From Primary Health Care to Universal Health Coverage

BARBARA MCPAKE: The health financing and privatisation debates were kickstarted by one of the World Bank’s very first forays into health policies and systems– its 1987 report, Agenda for Reform. The Agenda for Reform caused a furore, as it seemed to endorse a marketisation of health care, which had largely been agreed to be something that should be protected from market forces. The small print suggested that the rationale was an intention to reallocate public subsidy from hospitals to primary care by charging at hospital level in order to better subsidise primary care and divert demand to lower levels of the system. But that was largely missed in the debate, and possibly not only the debate.

Arguably, the Bank’s own staff missed the detail of these paragraphs. And certainly, the report prefigured a wave of generalised marketisation of health sectors, especially through introduction of user fees at all levels of health systems and with considerable, often unsuccessful, attempts to develop various forms of health insurance intended to replace tax-based funding and private sector provision of health care. Both the World Bank’s top-down and UNICEF’s– also WHO’s, but generally identified with UNICEF– bottom-up Bamako Initiative proposed user fees as strategies to support PHC. The rationale for the Bamako Initiative was quite different.

The lack of resources at primary level were considered only remediable by generating resources at that level through revolving drug funds, where initial supply of drugs is replenished from the revenues generated from their sale or similar. But the main critique was similar. Expecting users of services to pay when sick is regressive, constrains access to care, penalises the sick, and demands payment at a time when the household may have least capacity to pay. It might be seen as a last resort when more progressive and prospective or in-advance-of-need payment strategies are unavailable. We’ll revisit these arguments in the financing module. The resulting waves of indiscriminate user fee introduction following the Agenda for Reform publication therefore had predictable consequences, such as those listed here.

A reduction in levels of use of health care in many cases, despite continued need for care. Limited resource generation. And little progress in improved service quality.

After the Agenda for Reform, the World Bank became much more actively involved in the health sector and in 1993 focused its main annual report, the World Development Report, on health. There were two main elements of this report, a reiteration with some softening of the ideas of Agenda for Reform and a proposal and detailed cost effectiveness work to support it that public subsidies should focus on an essential package of services determined on cost effectiveness criteria, similar but less narrowly defined than the selective primary health care idea. A heavy reliance on out-of-pocket payment is a characteristic of lower-income countries.

And there is a very clear association between reliance on out-of-pocket expenditure and incidence of catastrophic health expenditure judged liable to push households below the poverty line. So the pendulum swung. And countries started trying to remove their user fees. But it isn’t always straightforward to reverse policy decisions. Systems had come to rely on fees. And they needed to be carefully dismantled so as not to cause health workforce dissatisfaction, drug stockouts, and otherwise open up shortfalls in health care supply. The World Health Report of 2000 is another major landmark in the story. The main text captured current thinking and how to manage the tensions between financing and service delivery, public and private roles, even comprehensive and selective primary health care visions.

But the health system ranking exercise contained in its appendix dominated the debate and proved highly divisive. Overall, this may have set the cause of working on health systems backwards by making it a politically treacherous terrain to enter. We reviewed the main ideas in the 2010 World Health Report in the last section of this module. But this report also was a major landmark, highlighting the concept of universal health coverage, although largely limiting the conception of UHC to a financing issue. As the idea has developed, there has been a much greater balancing of the concept across ensuring adequate finance to support service delivery, population coverage, meaning inclusion and accessibility to available services, and extending geographical as well as financial access to care.

This is another way of looking at the report’s concerns with selecting appropriate services, technologies, and medicines, minimising reliance on out-of-pocket spending, and reducing inefficiency and inequity. Covering the whole population with all services at no out-of-pocket cost is represented by the outer clear box. The inner blue box represents the current resource availability, or budget. With efficiency savings, it can stretch further than without. And with attention to generating new resources as recommended, the box can grow. But whatever size it is after that, increasing one dimension has the effect of reducing what can be done in another dimension. What often seems to happen is that an overambitious idea of what can be covered drives policy.

We propose the Swiss cheese UHC model to characterise the impact of that. Holes open up in quality, in unavailability of services that are expected to be there, and in uncovered population groups. Some of these may arise randomly. But mostly, they systematically impact on the poorest and most vulnerable and discriminated against groups. Established in 2000 and intended to be achieved by 2015, three of eight Millennium Development Goals were directly health related. And arguably, all were indirectly so, giving health a strong focus in development activity over this period. The MDG set hard targets for improvement and a hard deadline for getting there. And while many were not achieved, especially in sub-Saharan Africa and fragile and conflict-affected settings, progress was made nearly everywhere.

In contrast, the Sustainable Development Goals are more numerous and larger. Good health encompasses all three of the health-related MDGs and much more besides. It has 13 specific targets, including, by 2030, ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health, international strategies, and programmes. 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. No date is set for the more broadly defined UHC goal, though.

Primary health care is still considered the basis of universal health coverage by many, now more likely to be termed “comprehensive primary care,” which for some is a narrower, health service-focused idea than comprehensive primary health care. Few argue with the three Ps of health financing– Protect the poor, Pool risk, and Prepay. The need for strong public leadership in stewarding the health system as a whole is mainly accepted. Health outcomes are ever more contingent on the growing interdependencies of sectors and systems discussed by Frenk and colleagues in your previous reading.