Advancing universal health coverage in Asia

By using an innovative methodology to compare different public healthcare strategies in Cambodia, China, Indonesia, the Philippines, Thailand and Vietnam, the researchers indentified key factors that influence how much of the population can access healthcare, what kind of services they receive, and how efficiently the system is funded.

Their research, conducted within the HEFPA project with the support of the European Commission, has since fed into several follow-up initiatives aimed at improving the accessibility and affordability of care in countries where low-income groups have inadequate coverage and face financially crippling out-of-pocket expenses for treatment.

“Universal health coverage is a big buzzword in the international community. Many countries have implemented initiatives to provide care for their population, but there are big differences in the depth of care provided, how accessible it is and how it is funded,” explains Eddy van Doorslaer, a professor of health economics and coordinator of HEFPA at the Erasmus University Rotterdam in the Netherlands.

Socio-economic, political and demographic factors all influence how universal health coverage can be implemented. But without it, low-income families faced with large out-of-pocket expenses will often delay or forgo treatment, or if they seek treatment they risk being pushed deeper into poverty by the financial burden. Social insurance schemes are part of the solution, but as HEFPA’s research shows, they are not all equally successful.

Among the countries studied in HEFPA, Thailand’s universal health insurance system stands out as the most effective. However, it leverages Thailand’s pre-existing network of hospitals and medical facilities that many other developing nations lack and is financed through tax revenues that many other nations with large informal economies cannot afford.

Other countries have taken alternative routes. Some, such as the Philippines and Vietnam, are attempting to combine tax-financed coverage of low-income households with voluntary enrolment in social health insurance for wealthier groups not covered through formal-sector employment. But succeeding in this strategy requires the acquisition and utilisation of a good understanding of the factors that motivate people to insure themselves or not.

Two randomised studies conducted by HEFPA in Vietnam and the Philippines revealed that subsidisation of insurance premiums by up to 25% and 50%, respectively, along with the provision of information on the benefits of insurance, was insufficient to bring enrolment rates anywhere close to universal coverage.

Aligning supply and demand

Concerns about the affordability of insurance – even with the subsidies – scepticism about the benefits and difficulties of completing forms and enrolment procedures appeared to be key factors in limiting uptake. In Indonesia, for example, the deployment of a public insurance scheme has contributed to increased use of healthcare services, although many people only enrol when they need treatment, resulting in the cost of claims far surpassing the revenue generated from insurance premiums.

Where there is sufficient funding, the effectiveness of healthcare is determined by how the money is spent. In China, where the HEFPA team looked at the staggered rollout of the New Cooperative Medical Scheme across different regions, the researchers found that funding of inpatient care, but not outpatient treatments, led to many people being hospitalised unnecessarily, while fee-for-service payments to providers created incentives to overprescribe drugs.

“We found that access to healthcare is not only contingent on demand-side parameters, but also on how providers are paid and managed,” Van Doorslaer says.

Aligning demand and supply within the healthcare system, training professionals to manage coverage effectively, providing incentives for enrolment in social insurance schemes, increasing awareness and educating people about the benefits are all strategies that countries can use to effectively increase healthcare coverage, the HEFPA researchers found.

The project’s results and recommendations have been disseminated to policy-makers in several countries with the aim of improving the implementation of universal healthcare systems. The HEFPA results are also feeding directly into new healthcare initiatives.

In Indonesia, a follow-up project has been launched to support the training of professionals in health insurance and finance skills to support universal health coverage implementation. Erasmus University is also involved in several applications for funding of similar research work in low- and middle-income countries.