Going Universal: How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom up

Cotlear, Daniel, Somil Nagpal, Owen Smith, Ajay Tandon and Rafael Cortez, Going Universal: How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom up, Nepalese Journal of Management Science and Research, Vol.1, No.1 (February, 2016), pp.97-8.

Washington, DC: World Bank, 2015

ISBN: 978-1-4648-0610-0

XIX + 265 pp.

As noted by Dr. Timothy Evans in the foreword to this study of universal healthcare (UHC) in 24 developing nations, UHC has the three interlinked benefits of improving people’s health, reduces poverty and fuels economic growth (p.xiii). One of the principal problems faced by poor people is their vulnerability to health problems within the household to the sudden need to find cash to pay for treatment and medicine. If a system can be devised to enable people to avoid this vulnerability, it gives the poor more security in planning to improve their quality of life in the future. There is also the equity issue; after the Second World War, one of the central policies used to make exhausted Britain ‘a land fit for heroes’ was the creation of the National Health Service to provide UHC free at the point of use to anyone who needs it irrespective of class or any demographic characteristic. Nation building on a genuine level requires UHC of some sort and, once it has been implemented, people very quickly come to the realisation that their country could not manage without it.

This book is divided into thematic chapters based on the comparisons of different programmes. These include strengthening accountability, improving health care provision and managing money. Since this is a World Bank project, it is inevitable that the text will move towards the identification and creation of policy and so it is here. So, in terms of policy, the team makes these propositions:

“The bottom-up approach is a viable option for developing countries.

Prioritizing the poor and vulnerable within a bottom-up approach may require identification and targeting capacities to be developed.

Health policy makers should be active in designing and strengthening national identification and targeting systems.

There is no ‘best practice’ model capable of accommodating any country at any stage of development.

The quality of UHC programs’ implementation often improves as they mature.

The road to UHC often uses stepping stones (p.6).”

These are then used to create the following implications:

“A focus on priority setting using more systematic and institutionalized processes that consider evidence and stakeholder views is vital because resources will always fall short of the huge range of potential health care services.

Noncommunicable diseases (NCDs) seem to be the widest gap in service coverage, and need attention given their overwhelming share of the disease burden.

Delivering the promised coverage requires planning and effort.

Strengthening programs’ management capacity, particularly in contracting providers and purchasing strategically and effectively, will be vital (pp.7-8).”

UHC is undeniably a complex issue requiring support and contributions from numerous institutions and organizations. Consequently, as noted above, it is not possible to identify programmes of excellence which can be applied everywhere or, at least, widely. The methodology chosen for this study, which analyses and compares 26 programmes from 24 different countries, seems subject to the problem that in order to find sufficient common ground with sufficient breadth and depth of coverage, that the results might become anodyne. Perhaps this is a reason for the comment in the foreword that this book is not necessarily particularly helpful for policy-makers, as the implications above perhaps indicates. What perhaps is more useful is the understanding of the different ways that similar issues affecting countries may be addressed from different perspectives. Even these comparisons can be a little vague, as for example this section on the private sector:

“Efforts to expand the stock of resources include engaging with private providers and incentivizing public providers. About half the programs make use of private providers. Many UHC programs are also trying to improve the performance of publicly run health facilities by granting them more financial autonomy and flexible cash management at primary, secondary, and tertiary levels. While not enough is known about the efficacy of these reforms, it is known that not all incentive systems get it right at the first attempt and need to be monitored, and reformed, as they evolve (p.12).”

This is evident from the situation at Thailand, where important and sometimes seemingly intractable problems have blighted the UHC system. Introduced during the Thai Rak Thai administration of Thaksin Shinawatra (also the founder of Shinawatra University), the 30 baht (approximately US$1) scheme provided low cost UHC to the whole of Thailand and became immediately popular. However, provision of services is uneven because, in part, the country’s education system sees entrance into medical school almost entirely limited to the leading candidates who come from expensive and exclusive Bangkok schools. This means that many medical doctors are unwilling to work outside Bangkok and have also become associated in some cases with the anti-democracy movement that, borrowing tactics from the American far right, has sought to oppose every action of the government on an ideological-obstructionist basis. This has involved some senior doctors and hospital administrators break the Hippocratic oath by refusing to treat wounded police officers and others. In the face of such opposition, the democratically elected governments of the country have sought to employ a variety of different means by which to encourage compliance and maintain UHC for the Thai people. It was notable that after the coup of 2014, the junta leader announced that the UHC would be curtailed and then had hastily to cancel the cancellation after public outrage even from among his own establishment supporters and the popular media. Thailand’s endlessly malleable sense of Thainess has now evidently evolved to the extent that it incorporates access to UHC as an essential element.

Produced to the expected professional level of production by the World Bank team, this is a useful contribution to the study of healthcare systems in developing nations. In common with most areas of government policy, UHC is is not often systematically studied according to a rigorous framework and with a genuine attempt to assess its efficacy in achieving its goals. This is a source of useful evidence.