Elsevier

The Lancet

Volume 380, Issue 9845, 8–14 September 2012, Pages 917-923
The Lancet

Series
Does progress towards universal health coverage improve population health?

https://doi.org/10.1016/S0140-6736(12)61039-3Get rights and content

Summary

Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance.

Introduction

WHO and many other commentators have called for countries to take concrete steps towards the achievement of universal health coverage, which in its simplest formulation means providing all people with access to needed health services of sufficient quality to be effective, without their use imposing financial hardship.1, 2, 3 Stronger reliance on prepaid health spending and risk pooling mechanisms are regarded as key indicators of progress towards universal coverage (panel). One fundamental objective is to reduce the financial barriers that people face to gain access to necessary health care. High reliance on out-of-pocket payments in health financing is associated with an increased risk of households being affected by financial catastrophe, being pushed into poverty (or further into poverty) because of health-care payments, or forgoing needed treatment because of inability to pay.1, 5, 6

Key messages

  • A greater reliance on prepaid health spending and financial risk pooling is regarded as a key sign of progress towards universal health coverage

  • The direction and strength of the links between pooled prepayment, insurance mechanisms, and population outcomes can be affected by many factors

  • State-of-the-art quantitative methods provide evidence on the causal effect of broader health coverage on population outcomes

  • Broader health coverage generally leads to better access to necessary care and improved population health, with the largest gains accruing to poorer people

  • The health gains derived from broader coverage are likely to depend on factors such as institutional framework and governance arrangements

  • Countries with enough resources should regard progress towards universal health coverage as a key investment target

  • Donors have an important role in ensuring that the poorest countries have the sustained ability to invest adequate resources in the enhancement of coverage

Even though financial protection is in itself regarded as a valuable objective in many societies, expanded coverage is also justified on the grounds that it leads to health improvements, particularly for poor people.1, 7 This reasoning often lies behind efforts to expand access to health services through pooled prepayment mechanisms that have an insurance function. The logic is that such pooling mechanisms will increase access to care by enhancing the availability and affordability of needed services, and thereby improve health.8

The figure illustrates the underlying argument by showing, in a simplified way, the potential causal chain from pooled prepayment (publicly or privately funded) to coverage (effective access to care and financial protection) to health outcomes. There can also be reverse causality in the chain if changes in population health status trigger changes in the amount of pooled funds available for health.

Although the causal pathway from pooled prepayment to universal coverage and health is often taken for granted in the international debate, findings from empirical research have not always shown that population health systematically improves in response to enhanced risk pooling and prepayment. There are theoretical reasons why those links might be weak or non-existent at the population level, since the relations in question could be affected by many other elements, represented by the vertical arrows in the figure. For example, a rise in government health spending—which usually takes the form of prepaid funds and amounted to 60% (IQR 45·4–75·6) of total health spending across 192 countries in 20089—might be accompanied by a matching reduction in prepaid private health expenditures. This situation could result in no changes in total prepaid spending, service use, or health status.

Even if extra government spending does increase the total amount of pooled resources devoted to health care, its effect on health might be disappointing if the targeting of funds is poorly aligned with population needs.10 Furthermore, the magnitude of any health gains is likely to depend on the identity of the beneficiaries. Poor people will usually stand to gain most from increased access to health services, so if access improves only for small groups of richer people, there could be few observable gains in aggregate.

Robust quantitative evidence is necessary to substantiate that the predicted causal pathway does occur in practice for populations, and to identify the main system-wide factors affecting the strength of the relation. Our aim is to synthesise the most rigorous, relevant empirical evidence produced so far, with a focus on system-level and cross-country statistical research.

Section snippets

Does pooled health spending improve population health?

National progress towards universal health coverage is intertwined with steps in the direction of a so-called health financing transition, characterised by rising per-head health spending and an increasing use of pooled health funding.11, 12 This trend has been accompanied by overall improvements in health status indicated, for example, by rising life expectancy and downward trends in child mortality rates.9, 13 The empirical challenge is to assess the extent to which these observed relations

Do insurance mechanisms improve population health?

A growing number of researchers have examined the relation between population outcomes and broader coverage through publicly and privately funded schemes that have an insurance function. The evidence is almost exclusively from individual country studies rather than from a comparative international perspective. One conclusion that emerges from this work is that expanded insurance mechanisms generally lead to improved coverage (access to care and financial protection) and improved health

Evidence and policy implications

A key objective of moving towards universal coverage is to improve population health through the reduction of financial barriers to needed services. We have summarised the most rigorous evidence on the causal pathway from a methodological viewpoint, and believe that overall it offers important insights.

The reviewed work supports the idea that expansions in coverage measured by higher levels of pooled health spending normally lead to better population outcomes. However, the magnitude of the

Search strategy and selection criteria

We searched for studies that examined the population health effects of extended pooled prepaid health expenditure and insurance mechanisms as proxies for progress towards universal health coverage, and focused on quantitative evidence based on data from the broader national and cross-country levels. We searched the JSTOR, Google Scholar, Ideas-RePEc, and PubMed bibliographic databases, with combinations of the terms “health”, “spending”, “expenditure”, “insurance”, “coverage”, and “outcomes”.

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