What would you do if your child fell ill, your father developed diabetes and required expensive drugs and dialysis, or your sister was diagnosed with breast cancer? A recent report found that one in four households in 40 developing countries resort to borrowing money or selling assets to finance healthcare in these situations. In Zimbabwe, this might mean bartering your family’s peanut crop, in the United States you might resort to internet-based crowdfunding to raise funds, or in Niger selling your family’s cattle to pay the bills.
This dilemma of how to pay for health related expenses is not new. While in some countries, such as Japan and the UK, steps were taken decades ago to provide subsidised healthcare, the majority of countries have left this question to their residents, often with dramatic results.
Driven by the World Health Organisation, the World Bank and civil society, the universal health coverage (UHC) movement has grown up around the idea that ensuring basic health needs should never entail facing financial ruin regardless of who you are or where you live. The movement gained prominence in the development community after the second world war with WHO declaring health a fundamental human right, but more recently, the case for UHC has been substantiated with the release of a major report on health financing (pdf) in 2010 and a UN resolution in 2012. The principles of UHC now make up a fundamental component of the sustainable development goals (SDGs).
But while tangible progress is being made to embrace the concepts of social and financial inclusion in the health sector, for many the question still remains: how can I pay for the care my family and I require? Some will answer this query by turning to employer or state-provided insurance (pdf), typically available to members of the formal economy. Those less fortunate might turn to family or a moneylender for cash, or worse even be held at the health facility until their family could pay the charges – fear of this has put off expectant mothers in Nairobi slums from seeking professional healthcare. This is why the UHC movement goes to pains to emphasise that radical change must occur in order that health coverage be extended to the world’s most vulnerable populations.
So, what to do? Some countries are already on the way to adopting significant reforms. A recent analysis by the World Bank of 24 countries (pdf) outlined the diverse approaches being used, including cost sharing, pooled risk and cash transfers. Where health coverage does exist it is often not comprehensive, and patients in many countries still end up out of pocket.
But some countries are on the road to getting this right, including Thailand which has had a UHC scheme in place since 2002, Rwanda, where community-based health insurance covers a majority of the population, and Mexico which through the Seguro Popular programme has extended financial coverage for health across its population in a short period of time. These efforts are being supported at the global level by a growing coalition of countries, and the existence of this coalition constitutes a major step forward that will aid in negotiating the complex world of UN politics in support of UHC.
The emerging private sector leadership within the financial inclusion sector also has a potentially important role to play in achieving universal health coverage through innovative and groundbreaking approaches to the provision of financing to the poor. These initiatives will help to open new avenues of funding previously untapped for health, such as leveraging private sector contributions to match ongoing donor-funded projects; pooled funding specifically available for women’s and children’s health; and crowdsourcing. At the same time, while these ideas are gaining traction, questions have also been raised concerning possible conflicts of interest when involving private sector partners and difficulties associated with accountability related to crowdfunding.
Centralised, government-driven financing of health has long been a subject of discussion by policymakers who debate the pros and cons of one-payer systems, the appropriate level of government intervention in the healthcare market, and questions of choice within healthcare provision. However, the provision of private financing that targets the needs of the world’s poorest and most vulnerable is a potentially radical development.
The deliberate intersection of health policy and finance policy may be the innovation that enables us to expand the amount of funding available for the SDGs. The impact of financial inclusion for health is also now being documented. For example in Bihar, India, a recent study found a positive impact on the health of women and their families as a result of digitised cash transfers. Another recent study documents the impact of financial inclusion approaches on expanding access to water, sanitation and healthcare, also in India.
As we enter this new era of development we must adopt a new mindset and new tools. The fact that the SDG framework includes and promotes equity as part of its fundamental platform is already radical in and of itself; the realisation of the principles of social and financial inclusion for health will be a global game changer.
Christine Sow is the president and executive director of the Global Health Council
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