Universal health coverage, is it the future of Africa?

On Thursday February the 5th, Kings Think Tank hosted the first global health event of the second semester, welcoming the expertise of world-renowned health economists and lecturers. Speakers included Mr. Robert Yates, Senior Fellow in Chatham House and Project Director of the UHC Policy Forum, Dr. Josephine Borghi
Health Economist at the London School of Hygiene and Tropical Medicine, and Dr. Sridhar Venkatapuram, Lecturer in Global Health and Philosophy, at King’s College London.

The discussion began with Dr. Ventakatapuram’s speech about the arguments for universal health coverage (UHC), from an ethical and philosophical perspective.  His key message was the need for equity. Many see equal access to healthcare as a moral right. The three key issues governments struggle with are: who to include in universality of healthcare; exactly which services to provide; how much of the cost of healthcare is covered.

These three concepts are often portrayed in three dimensions as part of a “universal health cube”. The cube can be infinitely large, depending on the answers to the above questions. Therefore the concept of universal healthcare is a slightly confusing one. Some models of care may be “more universal” than others, but ultimately it may not be cost-efficient, or sustainable, for governments to provide every possible service, free at the point of care, to every single consumer of the healthcare system.

Dr. Ventakatapuram touched on the issue of prioritization. Should we prioritize someone who gets injured in the army, fighting for his or her country, over someone who has alcoholic liver disease? A truly universal system would provide healthcare to everyone. In a world with limited resources, universal coverage may be impossible and prioritization becomes a key issue facing policy makers and healthcare professionals. In terms of the “universal health cube” mentioned earlier, this would reflect the question of who to include, and indeed many countries choose only to cover those who cannot afford to buy healthcare themselves.

The next speaker gave a slightly different point of view. He spoke about the politics behind universal health coverage. The public like security and the reduction in uncertainty provided by universal healthcare, making it an easy sell to politicians. UHC has historically been used as a political tool by new regimes to gain public support, often after periods of conflict. Its recent popularity can largely be attributed to a shift in political attention. It was pointed out that successful implementation of UHC requires leadership and vision from the head of state, and various case studies illustrate this fact.

Dr. Agnes Binagwaho, the Minister of Health of Rwanda, speaking through a video message, highlighted some of the practical issues of implementing UHC. In a developing country like Rwanda, standard of care across the country must be equalized, for universal healthcare to be achieved. Not only is access to care important, but also quality of care. In the long-term, education of the healthcare workforce and development of infrastructure in rural areas are necessary in the drive to achieve UHC.

Finally, Dr. Borghi spoke about the economics behind the idea. The most important question for policy makers is which system is most cost-effective in achieving UHC.  A social insurance system may work in much of Europe, but in Africa, where the informal employment sector is so large, it could prove ineffective.

In an insurance system, problems of adverse selection may arise, where two consumers may pay the same premium, whilst having largely different risk profiles. One of these consumers may not tell the insurance company he smokes, allowing him to pay the same premium as a non-smoker (at less risk of a particular disease). Thus, risk free individuals will find it less attractive to purchase insurance. They would have to pay the same amount as higher risk people, into the collective “risk pool”, whilst premiums are pushed up over time due to high claimant rates from the large proportion of high-risk individuals insured.

A tax based system as in the UK, also could pose problems if imposed on African countries. Lack of education and wide wealth inequalities mean many do not want to pay for others. Many citizens of African counties question the basis of UHC, and, in equally large proportion, question the government’s ability to efficiently re-distribute wealth via UHC.

It was said that to increase the appeal of UHC to key factions in society, governments should recognize the need for quality assurance. One of the most recited arguments against having both a public and private healthcare system (as would often be the case if countries moved towards UHC) is that the public system becomes a poor-man’s system. The rich opt for private care, injecting more stimuli into this system, whilst the state funded public sector lags behind due to a pulling of both financial and human resources, into the higher-quality private sector. Thus mechanisms to prevent this quality gap between the two systems must be developed.

If you would like to explore the question of what mechanisms should be developed, whether UHC should be implemented in Africa at all or if the NHS should be privatised in the UK, and put together your findings into a policy recommendation, do contact editor@kingsthinktank.org.

Vageesh Jain

Global Healthcare Editor

King’s Think Tank

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