What services should be covered first and at what quality level?
The evidence strongly supports the strategy of extending coverage to the whole population for a priority package of services. What services should then be included in this initial package? What level of quality should be ensured in their delivery? The overall objective ought to be to include services that have the maximum impact on population health outcomes, reduce financial hardship for households and limit ine qualities. The preferences of the population should also be taken into account: their evaluation might be less technical, but their opinions are crucial to ensure buy-in to support the UHC strategy.
Value for money:
WHO proposes three criteria to consider in evaluating services to cover: cost-effectiveness, priority to the worse off, and financial risk protection. The evidence avail able shows that policymakers should prioritize primary healthcare interventions (especially preventive services)48 and some hospital services (for example, facility-based deliveries) over specialized tertiary hospital services, providing coverage for the latter only when households are being impoverished by paying for these services out-of-pocket. There have been many excellent examples of countries investing in district and com munity level health services, often delivering impressive results.
China’s famous barefoot doctors program, introduced in the 1960s, focused on simple primary care interventions and enabled China to achieve good population health indicators at relatively low cost. More recently, Ethiopia has achieved impressive reductions in child mortality that have largely been attributed to its community health worker scheme. There are also many examples of countries overinvesting in urban specialist services, due to political pressure from wealthy urban populations, powerful healthcare providers and professional groups. A recent controversial high-profile project to build a state-of-the-art tertiary hospital in the capital of Lesotho, which appeared to reduce funding for rural health budgets, is a good example of this phenomenon.
Quality and user acceptability:
Merely ensuring that a package of affordable services is offered to the population is not enough to achieve the goals of UHC. Services need to be of good quality, so that they can be effective in delivering improved health outcomes. For example, people requiring curative services should receive accurate diagnoses and appropriate treat ments and medicines. However, in many countries this is not the case, as has been shown for both public and private health service providers in India. A study in the state of Madhya Pradesh found that 67 percent of healthcare providers had no medical training, correct diagnoses were rare and incorrect treatments were prescribed widely. In addition, the population needs to make use of and value the services. They should therefore be readily accessible, provided in a timely manner and take into account the preferences and aspirations of individual service users and the cultures of their communities. Importantly, in a publicly financed system richer members of society should feel confident to use the services they are funding, so they have a stake in sustaining and improving the system. Governments therefore need to adopt a systematic approach to improving quality, addressing issues of effectiveness and patient safety. England’s NHS provided a good example of how a national health system can formulate such a strategy in 2008, with the publication of High Quality Care for All. However, it is not sufficient to produce a quality improvement strategy; governments need to have effective institutions to implement the necessary reforms, as we will discuss (see ‘How to implement UHC’).
Access to medicines:
Medicines deserve particular attention when defining a priority service package, as their availability is a key driver of healthcare-seeking behavior for people across the world. This has recently been demonstrated in South Africa, a country on the verge of implementing major UHC reforms, where a study showed that people prioritize medicine availability above many other service attributes, including human resources and the state of healthcare facilities: “Communities are prepared to tolerate public sector health service characteristics such as a long waiting time, poor staff attitudes and lack of direct access to doctors if they receive the medicine they need, a thorough examination and a clear explanation of the diagnosis and prescribed treatment from health professionals.” Inadequate access to medicines can generate widespread dissatisfaction in the population and prompt major political campaigns, such as those related to the unaffordability of anti-retroviral medicines for people with HIV in the developing world – especially in Sub-Saharan Africa. A recent documentary film, Fire in the Blood, charts the success of the global campaign to reduce the prices of these life-saving medicines to make them more accessible to people living in developing countries.
In India, politicians and health planners are recognizing that tackling access to medi cines is a popular and efficient way to launch UHC reforms in a country often referred to as the ‘Pharmacy of the World’. For example, following intense pressure from civil society organizations, the state of Rajasthan introduced a program to provide 324 free generic medicines throughout the entire public system. In six months the use of public facilities had increased by almost 50 percent. Despite initial opposition to this strategy, the new Indian Government of Prime Minister Modi has announced that it intends to roll out a similar program to provide free generic medicines to the entire population of India. Examples such as these demonstrate that decisions about what services to cover, and to what level of quality, are highly driven by local factors and political pressure. This chapter has sought to make the case that policymakers should give a high priority to achieving universal coverage for the whole population, for a priority package of services that are right for their local context.
Source ; Report of the WISH Universal Health Coverage Forum