Universal health coverage is not universal health insurance

The Economist has a survey on universal healthcare. Surprisingly for an Economist Survey, though predictably very rich on facts and descriptives, it comes out as being very sloppy and misleading in its analysis and prescriptions. The most striking being the casual substitution of universal health care coverage with universal health insurance. 

In fact, this article has clearly made up the mind that universal health coverage is possible only with the insurance approach, and that too one which involves the universal coverage of a basic minimum set of commonly afflicted medical conditions. Sample this about the Thailand's universal health coverage scheme,

Introduced in 2002, Thailand’s scheme has become a model for other countries trying to extend coverage. It shows that universal health care can be affordable if policymakers think carefully about how to spend scarce resources. And it demonstrates the power of health insurance to bring “the magic of averages to the aid of millions”, as Winston Churchill put it.

Really? The successful Thai health care system, as we see it today, far from being a simple health insurance scheme introduced in 2001, is the result of persistent efforts initiated in the seventies. In fact, it is not even a health insurance scheme, based on the conventional understanding of market-driven health insurance. It is built on a robust network of world-class government owned health care facilities, very streamlined gatekeeping referral system, and an incentive compatible capitation based budget spending. The last two are, in many ways, critically dependent on the first. The so-called insurance, is just a dressing up of all the aforementioned ingredients and universal application across all population categories, and predominantly publicly financed.

I have blogged on several times, including this most recently, about the impossibility of realising satisfactory enough universal health coverage without improving primary health care. I have also written here about the fiscal unsustainability of doubly universal health coverage - cover both population and medical conditions. 

But the Survey has several very striking factual snippets. A few samples. On the importance of health to economic growth,

A study found that in Britain as much as 30% of the growth in GDP between 1780 and 1979 may have been due to better health and nutrition. A paper by two leading economists, Dean Jamison and Lawrence Summers, found that 11% of the income gains in developing countries between 1970 and 2000 were attributable to lower adult-mortality rates.

On the general state of global health care

A study, in 2015, for the Lancet, a medical journal, estimated that 5bn people around the world cannot get basic surgery such as a caesarean section, a laparotomy (an incision into the abdominal wall) or a repair for a fractured bone. According to the paper from the World Bank and the WHO, 800m people spend more than 10% of their household budget on health care, and nearly 100m are pushed into extreme poverty (defined as having less than $1.90 a day to live on) every year by out-of-pocket health expenses. This chimes with smaller-scale studies. A survey last year of patients at a government hospital in Uganda discovered that 53% of their households had to borrow money to pay for treatment and 21% sold possessions. About 17% lost their job... In rural India, for example, 66% of the population does not have access to preventive medicines, and 33% must travel more than 30km to get treatment.

In case of tertiary care like surgery, it is understandably even worse,

Nine in ten people living in developing countries do not have access to “safe and affordable” surgical care, according to a report in 2015 by the Lancet (see map). About 60% of operations round the globe are concentrated in countries with only 15% of the world’s population. In rich countries a rough rule of thumb suggests there will be about 5,000 operations per 100,000 people every year. But according to the African Surgical Outcomes Study, a survey of 25 African countries, the median rate on that continent is just 212 per 100,000... The 25 countries in the African Surgical Outcomes Study had an average of 0.7 surgeons, obstetricians and anaesthetists per 100,000 people, compared with a typical figure of more than 40 in the rich world. Over half the district hospitals in one study of eight African countries had no anaesthesia machine. Often the kit is donated, and few locals know how to fix it. One survey suggests that 40% of donated surgical equipment in poor countries is out of service... In 2010, 17m lives were lost from conditions needing surgical care, dwarfing those from HIV/AIDS (1.5m), TB (1.2m) and malaria (also 1.2m). Roughly one-third of the global disease burden measured by DALYs is from conditions requiring surgery.

But the challenges are immense. On the sorry state of healthcare in Sierra Leone, a reminder that these countries need hard resources, human and capital. Innovations, howsoever cute, is only tinkering at the margins. 

Life expectancy was already just 50 years, and an eighth of children died before their fifth birthday... Before the outbreak the country had just one doctor for every 50,000 people. (America has one for about every 400; China one for 275.) Then 7% of Sierra Leone’s health workers died from Ebola during the epidemic.

On the pervasiveness of informal providers,

In many developing countries people get their health care mostly from informal private providers such as drug shops or unqualified practitioners. In India, informal providers account for three-quarters of all visits. The figures in other countries are similar, if mostly less extreme: 65-77% in Bangladesh, 36-49% in Nigeria and 33% in Kenya.

Quality in health care, unlike in case of education, is less discussed. But it may be even worse, with disastrous consequences,

In one Chinese study the average consultation time was a minute and a half. In India the average length was double that, but one-third of the visits lasted just one minute and featured a single question: “What is wrong with you?” Only 30% of consultations in India and 26% in China resulted in correct diagnoses, and patients were more likely to receive unnecessary or harmful treatment than the correct sort. Studies in Paraguay, Senegal and Tanzania have produced similar results... In a study in Delhi only 25% of providers asked parents whether there was blood or mucus in the child’s stool, a clear symptom of such disease.

But there are a few shining lights,

In both Chile and Costa Rica income per person is roughly 25% of that in the United States and health spending per person just 12%, but life expectancy in all three countries is about the same. Rwanda’s GDP per person is only $750, but its health scheme covers more than 90% of its population and infant mortality has halved in a decade.

Is Thailand the most impressive healthcare story of our times?

Costa Rica is another impressive exception,

Between 1995 and 2002 Costa Rica established more than 800 “Equipos Básicos de Atención Integral de Salud”, or integrated primary-health-care teams, each looking after 4,000-5,000 people. The teams are made up of a technical assistant, who visits patients at home; a clerk who keeps up-to-date records; a nurse; a doctor; and a pharmacist. The doctors have a lot of scope to run the teams the way they think best, but the health ministry holds them accountable for their patients’ outcomes. Before the programme was in place, just 25% of Costa Ricans had access to primary health care; by 2006 the share had risen to 93%. It was introduced in stages, which enabled researchers to assess its impact. A study in 2004 found that for every five years it was in place, child mortality declined by 13% and adult mortality by 4%, compared with areas not yet covered. Another study estimated that 75% of the gains in health outcomes resulted from the reforms.

And this too is impressive,

Ethiopia since 2004 has trained more than 38,000 “health extension workers”, rural high-school graduates who undergo a year’s training before being sent back to their local area. They have helped cut child and maternal mortality by 32% and 38% respectively. In Rwanda each village has to have three community health workers, elected by their peers, who offer basic services and make referrals. “People who have a minimum education can do a lot,” says Agnes Binagwaho, a former health minister.

But the lessons drawn from these successes may have far less relevance than we think,

One lesson from countries like Rwanda is that closing the gap between knowledge and action requires reforms far beyond the consultation room. Training helps, but so do incentives and accountability. When Rwandan health workers were paid to adhere to clinical guidelines, their performance improved. And when rural Ugandans were given more information about the quality of local health services, clinicians did a better job. When Rwandan health workers were paid to adhere to clinical guidelines, their performance improved. And when rural Ugandans were given more information about the quality of local health services, clinicians did a better job.

These lessons may appear very simple and hardly innovative. And they are undoubtedly the way forward. But unfortunately, thanks to very weak state capacity, it is very difficult to translate these lessons into action in scale with high fidelity. One more illustration of why instead of expending disproportionate energies chasing innovation and technology, the international development community should be striving to fix state capacity. The returns are orders of magnitude higher. And it is true of every sector!