Establishing strong institutions for Universal Health Coverage
The successful implementation of UHC reforms depends on developing a broad range of effective institutions. Where institutions are weak or are potential impediments to progress (for example if they are corrupt) there may be a need to invest heavily in strengthening institutional capacity. It may be necessary to create totally new institutions to introduce arrangements that strengthen the purchasing function.
The Lancet Commission on Investing in Health highlights six institutional functions that must be satisfied to support the successful implementation of UHC.
• Institutions for information.
• Institutions of deliberation.
• Institutions of finance.
• Institutions of stewardship.
• Normative institutions.
• Institutions of independent accountability
Building a strong purchasing function :
We have seen the impact that the institutional setup for provider payment can have on the success of various mechanisms (see ‘How to pay for UHC’). The strength and approach of the purchasing function is another critical factor. First, countries need to make a strategic choice on the best institutional arrangement to maximize efficiency: the purchasing function could remain within government structures, be managed by a semi-autonomous agency (usually on a not-for-profit basis) or even contracted out to a private for-profit organization such as an insurance company. While there is no consensus on which option is best, countries need to carefully evaluate the capacity of their institutions, including their ability to regulate non-state purchasers. Thailand is an example of a country that has created a semi-autonomous agency to purchase health services for members of its tax-financed, Universal Coverage Scheme.
This body, the National Health Security Office, is governed by a 29-member board from public and private sector organizations and has a high level of representation from civil society organizations95. The 10-year review of the Thai Universal Coverage Scheme has attributed a lot of the success of their reforms to the performance of this agency in driving down costs and maintaining quality standards.96 In India, a different approach has been followed, with management of the state level insurance schemes for the poor contracted out to private sector insurance companies. While there has not been a systematic review of these schemes, some research papers and articles in the Indian media are questioning the performance of these organizations in controlling costs and meeting the needs of members.97, 98 Furthermore, extensive evidence from the US would indicate that competing private health insurance companies are not very effective at driving down costs.
Monitoring progress towards the UHC goal:
It is crucial that leaders and key stakeholders in UHC reforms are able to monitor the country’s progress towards UHC. This enables health planners to determine whether the strategy is being implemented effectively and what corrective measures are needed to improve health systems, revise financial allocations or amend the overall strategy. The World Bank and WHO, after an extensive consultation exercise, have recently produced a joint framework document on measuring progress towards UHC.100 In this paper they recommend using indicators that measure the two key elements that make up the UHC definition, namely health service coverage and financial protection. Specifically, they propose indicators that measure the effective coverage of both preventive and curative health services, and financial protection measures that track catastrophic and impoverishing health expenditures. They recommend measuring both the aggregate level of these indicators and their equitable distribution, stratified by wealth quintile, place of residence and gender.
Availability of resources:
Money is perhaps the most critical resource needed for the successful implementation of UHC. While ‘How to pay for UHC’ discussed in depth the mechanisms needed to provide appropriate funding to expand coverage of health services, it should be noted that the implementation process requires a specific budget. Deciding that a certain service package should be covered and providing funding for it is only a first step. The health system needs to be capable of delivering these benefits to the population. Two resource-related factors are critical: the availability of properly skilled healthcare workers and the appropriate supply of, and access to, medicines and medical equipment.
Source : Report of the WISH Universal Health Coverage Forum