To Achieve Universal Health Coverage, Get the Incentives Right

Achieving universal health coverage in the next 20 years will depend on many factors, but one of the most important is getting incentives right. Around the world, and in every society and social strata, we need to look at whether people have the right mix of incentives to avoid unhealthy lifestyle choices, and to access preventive health, such as vaccinating their children, using contraceptives for birth spacing or to avoid pregnancy, using condoms for disease prevention, and sleeping under bed nets in malarial zones. But just as importantly, we need to ensure that health care providers, both individual and institutional, have the right alignment of incentives to deliver high quality, affordable health services and pharmaceuticals.

According to a report published by The Lancet Commissions in December 2013, titled “Global health 2035: a world converging within a generation,” insurance will be a primary tool in achieving universal health coverage in low- and middle-income countries. Current levels of insurance coverage are low in most low-income countries, but by 2035, the authors predict that publicly financed insurance will universally cover access of poor people to essential services, including against non-communicable disease. A broader benefits package will cover all strata of the population, with exemptions for the poor.

Insurance schemes have been launched in many low-income countries, with varying degrees of uptake and success. Community health insurance funds are one approach to reaching underserved communities, and complement national health insurance funds and private insurance. In Tanzania, about 23 percent of the population was covered either by national or community health insurance in 20151, and that figure will continue to grow.

But the design of insurance schemes is tricky. Ghana has seen challenges with its insurance scheme due to slow growth of subscribers, lack of access, uncooperative providers, unaffordable premiums for lower-income populations, and cost escalations2. Aligning incentives is also tricky; policies must encourage enrollment and incentivize clients to seek health care for prevention more than curative services. Health workers must be incentivized to provide quality services and supplies that yield good health outcomes. And the broader health system must be strengthened to respond to demand while containing costs to stay financially sustainable.

There are many models for health insurance, some better than others. Middle-income countries can serve as models of how to—or how not to—establish insurance schemes within the context of broader health sector reforms. One example of getting the right mix of policy changes, system reforms, and provider and client incentives is Romania, where reproductive health was a national priority.

Part Two: Romania Case Study: Increasing Access to Reproductive Health Services and Supplies by Getting the Incentives Right

1 Mkama, Ashery, 2015. “More people register with insurance fund.” The Daily News, 22 October 2015. http://dailynews.co.tz/index.php/home-news/43435-more-people-register-with-insurance-fund.
2 Gajate-Garrido, Gissele and Owusua, Rebecca. 2013. The national health insurance scheme in Ghana: Implementation challenges and proposed solutions. IFPRI Discussion Paper 1309. Washington, D.C.: International Food Policy Research Institute (IFPRI). http://ebrary.ifpri.org/cdm/ref/collection/p15738coll2/id/127958.

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