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Vaccinate children or fund dialysis for kidney patients? With limited healthcare budgets, many developing country governments face tough choices about what health services to offer. Yet much health spending in developing countries is not based on evidence of what is most efficient and effective. CGD research shows governments how to make better decisions for better health. And our work has already led to the creation of the International Decision Support Initiative—a global partnership helping policymakers make better-informed decisions that save money and lives.
Update: Here’s a recap of key moments from Friday’s #HealthForAll Twitter chat!
Each year, millions of people fall into poverty because they have to pay out of pocket for medical care. At least half of the world’s population does not have access to essential health services. Universal health coverage (UHC) is the goal of ensuring that everyone, everywhere can access quality health services without the risk of financial hardship.
We can make UHC happen in our lifetime by targeting investments and incentives on the highest impact interventions among the most affected populations in developing countries.
Starting Saturday, with World Health Day 2018, a drumbeat of activities will focus on increasing political will to advance health for all. The series of events include: the 71st World Health Assembly (WHA) in May, the United Nations General Assembly in September, and the marking of the 40th anniversary of the Alma-Ata Declaration in October in Almaty, Kazakhstan. It is anticipated that a new Alma-Ata Declaration will be set in motion and adopted at the WHA in 2019. These moments provide an opportunity to help shape and accelerate the UHC agenda.
Countries at all income levels are proving that UHC can be both achievable and affordable. However, current global funding has leveled off while the need for life-saving services and products has not. Governments and global health funders need to do more with existing resources.
Over the coming months, we at CGD will be highlighting three areas in particular that will impact efficiency and achieve more health for the same amount of money, particularly in low- and middle-income countries:
Adoption of an explicit, evidence-based Health Benefits Package—a defined list of services that are and are not subsidized—is essential in creating a sustainable UHC system. It is key to evaluate how much health an intervention will buy for each dollar.
Better data and performance verification—combined with results-based funding—is a powerful instrument for UHC mechanisms. There is the potential to improve efficiency of the health system and increase productivity of health workers, while ensuring quality, equitable services at an affordable cost.
Tomorrow, CGD (@CGDev) and I (@glassmanamanda) are looking forward to teaming up with Loyce Pace (@globalgamechngr) and the Global Health Council (@GlobalHealthOrg) for a Twitter Chat from 10-11am ET. By working together, we can share best practices towards greater efficiencies and improve access to quality health care services for everyone, everywhere.
As developing nations are increasingly adopting economic evaluation as a means of informing their own investment decisions, new questions emerge. The right answer to the question “which perspective?” is the one tailored to these local specifics. We conclude that there is no one-size-fits-all and that the one who pays must set or have a major say in setting the perspective.
Tomorrow, December 12, marks the fifth annual Universal Health Coverage (UHC) Day. Half a decade after the landmark UN endorsement, more countries than ever are working to translate UHC goals into reality through defined, tangible, equitable, and comprehensive health services for their populations. To celebrate, CGD is pleased to host a short program—Better Decisions, Better Health: Practical Experiences Supporting UHC from Around the World—featuring a keynote from Dr. Mark McClellan, who has been at the forefront of improving the quality and value of healthcare in the US, and presentations from experts on practical experiences supporting UHC from Southeast Asia, sub-Saharan Africa, and at the global level.
Each year, millions of people fall into poverty because they have to pay out of pocket for medical care for themselves or a loved one. Many more can’t even access healthcare, creating serious risks for population health and disease outbreak and epidemic. UHC is the goal of ensuring that everyone, everywhere can access quality health services without the risk of financial hardship.
Last week, in his keynote address at the DCP3 launch event in London, WHO Director-General Dr. Tedros Adhanom Ghebreyesus reaffirmed UHC as his “top priority.” He acknowledged that UHC is no easy task, and that it requires “political commitment and technical expertise” and that tough decisions “must be made about finite resources.” Tomorrow, we will celebrate and highlight how countries are addressing these challenges and making huge progress in their commitments to UHC.
Following a recommendation of the CGD working group on Priority-Setting in Health in 2012, the International Decision Support Initiative (iDSI) was established in 2013. iDSI is a global network of health, policy, and economic experts working with countries to get more health and better value for every dollar they spend, so that they can achieve fairer, higher-quality, and more sustainable UHC. iDSI forms regional and global partnerships that support and share knowledge with one another in order to achieve real-world health gains and build progress towards the health Sustainable Development Goal (SDG 3).
During our event tomorrow, we’ll hear from iDSI partners about challenges and successes in their paths towards UHC. We will also explore how we can continue our efforts in the future, especially with Dr. Tedros’ announcement of the five-year strategic plan to see 1 billion more people with health coverage by 2023.
We need to work together to make smarter investments in health and tough choices based on rigorous evidence and evaluation of the costs and benefits of different healthcare policy decisions. Join us (RSVP here) tomorrow as we celebrate our achievements so far and gear up for the work ahead in this movement towards UHC.
With aid budgets shrinking and even low-income countries increasingly faced with cofinancing requirements, this is the right time for global health funders such as the Global Fund and their donors to formally introduce Health Technology Assessment (HTA), both at the central operations level and at the national or regional level in recipient countries. In this CGD Note, we explain why introducing HTA is a good idea. Specifically, we outline six benefits that the application of HTA could bring to the Global Fund, the countries it supports, and the broader global health community.
How can countries get optimum health value for their money? What's a health benefits plan and why do countries need them? How should countries decide what's included in their health coverage and what's not? A new CGD book from Amanda Glassman, Ursula Giedion, and Peter C. Smith answers these questions and more.
Vaccinate children against measles and mumps or pay for the costs of dialysis treatment for kidney disease patients? Pay for cardiac patients to undergo lifesaving surgery, or channel money toward efforts to prevent cardiovascular disease in the first place?
For universal health care (UHC) to become a reality, policymakers looking to make their money go as far as possible must make tough life-or-death choices like these.
Many low- and middle-income countries now aspire to achieve universal health coverage, where everyone can access quality health services without the risk of impoverishment. But for universal health care to work in practice, the health services offered must be consistent with the available funds, and this implies very difficult decisions—particularly for low- and middle-income countries that are resource-constrained, but where demand for high-quality health services and technologies is increasing rapidly.
In collaboration with iDSI, we’re launching a new book, What’s In, What’s Out: Designing Benefits for Universal Health Coverage. It shows how a defined list of services that will be funded with public monies (called a “health benefits package” or HBP—known in the US as “essential benefits”) can help bridge the gap between the aspirational rhetoric of universal health care and the real budgetary limitations that many countries face. A good HBP should be practical and made in consideration of the fiscal, human resource, infrastructural, and geographic constraints of that setting. When done well, the HBP defines the health services a government can deliver, and ensures health services are fairly and equitably delivered to citizens—and are cost-effective.
Leading experts and policymakers from more than 15 countries contributed to the book. Together, they consider the many dimensions of governance, budgets, methods, political economy, and ethics that are needed to decide “what’s in and what’s out” of a HBP in a way that is fair, evidence-based, and sustainable over time.
Set fair and transparent processes to select, revise, implement, and monitor the HBP.
Not only does the creation of a HBP include the work of designing a sustainable benefits package by using methods exercises to identify the services that will be financed with public resources, but it also requires updating, monitoring, evaluating, and implementing. Like the package itself, the design process for the HBP must be consistent with time, financial, and human resources available. Inclusion or exclusion of specific medical interventions can have life-or-death consequences for specific groups, but the establishment of a fair and technically sound process for priority-setting can help increase overall public buy-in. Adherence to good governance principles during the HBP design process—transparency, consistency, and stakeholder participation—helps sensitize stakeholders to the rationale for setting limits and can thus improve the package’s legitimacy and sustainability.
Use rigorous methods to get the most health for your money.
Since the HBP requires tough decisions, the design process must be thorough and it requires the necessary resources to ensure fairness and technical rigor. Not only does a benefits package need to be explicit, but for it to work properly, its components must be selected by consistently applying an explicit set of criteria. Cost-effectiveness analysis allows a country to rank different interventions and select treatments that will achieve the most health for the given budget. The cost-effectiveness threshold will vary according to context-specific factors. While simple cost-effectiveness analysis only considers health gain, a range of more sophisticated methods account for other factors, including financial risk protection, health systems constraints, equity considerations, and more.
Manage the ethical, legal, and political implications of inclusion and exclusion decisions.
When making the hard choices to decide what’s in and what’s out of a HBP, political, legal, and ethical stakes are high. Policymakers should be sure to consider ethical implications throughout the HBP design and adjustment process. They should try their best to include fair processes and procedures, avoid harms to individual patients, and offer respect and dignity for patients.
Rather than a technical manual for conducting health technology assessments or cost-effectiveness analysis, this book puts HBP development and design methods into a broader context and considers how these methods may be applied to coverage decisions in low- and middle-income countries. It offers a collection of views and perspectives, and also provides real-life examples of HBP design and adjustment in order to show the diverse approaches to priority-setting around the world.
We’ve learned a lot from compiling this book and we’re excited to share these lessons with you. We encourage you to check out our webpage and to order your copy of the book. We also hope you’ll join us on Wednesday, October 11 for a policy breakfast to celebrate the book’s release. We’ll hear from Ole Norheim, Tim Evans, and Eduardo Gonzalez-Pier on their experiences in running benefits plans policies around the world, and how the book and related efforts can help to translate UHC from rhetoric to reality.
Many low- and middle-income countries aspire to universal health coverage (UHC), but for rhetoric to become reality, the health services offered must be consistent with the funds available, which may require tough tradeoffs. An explicit health benefits package—a defined list of services that are and are not subsidized—is essential in creating a sustainable UHC system.
Global health policy enthusiasts will be excited to see that WHO has recently published a draft Concept Note on the 2019-2023 Programme of Work under the stewardship of its new Director-General, Dr. Tedros Adhanom Ghebreyesus (or Dr. Tedros, as he is generally known). The note will doubtless stimulate much discussion within WHO and among its stakeholders and—perhaps inevitably at this stage in the DG’s tenure—much of the detail remains to be filled in. However, the note does have an important role in establishing the key themes for the Organization in the next few years, and as such, it is disappointing that it does not offer a clearer storyline of where WHO wants to go.
We see two glaring missed opportunities: 1) more centrality to universal health coverage (UHC) as an organizing principle for WHO and its work, and 2) more emphasis on enhancing the value for money of public spending on UHC and elsewhere.
Missed opportunity #1: reiterate the centrality of UHC in reaching WHO goals
The first missed opportunity is the failure to reiterate the centrality of UHC to what WHO hopes to achieve. This is surprising as much of the success the WHO has had in recent years in setting the global policy agenda stems from its presentation of the moral and economic case for UHC, particularly in the World Health Report 2010.
By contrast, the treatment of UHC in the current Concept Note is fleeting and superficial. Its opening section “What does the world need?” contains a grab bag of “global health challenges,” leading off with the threat of pandemic flu. This is a missed opportunity to lay out the appeal and power of UHC as an integrative concept. Indeed, the best chance the world has to prevent outbreaks of diseases old and new, to cope with threats to health arising from conflict and natural disasters, to secure financial protection for citizens, to manage and contain the growth in non-communicable diseases, as well as all the other things listed, is if countries move towards sustainable and equitable financing of their health systems through implementing UHC.
The note also begs the question: what exactly would WHO’s role be in supporting countries in their progress towards UHC? Had they been more specific on where WHO can add value in supporting countries to reach their UHC vision, the authors of the draft strategy could be setting out measurable indicators and attributable results of WHO’s activity, which can then be used to inform the outcomes based agenda they advocate. Would WHO be offering advice and setting global norms? Would it be involved in or even leading efforts to devise progress indicators and help collect data and report progress against those as the latest edition of GBD has done? Would it go further and set standards for minimum benefits, populating the famous WHO UHC cube? Would it help countries track expenditure or provide advice on financing and provision arrangements? Would it do even more as suggested and become more operational (and what would this look like in country settings)? And if most or all of the above, where would the capacity come from—and would an alternative not be working with others operating in this space, leveraging already committed resources and expertise in a synergistic fashion? In the spirit of setting priorities and given finite resources, WHO must surely realise that its advocacy, global coordination, and norm-setting role are its real strengths.
What makes this neglect particularly surprising is that UHC is a prominent part of the platform on which Dr. Tedros stood and was elected by the World Health Assembly. Dr. Tedros’ campaign materials prominently list Health for All as the first priority and states clearly that:
“Health for all” must be the centre of gravity for efforts to achieve all of the SDGs … WHO’s top priority must be to support national health authorities’ efforts to strengthen their core responsibilities … Achieving universal health coverage is an ambitious goal, but it is one that can and must be achieved to create a healthier and more equitable world.
No comparably strong statement appears in the present document which does not get around to discussing UHC directly until page 6, hidden between health emergencies and priority SDGs.
Missed opportunity #2: emphasize value for money in health spending and its uses
The second missed opportunity is about value for money (VfM). The UHC section of the note would be an ideal place to discuss prioritization of spending at country level, based on existing financial envelopes, while also making robust cases to countries’ treasuries for more. Instead we are given a bill: “Achieving the SDG health targets would require new investments increasing over time from an initial US$ 134 billion annually to $371 billion, or $58 per person, by 2030.” There is no mention of the need to spend better, as is clearly set out in WHO’s report on SDGs in Africa; and no mention of the lack of correlation between more spending and better outcomes.
When the note does get around to talking about VfM (on page 9), the discussion seems even more underdeveloped than the discussion of UHC. VfM should be a critical concept for WHO. But the note seems to take the narrowest possible interpretation of value for money, stressing the need for WHO to measure outcomes and operate sound financial management.
Yet as a global normative agency, WHO has a far broader duty—to guide those with the responsibility for managing the world’s health systems to adopt economic appraisal and prudent management practices. A good start would be to declare that WHO will operate on the principle of VfM in all policies, a principle which can be the responsibility of the organisation’s first Chief Economist as Glassman has argued recently.
So, WHO should adopt a reference case for economics to be incorporated into all WHO programmes and all norm setting functions, including new additions to the Essential Medicines List, especially when the new items are: expensive on-patent products; Standard Treatment Guidelines norms in high priority areas such as antenatal care; investment cases for MDG technologies which the Global Fund and UNITAID will go on to purchase at volume; diagnosis and treatment targets such as the 90-90-90 target for HIV; and treatment initiation thresholds for HIV/AIDS. All of this is necessary to ensure that money which flows into health systems is used to the greatest benefit of the target populations and to convince those who fund WHO that it is serious about the VfM agenda. Another important role that WHO could pursue is to promote VfM at the country level especially for transitioning countries—WHA2014 HITA is great starting point. As stated in the Resolution, WHO can help build local capacity for countries to select products, negotiate prices and fees, manage providers through performance contracts where possible, control for and reward quality. Without such capacity the bill for implementing UHC will be much higher and selling the costs to country Ministries of Finance will be harder. Indeed, given the focus of the note on performance indicators for WHO, building in-country capacity is something WHO could be held to account to and that could be linked to better progress towards UHC.
Dr. Tedros himself has said that “the right of every individual to basic health services will be my top priority.” Parsing “basic” as “affordable” puts UHC and VfM at the heart of the DG’s vision. Alas, this clear and compelling vision seems to have got lost in the present Concept Note, which presents a WHO trying to respond to a disparate collection of problems, but with no clear organizing concept of how to tackle the underlying systemic causes of these problems or prioritize competing demands on the Organization’s scarce resources.