UHC is a political process from the start

Across Asia and Pacific, political leaders have recognised that successful UHC reforms are extremely popular and can be a potent political tool to help win and sustain power. UHC can generate huge benefits for some groups in society but can have significant costs for other groups. This, in turn, can result in considerable political costs and benefits (in terms of popularity) for governments and political leaders overseeing reform processes. Given the high political stakes involved, it is not surprising that UHC reforms in the region have often been led by the head of state (eg, Prime Minister Hayato Ikeda in Japan (1963), President Park Chung Hee in the Republic of Korea (1977) and most recently President Joko Widodo in Indonesia (from 2014)). In particular, fulfilling the equity principle underlying UHC (that healthy and wealthy people subsidise services for the poor, vulnerable and sick) requires a strong role for the state in establishing and governing a progressive health financing system. Many analyses of large-scale UHC programmes in Asia have cited political reasons as the main motivation behind these reforms.20 ,24 ,25

Closing primary healthcare gaps is the foundation

Closing primary healthcare gaps should be the foundation of UHC reforms.26 Countries that want to make rapid progress towards UHC should prioritise primary healthcare, including prevention and health promotion as a first step. Well-structured, efficient primary health services can meet most of the health needs of the population. Engaging communities and removing barriers to access is a core dimension of strengthening primary care. These measures include removing non-financial access barriers, including perceptions about poor quality; language and cultural barriers; lack of appropriate services (eg, for adolescents); indirect costs; and poor community engagement in health. Some of these barriers can be addressed through strengthening health services while others, such as the indirect costs of accessing care, may involve other social protection measures such as cash transfers.

Improve the quality of care through sustained health systems strengthening

For many countries, the risk is that UHC is launched, entitlements are announced, but the services promised are not available.27 Promises concerning service coverage have to translate into usage in practice. Although hard to measure, quality is generally thought to encompass several defining features, including patient safety, effectiveness, people-centredness and delivering integrated services. Perceived quality is what patients think about the quality of care they receive and it is judged by the experience of attending health services. The main determinants of quality include availability of drugs; qualified, available and respectful health staff; and integrated, appropriate services that meet community needs.1

Make progress with social and economic determinants of health

Health services alone do not engender health and there are a number of important contributors to health that lie outside the health sector's direct authority. Nutrition underpins health to such an extent that it is linked to 45% of child deaths.28 Water, sanitation and hygiene; gender empowerment; household income (poverty); quality of housing; infrastructure; and education (especially for girls and women) all drive health outcomes.29 Countries and states that have made the most progress in improving the social and economic determinants of health can also demonstrate the best health outcomes. Other policies can have a significant impact on the promotion of healthy behaviour, including, for example, excise taxes on tobacco products, taxes on sugar and sweeteners, legislation to enforce the use of bicycle helmets, seatbelts and other measures.

Public financing is critical

Public financing is critical and directly related to more equitable health systems.30 As countries in Asia and Pacific have become wealthier, their health financing systems have developed in similar ways. First, as their economies have grown they have spent more on health as a share of their GDP, indicating a growing societal demand for health services. In common with the rest of the world, high-income countries in the region now spend around 9% to 12% of their GDP on health, middle-income countries spend between 5% and 9%, and low-income countries spend < 5%. Second, the composition of the health financing systems has changed, with the share of public financing (from general taxation and social health insurance) growing over time and replacing private voluntary financing (mostly in the form of OOP health financing). This is demonstrated across the region where private financing dominates in low-income and lower-middle-income countries, whereas public financing is dominant in higher-income countries.

These health financing trends show that economic growth is the main driver of increasing overall health spending, and it is political pressure from populations that lead governments to enact legislation to give public financing a dominant role.31 Populations and politicians have realised that only publicly governed health financing systems can enforce the cross-subsidies required from the rich to the poor and the healthy to the sick, which are necessary to achieve UHC. Politically driven financing transitions have been evident across Asia and Pacific over the last few decades, with many countries socialising their health financing systems, for example, Japan (1963), Republic of Korea (1977), Thailand (2001), Nepal (2008), China (2009) and Indonesia (2014).

Large increases in public funding gives countries the financial resources to increase the availability and quality of health services while reducing the burden on households financing health services out of their own pockets. Figure 3 shows that in countries spending more than 3% of GDP of public finances on health, OOP spending was <20% of THE. This is important because below this level OOP spending tends to be less catastrophic and impoverishing in nature.32

• Download figure
• Open in new tab
• Download powerpoint

Figure 3

Public health financing replacing out-of-pocket expenditure in Asia and the Pacific World Bank 2014.

Pool funds to increase efficiency and equity

Moving away from financing a health system through direct OOP payments requires introducing or strengthening forms of prepayment and the pooling of health funds to protect the population against the financial risk of paying for services. Pooling funds can drive equity.19 ,21 In creating these pools, it is important to emphasise that only publicly governed risk pools, where contributions are compulsory and progressive (related to people's ability to pay), can meet the equity requirements for UHC. Private voluntary insurance schemes do not achieve this outcome because there is an incentive to exclude high-need people in society and for richer or healthier members to refuse to pay higher contributions. Those less likely to use health services tend not to join, which limits cross-subsidisation. All countries can take steps towards increasing cross-subsidisation even if fully combining all public pools of funds is not immediately feasible.

Priority setting for equity is a political process

Priority setting is the process of deciding what health services should be covered under UHC, and who should benefit and when. Priority setting is an inherently political process and is often controversial since it leads to choices about who in society will benefit from public resources and who will not. If countries used cost-effectiveness analysis, including explicit and transparent methods such as health technology assessment, to re-allocate available health funding to equity-enhancing health interventions, many more lives could be saved. Few countries can afford to immediately fund a full package of services to all citizens and the vast majority take incremental steps over time.5 One key decision to be taken in working towards UHC is whether to prioritise coverage of people with a basic package of care or to extend the quality and range of services to be offered to a more limited group, such as the formally employed. Coverage of the whole population with a defined range of services leads to improved population outcomes and lower inequalities than covering a narrow group of citizens with higher quality services.33 This approach also promotes equity and embeds the principles of cross-subsidy from the start.34 ,35

Engage the private sector to support UHC

Across Asia and Pacific, the majority of outpatient health services are delivered by private health providers, although in most countries inpatient care is still mainly delivered in public-sector hospitals.36 The challenge for countries is to find ways to engage private providers, maximising their potential to increase the coverage of basic services to all people while minimising their incentives to oversupply and overcharge for services. Whereas public financing is essential for UHC, when it comes to the provision of services there is much more scope to deliver services through a mixture of public and private providers.

Make UHC a long-term proposition

Although one political party may seize an opportunity to launch UHC, ultimately, a UHC system has to be seen as a national goal, belonging to all and one that needs sustained, enduring, cross-party and intergenerational commitment.5 In Japan, Republic of Korea, Sri Lanka, Thailand and other countries with well-developed UHC systems, populations have come to expect UHC as their right and politicians stand on platforms that include how—not whether—they will protect and advance that right.24 Reaching this ‘tipping point’ on the UHC journey is a vital milestone if the system is to become resilient in the face of inevitable challenges. As a dynamic process, UHC needs to contend with: the ebb and flow of national economic growth that can stall UHC; population health needs that change constantly due to ageing, migration, old and new diseases; the health impacts of climate change; and, natural disasters.

Build accountability through transparent progress tracking and monitoring

The UHC journey is unique to each country. Maintaining momentum towards the achievement of UHC goals requires timely and reliable data, the willingness to undertake course corrections at periodic intervals and a strong sense of accountability to citizens. Open and transparent accountability helps policymakers maintain commitment and focus. It helps to ensure resources are used as intended. And, it supports citizen empowerment to track progress and provide feedback, deepening citizen engagement. Most countries that have made progress with UHC also have good data collection and analysis at the heart of their systems founded on a health management information system.