Universal Health Coverage (UHC) Implementation

Implementing pro-poor pathways towards universal health coverage

In July, the CIH hosted a three-day workshop at the Rockefeller Foundation’s Bellagio Center to advance the discussion of how countries can successfully implement pro-poor pathways towards UHC. The meeting brought together 21 UHC practitioners and academics, including officials from the Ministries of Health of Myanmar, Ethiopia, Ghana, Argentina, Mexico, Sri Lanka, and Thailand, and representatives of global health agencies, foundations, universities, and think tanks.

Universal health coverage (UHC)—ensuring that everyone has access to high quality, affordable healthcare when needed—can be a vehicle for improved equity, health, financial well-being, and ultimately, development. Yet, for these outcomes to be achieved, a number of questions about how to implement policies aimed at moving closer to UHC must be answered.

The Lancet Commission on Investing in Health, in its Global Health 2035 report, outlined an ambitious investment framework for global health. This framework including the endorsement of “pro-poor” UHC — pathways to UHC in which there is a determination to include poor people in service provision from the outset. The CIH made the case that these pro-poor pathways are the most efficient way to improve health and financial risk protection.

Countries worldwide are now embarking on health system changes that move them closer to achieving UHC.  As they do so, they can draw from a significant body of research and country evidence about the technical aspects of UHC implementation — which we call the “what” of UHC — such as defining service packages and developing health financing systems. However, there is little information available on what we call the “how” of UHC implementation, for example: how do countries build and sustain political commitment for UHC over time? How do UHC leaders manage opposition to pro-poor service delivery? How can countries secure and maintain adequate long-term health systems finance while moving away from out of pocket payments?

This lack of information on the “how” of UHC is in part due to the non-linear process through which countries implement health system reforms. There are often stops and starts that are influenced by politics, administrative and technical challenges, and resource constraints—as well as the ever-evolving fiscal and political environments in which UHC decisions are made.

At the Bellagio meeting, UHC experts shared their experiences to build the evidence on how countries can overcome these difficult, and often sensitive, challenges of UHC implementation to best ensure the success of emerging UHC schemes. The meeting focused on a set of seven key questions across five domains.

Participants shared their country experience to build the evidence base on these emerging questions about the politics and challenges of introducing and expanding pro-poor UHC programs.

Bellagio Participants

Participant bios

• Jesse Bump: Executive Director, Takemi Program in International Health, Harvard T.H. Chan School of Public Health, USA
• Cheryl Cashin: Senior Program Director, Results for Development Institute & Joint Learning Network, USA
• Kalipso Chalkidou: Founding Director, NICE International, UK
• David Evans: Bellagio meeting chair, and Scientific Project Leader, Swiss Tropical and Public Health Institute, Switzerland
• Eduardo Gonzalez-Pier: Deputy Minister of Health, Mexico
• Yan Guo: Professor, Peking University School of Public Health, China
• Jeanna Holtz: Principal Associate, Health Finance and Governance Project, Abt Associates, USA
• Daw Thein Thein Htay: Deputy Minister of Health, Myanmar
• Carol Levin: Senior Health Economist, Disease Control Priorities Network, USA
• Robert Marten: Senior Program Associate, Rockefeller Foundation, USA
• Sylvester Mensah: Former Chief Executive of NHIA; currently in charge of Special Duties, Office of the President, Ghana
• Ariel Pablos-Mendez: Assistant Administrator for Global Health, USAID
• Ravindra Rannan-Eliya: Executive Director, Institute for Health Policy, Sri Lanka
• Martín Sabignoso, National Coordinator: Plan Nacer & Plan Sumar, Argentina
• Helen Saxenian: Independent Consultant, USA
• Neelam Sekhri Feachem: Associate Professor, Epidemiology & Biostatistics, University of California, San Francisco, USA
• Agnes Soucat: Global Lead: Health, Nutrition, and Population, World Bank
• Viroj Tangcharoensathien: Senior Expert, Health Economics, Ministry of Public Health, Thailand
• Hong Wang: Senior Program Officer, Bill & Melinda Gates Foundation, USA
• Addis Tamire Woldemariam: Director General (Chief of Staff), Office of the Minister, Ministry of Health, Ethiopia
• Gavin Yamey: Professor of the Practice of Global Health and Public Policy, Duke University, USA

Bellagio Report

The policy report outlines the key lessons and recommendations that emerged from the discussions at the Bellagio meeting on how to implement pro-poor UHC. This report seeks to fill the gap in the empirical research by highlighting country experiences in initiating and implementing UHC reforms and the lessons learned through these experiences. The practice brief summarizes the key messages from the Bellagio workshop for use by health reformers, policymakers, program managers, and UHC advocates.

Bellagio Statement: Implementing pro-poor Universal Health Coverage
Policy report: Implementing pro-poor Universal Health Coverage
Practice brief: Implementing pro-poor Universal Health Coverage

Background paper

The background paper, prepared for discussion in Bellagio, outlines the evidence on the technical aspects of UHC implementation – highlighting key findings from the literature and interviews with global UHC implementers and researchers on what steps countries have taken to implement pro-poor UHC. The policy brief provides a summary of the main messages from the literature and interviews.

Background report: What steps are countries taking to implement pro-poor universal health coverage?
Policy brief: What steps countries are taking to implement pro-poor Universal Health Coverage?

Presentations from Bellagio Workshop

Progressive UHC as laid out by Global Health 2035

• Agenda and roadmap, Gavin Yamey
• Progressive UHC: Global Health 2035’s vision, Agnes Soucat

Country experience implementing progressive UHC

• Argentina’s UHC Experience, Martin Sabignoso
• China’s UHC Experience, Guo Yan
• Mexico’s UHC Experience, Eduardo Gonzalez-Pier
• Sri Lanka’s UHC Experience, Ravindra Rannan-Eliva
• Thailands’s UHC Experience, Winai Sawasdivorn
• Thailands’s UHC Experience, Viroj Tangcharoensathien

Generating and sustaining political will and financial commitment for progressive UHC

• Engaging the public in UHC service packages decision-making, Sylvester Mensah

Generating and using information to support progressive UHC implementation

• Evidence use to inform service package development, Jeanna Holtz

Measuring and maintaining financial protection

• Extended cost-effectiveness analysis, Carol Levin

Managing UHC growth — Institutional Capacity

• Approaches to strengthen institutional capacity, Jesse Bump
• Comparison of donor and country roles, Jesse Bump, Robert Marten, Stefan Nachuk

Investments and incentives to ensure quality and increase efficiency

• Global overview of how incentives are being used to motivate quality, Cheryl Cashin

Summary of key lessons

• Workshop overview, Gavin Yamey