Universal health coverage is the key to pandemic management: An important analysis:
Over the past twelve months, COVID-19 has killed more than 2.4 million people. However, this is likely an underestimation; many countries do not count the deaths of older adults in nursing homes or individuals who may have survived if not for the disruption in health service delivery systems. For example, there have been instances in which people avoided care because of fear of contracting COVID-19, lack of transportation due to the lockdown, or lack of money due to partial or total job loss.
From our experience with previous outbreaks — such as Ebola in 2014 — we know that testing, contact tracing, isolation, quarantine, and other scientifically proven preventive measures, coupled with the continued use of primary and secondary care, are crucial to avoiding deaths caused by outbreak-related disruptions. Thus, it is clear that the direct and indirect causes of death due to SARS-CoV-2 were predictable and preventable through the application of previously tried and tested public health practices.
However, the COVID-19 pandemic has shed light on the systemic flaws within health care systems worldwide that have made these practices unachievable. In various countries, we have seen how the lack of resilient health care systems backed by policies, strategies, and programs centered on universal health coverage — or UHC — contributed to a failed pandemic response and a disruption in the delivery of existing health care services.
The state has an obligation to ensure UHC: the provision of affordable, accessible, and quality health services to all.
Take the example of Rwanda. Thus far, the country has recorded around 5,100 COVID-19 cases — significantly fewer than the 204,000 cases recorded by the similarly populated U.S. state of Pennsylvania. Examining Rwanda’s response to COVID-19 through the nation’s UHC program can provide key transferable lessons to countries seeking to achieve this same progress.
Korea
Approximately 97% of Korea’s population is insured through the country’s universal single-payer healthcare system, which resulted from two milestones: the adoption of UHC in 1989 and then the merging of 370 insurance funds into to a single-payer system in 2000. Korea’s health system is mostly financed through the National Health Insurance (NHI) system and generally delivered by private health providers. All health providers are mandated to participate in the NHI and to treat patients under the same benefit packages and provider payments set by the NHI law. Total health spending is relatively high, at about 8.0% of GDP as of 2019, with 4.9% of GDP spending coming from government or compulsory sources. The country’s robust health infrastructure includes a high number of hospital beds per capita—12.3 beds per 1,000 people—along with 254 health care centers, more than 1,300 sub-health centers, over 1,900 primary health care posts, and 46 community health promotion centers across the country as of 2018. Significant investments in health data and technology have also been made in the country. These have been used to improve quality, efficiency, and effectiveness of service delivery.
Korea’s response to COVID-19 owes much to experience gained from the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, particularly the formation of an agency tasked with preparing for, and responding to, infectious disease outbreaks, the Korea Center for Disease Control and Prevention (KCDC). In the early days of COVID-19, Korea adopted a widespread testing strategy that included people who were asymptomatic. The roll-out of rapid diagnostic testing was a key pillar of the country’s response and relied largely on the country’s ability to quickly develop and manufacture tests. Shortly after the country’s first case was confirmed, KCDC officials met with more than 20 private sector partners to discuss mass production of COVID-19 testing kits. Within one week, on 4 February, the first company had been authorized to begin producing testing kits. In early February, testing was expanded with the help of a new, single-step, real-time reverse transcription-polymerase chain reaction (RT-PCR) test kit, which gave results in just six hours. By 20 February,12,000 people were tested in the country; by 8 March, over 180,000 people were tested. This enabled public health officials to track the spread of disease and effectively implement control measures.
Thailand
Thailand adopted a UHC policy in 2002. Its health insurance scheme, which covers close to 75% of the population, is funded through general taxes and managed by the National Health Security Office (NHSO), which allocates funding based on capitation, such as numbers of registered UHC-eligible members in service areas, for outpatient care and diagnosis-related group-based payments for inpatient care. Two decades after the introduction of its UHC policy, Thailand continues to monitor UHC population coverage, service coverage (both preventive and curative), and financial risk protection. According to the WHO Global Health Expenditure database, out-of-pocket expenditure has declined substantially—from 34% in 2001 to 14.8% in 2007 and 11.1% in 2017.
The country’s successful implementation of UHC, and its ability to achieve good health at a relative low cost, is largely due to comprehensive geographical coverage of primary health care (PHC)—with almost 9,800 health centers acting as gatekeepers for referral to secondary and tertiary care. Even before the implementation of UHC, and over the past four decades, Thailand had substantially invested in basic healthcare infrastructure and human resources for health. Since the 1970s, one of the unique contributors to the Thai health system has been the large corps of Village Health Volunteers (VHV), totalling more than one million. These VHV have helped support the prevention, detection, and reporting of COVID-19—minimising local transmissions, raising awareness in the community, and encouraging people to comply with disease control measures.
Thailand implemented a decisive, coordinated response to COVID-19, including the formation of the Center for COVID-19 Situation Administration, a national task force that provided daily briefings to the public, and implementing rolling curfews, lockdowns, and restrictions on international and domestic travel. In July, it had set up more than 200 COVID-19 laboratories to expand testing, while the country’s network of public and private hospitals has kept the fatality rate under 2%. On 21 August, the government announced Thailand had gone more than a month with no new cases.
Viet Nam
Viet Nam has invested heavily in its public health care system and health spending has outpaced the country’s recent booming economic growth. Since 2000, for every 1.0 percent increase in GDP per capita, public spending on health has increased by 1.7%. This has translated to an almost three-fold increase of spending in constant US dollars, from $46.2 spent on health per capita in 2000 to $129.6 in 2017. A social health insurance scheme was introduced in Viet Nam in 1992 and between 2000 and 2017, coverage in the scheme increased from 13% to 87% of Viet Nam’s population. Viet Nam’s tiered health system infrastructure also helps to ensure that local needs are met. Across the country, there are more than 13,000 public facilities, with an additional 35,000 health facilities in the private sector. Viet Nam’s health system is also performing well in terms of ensuring financial protection. The incidence of catastrophic health expenditure has reduced from 14.4% in 2006 to 9.4% in 2016 (at the 10% threshold). The country is also prioritizing preventive care: at least 30% of the total health budget is allocated for preventive services. As part of its commitment to achieving UHC and strengthening preventive care, Viet Nam has been moving toward building national emergency preparedness and response capacities to improve health security.
Viet Nam has been hailed for its response to COVID-19, issuing public health warnings based on risk assessment before the first had appeared in the country, instituting rigorous contact-tracing procedures, closing borders, and introducing the Prime Minister’s Directives on nationwide social distancing. However, the resurgence of cases in July in the coastal city of Da Nang and other cities/ provinces underscored the flexibility and responsiveness of Viet Nam’s health system. Rapid response teams and additional health workers were deployed to the outbreak’s epicenter, followed by the establishment of a 200-bed field hospital, the conversion of a stadium to a 1000-bed isolation facility, and the expansion of testing capacity. While number of cases increased dramatically during the first two weeks of August, the situation now appears largely under control. Viet Nam’s investment in UHC, particularly in preventive measures, have helped to ensure that sufficient infrastructure and systems existed to support COVID-19 response.