunities to make changes in health-financing strategies to support changes in service delivery, such as during the expansion of health insurance schemes. This may include the gradual introduction of more strategic purchasing of health services, and more strategic procurement of medicines. Other innovations are also needed, including in the development of new medical products and technologies for low- and middle-income countries, an area in which the region is already active.
For real progress to be made in all these priority areas, strong political commitment from heads of state is critical. The breadth of planning, funding and implementation of UHC needs a coordinated, cross-sectoral approach by governments, with finance ministries and national planning authorities working in partnership with ministries of health.
There are repeated demands from countries to learn from each other on how they have managed to make progress on UHC. There is a major “knowledge generation agenda”. As reported in this issue of the journal, it is encouraging to see research partnerships, such as the Asia Pacific Observatory on Health Systems and Policies and the Alliance for Health Policy and Systems Research, explicitly stimulate practical research on the different dimensions of UHC. More is needed.
Last, many partners can help to create demand for and maintain momentum on UHC. Evidence is needed for well-informed policy and advocacy and to promote accountability. This is hardly new but it is essential. There is much for the research community in the WHO South-East Asia Region to do in supporting all the different actors involved in driving forward the “business unusual” approach to achieving UHC in the region.
|1||World Health Organization. SDG 3: Ensure healthy lives and promote wellbeing for all at all ages. The goals within a goal: health targets for SDG 3 (http://www.who.int/sdg/targets/en/, accessed 31 January 2018).|
|2||Universal Health Coverage Forum 2017. Tokyo Declaration on Universal Health Coverage (https://www.uhc2030.org/news-events/uhc2030-news/article/tokyo-declaration-on-universal-health-coverage-441190/, accessed 31 January 2018).|
|3||Draft thirteenth general programme of work 2019–2023. Promote health, keep the world safe, serve the vulnerable. Executive board 142nd session. Agenda item 3.1. Geneva: World Health Organization; 2018 (EB142/3 Rev. 2; http://apps.who.int/gb/ebwha/pdf_files/EB142/B142_3Rev2-en.pdf, accessed 1 February 2018).|
|4||Regional Strategy for Universal Health Coverage. New Delhi: World Health Organization Regional Office for South-East Asia; 2015 (http://www.searo.who.int/entity/health_situation_trends/sear_strategy_for_uhc1.pdf?ua=1, accessed 31 January 2018).|
|5||1 by 4 strategic vision. A more responsive WHO in the South-East Asia Region. New Delhi: World Health Organization Regional Office for South-East Asia; 2014 (http://www.searo.who.int/mediacentre/features/2014/flyer_1by4.pdf?ua=1, accessed 31 January 2018).|
|6||The Decade for Health Workforce Strengthening in the SEA Region 2015–2024: the first review of progress, challenges and opportunities. Provisional agenda item 9.5. Regional Committee. Sixty-ninth session, Colombo, Sri Lanka, 5–9 September 2016. New Delhi: World Health Organization Regional Office for South-East Asia; 2016 (SEA/RC69/13; http://apps.who.int/iris/bitstream/10665/246273/1/SEA-RC69-13_9.5.pdf, accessed 31 January 2018).|
|7||World Health Organization, The World Bank. Tracking universal health coverage: first global monitoring report. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf?ua=1, accessed 31 January 2018).|
|8||Health in the sustainable development goals: where are we now in the South-East Region? What next? New Delhi: World Health Organization Regional Office for South-East Asia; 2016 (http://www.searo.who.int/entity/health_situation_trends/health_in_sustainable_devlop_goals.pdf, accessed 26 January 2018).|
|9||Financial protection in the South-East Asia region: determinants and policy implications. Working paper prepared by the WHO Regional Office for South-East Asia. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (http://apps.who.int/iris/bitstream/10665/259639/1/financial_protection_wp.pdf?ua=1, accessed 31 January 2018).|
|10||Thaiprayoon S, Wibulpolprasert S. Political and policy lessons from Thailand's UHC experience. ORF Issue Brief. April 2017, Issue 174. New Delhi: Observer Research Foundation; 2017 (http://cf.orfonline.org/wp-content/uploads/2017/04/ORF_IssueBrief_174_ThailandUHC.pdf, accessed 31 January 2018.)|
|11||Dayal P, Hort K. Quality of care. What are effective policy options for governments in low- and middle-income countries to improve and regulate the quality of ambulatory care? Policy brief, Vol. 4 No. 1. Geneva: World Health Organization (on behalf of the Asia Pacific Observatory on Health Systems and Policies); 2015 http://apps.who.int/iris/bitstream/10665/208217/1/9789290616955_eng.pdf?ua=1, accessed 31 January 2018).|
|12||Transforming and scaling up health professionals' education and training: World Health Organization guidelines 2013. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/93635/1/9789241506502_eng.pdf?ua=1, accessed 31 January 2018).|
|13||Global strategy on human resources for health: workforce 2030. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/250368/1/9789241511131-eng.pdf?ua=1, accessed 31 January 2018).|
|14||National health workforce accounts: a handbook. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/259360/1/9789241513111-eng.pdf?ua=1, accessed 8 February 2018).|
|15||Xu K, Saksena P, Jowett M, Indikadahena C, Kutzin J, Evans DB. Exploring the thresholds of health expenditure for protection against financial risk. World Health Report (2010) Background Paper, 19. Geneva: World Health Organization; 2010 (http://www.who.int/healthsystems/topics/financing/healthreport/19THE-thresv2.pdf, accessed 31 January 2018).|
|16||The world health report. Health systems financing: the path to universal health coverage. Geneva: World Health Organization; 2010 (http://apps.who.int/iris/bitstream/10665/44371/1/9789241564021_eng.pdf, accessed 31 January 2018).|
|17||Healy JM, Tang S, Patcharanarumol W, Annear PL. A framework for comparative analysis of health systems: experiences from the Asia Pacific Observatory on Health Systems and Policies. WHO South-East Asia J Public Health. 2018;7(1):5–12. doi:xxxxx.|
|18||Bhatnagar A, Scott K, Govender V, George A. Pushing the boundaries of research on human resources for health: fresh approaches to understanding health-worker motivation. WHO South-East Asia J Public Health. 2018;7(1):13–17. doi:xxxxx.|