The COVID-19 pandemic has tested even the best healthcare systems and brutally exposed the weaknesses in many countries’ provision.
It’s reminded us that good health and prosperity are inextricably bound together.
According to the World Health Organization (WHO), half of the world’s population can’t access the healthcare they need, and 100 million people are driven into poverty each year due to unaffordable health costs.
Whilst COVID-19 has brought immense suffering, it has also re-energized the political will to tackle poor healthcare and advance the cause of the United Nations Sustainable Development Goal (SDG) 3: Ensure healthy lives and promote well-being for all at all ages.
And the best way to achieve this is through universal health coverage (UHC). It’s the foundation for giving every citizen access to the best possible care, without fear of the costs, delivered by a system they trust.
The UN has set a goal of achieving global UHC by 2030, which has been described as the greatest gift a country can give its people. We all have a responsibility to make it a success.
A once-in-a-generation journey
Every country has its own unique combination of population size, wealth, geography, political culture and existing health infrastructure. Which means the path to UHC – and the form of system adopted – will to some extent reflect these preconditions.
But regardless of the starting point, all nations face common and immense challenges in designing and implementing UHC, making it a once-in-a-generation journey that can take many years to fully implement. In some cases, repeated attempts over decades have failed to produce a satisfactory and affordable universal healthcare system. In other instances, there has been remarkable progress. Until as recently as 2003, China had almost no insurance coverage for its large rural population, whereas today virtually the entire population (97 percent) has access to care. According to the Organisation for Economic Co-operation and Development (OECD), Mexico increased the proportion with public healthcare from 52 percent in 2002 to 91 percent by 2014.
Here at KPMG, our firms have proudly helped a number of governments around the world plan and implement UHC, from huge nations like China, India, Pakistan and Nigeria, mid-sized populations like Philippines, South Africa and Saudi Arabia, to smaller states such as Bahrain, The Bahamas and Trinidad & Tobago.
We’ve been particularly active in the Caribbean region, where most governments have committed to UHC to varying degrees to overcome poor access to healthcare.
As a result of these varied experiences, we’ve identified six building blocks that can determine the speed with which the system is introduced and the effectiveness of the subsequent care provision.
Six building blocks for effective universal health coverage
1. Clear governance and leadership
Something as comprehensive and long-lasting as UHC calls for a sustained level of government commitment. Political leaders must make themselves accountable for its implementation, which can help win public trust for what will be a long and costly venture. Government needs to involve all stakeholders, including health providers (public and/or private), communities and the general public.
The ongoing administration and governance requires transparency, with clear feedback mechanisms that are seen to be acted upon. In order to gain greater public support and confidence, health spending should be positioned as an investment (rather than a cost). For instance, analysis by KPMG estimates 5 percent economic growth within a generation, as a result of a UHC system reducing sickness and increasing productivity in the population. Another KPMG economic analysis of the Bahamas’ new National Health Insurance system suggests it will generate seven times its cost in terms of increased GDP through improved population health.
2. Robust and realistic financing
UHC requires considerable and continual investment – most countries spend at least 6 percent of their GDP on health. At a time when economies are struggling in the wake of COVID-19, this may seem like an impossible sum to find, especially if governments’ income tax revenue is low and/or variable, and citizens are unaccustomed to paying for health insurance.
There are five broad types of models for financing universal healthcare:
- Fully state-owned system funded by general taxation (UK NHS)
- Non-profit social insurance institutions co-funded by government and employers (Germany)
- National health insurance model funded by a single-payer national health insurance (Canada)
- Mandatory private health insurance with government subsidies for lower-income citizens (The Netherlands)
- Voluntary private health insurance (as in the US before the introduction of the Affordable Care Act)
Financing is inevitably a political decision, as it typically involves healthier and wealthier members of society subsidizing service for their sick and poorer fellow citizens. Although UHC involves compulsory tax and social insurance, taxpayers tend to buy into the ethos of a greater good and evidence suggests this is justified based on the resulting economic growth.
It’s highly likely that the private sector will be involved in parts of the system, whether it’s care provision or insurance. In order to build trust between public and private stakeholders, all claims for payment must be based on accurate and transparent data and governments should pay on time.
3. Resourcing the workforce
Adequate numbers of trained health workers are fundamental for ensuring equitable access to health services and achieving universal health coverage. The chronic and growing shortage of doctors, nurses, and community health workers is a well-reported and increasingly urgent crisis to address, forecast to be 18 million globally by 2030 – a fifth of the total needed. From retention to migration, the causes are varied but the impact threatens the future strength of health systems globally.
Recommendations to address this include improved productivity, greater preventative and community care, harnessing the emerging digital transformation of healthcare including investment in AI, robotics and telehealth (which has accelerated during the pandemic), expanding responsibilities for nurses and other non-physicians, and increased self-care.
4. Service delivery and infrastructure
Emerging delivery models are harnessing new and updated care pathways to better meet patient needs, improving outcomes for individuals, providers and the wider health system. Adoption and development of these is strengthening the capabilities and capacity of UHC across low, middle and high resource health systems. Examples include community care enabled by technology, data analytics to improve targeting of vulnerable individuals, and encouraging better lifestyles to reduce the incidence of chronic diseases. Given the range of actors, governments should encourage integration of the public and private sectors, of healthcare training and service delivery, and of the community and the hospital.
Infrastructure should reflect these new care models, with fewer mega hospitals and more local clinics, and careful alignment of new projects with the needs of the system. A strong, centralized procurement function makes a huge difference, by ensuring open price competition, reducing fraud, and focusing on value for money and outcomes by monitoring and reducing drug usage.
5. Strong information systems
Shifting care from traditional reactive models to proactive and predictive care is a key aim for many health systems looking to improve population health and reduce costs. With a robust data analytics capability, the universal health system can better understand health needs, forecast the impact of interventions, set care targets, measure the success of outcomes and incentivize good performance. At a macro level, it’s possible to better understand major health trends and identify where to invest resources for optimum results.
Singapore has invested heavily in health analytics, which is driving better allocation of resources through improved localized management of chronic conditions, reducing the strain on hospitals. Reliable, up-to-date and appropriately shared data enables public health monitoring and also ensures that providers are paid promptly and accurately.
6. Enabling legislation and regulation
The early stages of UHC need government legislation to set the wheels in motion, removing legal barriers and supporting continued coverage. Laws help assure core goals of equity and care quality and set out rules (and incentives) to ensure that all the various actors adhere to these goals.
Ongoing regulation and performance management is another critical factor. By setting clear targets for hospitals and clinics, incentivizing leaders, and publicizing the results, government and citizens can track the success of the UHC system.
A long, difficult but rewarding transition
We shouldn’t need a pandemic to bring home the value of UHC. But the events of the past year or so have reinforced the importance of healthcare to our lives – and the benefits of efficient care delivery to all citizens.
The real question is not “Shall we introduce UHC”, but “How can we implement UHC”. Attempts to implement UHC frequently stall due the sheer enormity of the task. Trying to swiftly create a comprehensive system can be too complex for many; the more successful examples initially aim for a basic level of healthcare coverage, before progressing to a more complete range of healthcare services. The experience KPMG brings to this multifaceted design, delivery and program management has made the difference for many countries in successfully taking their first steps.
I’ve been lucky to be part of several countries’ efforts to establish universal coverage. Along with my KPMG colleagues, I’m excited about helping many more to navigate their own path on a unique journey that can cement the growth of nations while caring for their citizens. More rewarding work is hard to find.