I’ve spent a lot of time in international meetings talking about the importance of universal health coverage (UHC), and the technical and practical considerations needed to bring UHC closer to reality. But missing from these discussions is acknowledgement – if not guidance – around UHC’s complex political economy; that when we spend more on health, more is at stake for all the actors in the system.
This message was articulated clearly and poignantly last week by health minister Alejandro Gaviria at Colombia’s “National Summit for Health”, where I was also privileged to attend. His words and the broader UHC experience in Colombia offers endless food for thought to international discussions in this space.
Colombia has a unique health system –most similar to the Netherlands in design– that uses public monies to expand access to a generous health benefits plan via public and private insurers that in turn contract public and private providers. After 15 years of implementation, the country consistently spends more than 20% of its public budget on health.
This has not been without controversy, but Colombia has achieved much – moving from 40% of the population insured to near-universal enrollment, the lowest level of out of pocket spending on health in the region, and measures of quality and timeliness of care that surpass many OECD countries. And unlike health insurance programs elsewhere, Colombia has had three independent, rigorous impact evaluations that found positive and significant effects of insurance enrollment on some measures of health, utilization of preventive care, and financial protection, particularly for the poor.
Yet in recent years, Colombia’s health system is also facing many challenges. There were several highly-publicized cases of corruption among insurers and hospitals. Providers were given a reimbursement loophole to access medicines not included in the health benefits plan, and spending –some necessary, others wasteful- soared. Patient experience leaves much to be desired. Incentives for and data on health status were not built into payment and regulatory systems.
My role at last week’s meeting was to put it all of these problems in context, making the point that Colombia looks pretty good to an outsider and that the politics and economics of universal health coverage and related reforms throw up similar challenges everywhere; that all countries go through multiple reforms trying to get it right. I also got to make my favorite points about the importance of priority-setting, incentives and value for money. And that “fraud happens, what’s important is its detection!” My slides are here (in Spanish).
But amidst these challenges, health minister Alejandro Gaviria speaks truth to power and tries to keep the Ministry focused on the bottom line – the well-being of the people that the health system is trying to serve. Here are some highlights from his closing remarks and earlier writing, that begin to illustrate why the political economy of UHC is such a relevant and thorny issue in all countries (my synopsis and translation below based on this video.
It won’t be easy to increase public or private spending… there is a global fact, all systems have to deal with this, it’s the growth of technology, the divorce between value and price, and the difficulty of taking decisions in this context. And this will continue to be a challenge.
It’s complex, not easy. We are not having a definitive reform, the reform. We are in a health reform, and others will come later… we can’t see earlier reforms as failures because they don’t solve all the problems. No, we will be in permanent reform, that’s what international experience shows. If we were conscious of this fact, perhaps we would be more realistic. This is one reform and there will be others, these are efforts of every day.
We start off thinking of a health reform that will benefit the people, not the agents in the system (“la gente no los agentes”). Quickly we see our efforts derailed by conflicts between different interest groups, conflicts on the redistribution of rents in the system. Everyone wants money. Insurers want to manage money directly. Private hospitals want direct funding without any questions. Public hospitals want a permanent flow of resources with no competition. Departments want more money and more autonomy. Universities don’t want to compete to train specialists. Health workers want to go back to old salary schemes. All dress up their interests in altruism. Yet the reform intends to align incentives to improve health and well-being, putting the patient at the core.
No one is ever happy with the referee, and that is the role that the Ministry has to play. But we have to acknowledge that there are legitimate interests that are not always consistent with the well-being of users, and we have to work together to overcome to deal with these obstacles to universal coverage.
Emerging markets like Colombia are in the midst of the demographic transition, while gains in education and wealth are transforming people’s expectations and demands for care. These same countries are now the principal sources of growth for the pharmaceutical and devices industries. Yet they lack the institutions necessary to manage these fiercely competing interests.
At the global level, we offer precious little guidance, advice and back up to ministries of health in coping with these kinds of problems. Minister Gaviria is in the middle of the maelstrom, and at the moment, we have nothing to offer but moral support. Let’s hope our support for UHC gets more sophisticated fast.