January 25, 2023
Excerpt—read the full article
One of the subthemes of Universal Health Coverage Day in December was "healthy environments," emphasizing the link between a person's environment and their access to healthcare. Progress towards Universal Health Coverage (UHC) depends on the efficiency of healthcare systems. Efficient healthcare systems can reduce costs and expand coverage to more people. It's important to understand the different types of efficiency to prioritize investments and not overlook simple public health improvements, which are crucial in expanding health coverage, and creating healthy environments for all.
December was Access to Healthcare month. It saw Universal Health Coverage Day, when an increasingly diverse chorus of voices called on policymakers and political leaders to prioritize access to healthcare for low-income people. The theme for the year emphasized ‘healthy environments’—a laudable aim, but does a healthy environment have anything do with health coverage?
The Universal Health Coverage (UHC) initiative has been growing for seventeen years, since the World Health Assembly first agreed a resolution saying everyone should be able to access health services without financial hardship. Today the world is still far from achieving it. Globally, as many as 100 million people are pushed into extreme poverty each year as a result of out-of-pocket health expenses.
The issue spans politics, economics, ethics, and of course, health outcomes. Progress toward UHC depends a lot on health system efficiency. This makes intuitive sense—when healthcare systems are more efficient, they can reduce the overall cost of providing care, making it more affordable for people to purchase coverage or for governments to expand coverage to more people.
However, it is not only the amount of efficiency that matters, but also the type. A deeper understanding of efficiency and its types helps in prioritizing investments, and makes it hard to discount many simple public health improvements. Indeed, such improvements could potentially be pivotal in the effort to expand health coverage to all, even creating healthy environments.
For many, the phrase 'universal health coverage’ conjures images of a utopian future in which perennial global problems, like inequality, have been conquered. But the vision is quickly dashed at the thought of cost. Ensuring access to quality healthcare for 8 billion people would continuously require such enormous sums that it seems we will only glimpse it in places like Scandinavia.
The headline benefit of UHC presented by campaigners is the reduction in financial hardship for people who get injured or fall ill without health insurance. Presented this way, UHC sounds like expensive charity: splash out as much as $1 trillion per year on public health coverage, and many poor people will be better off. If it continues to be understood as grand redistribution of resources, UHC will remain controversial. Instead it should be presented as a system that is cheaper and able to create better outcomes for everyone. Expensive as it may be to provide UHC, the alternative is (unsurprisingly) more expensive for society as a whole. Estimates of direct and indirect damages caused by a lack of access to healthcare tend to dwarf the estimates for costs of provision.
But this post is not about making the economic case for UHC. That has been done decisively by a multitude of experts—so much so, that a 2016 paper lamented the heaping-on of more evidence of cost-effectiveness. The debate must now shift to how—not if—countries should achieve it.
Efficiency normally weighs inputs and outputs—like the amount of light a bulb can generate per unit of electricity. It is quite straightforward, except: How long will the bulb last? How expensive is it? How difficult is replacing that type of bulb? How expensive and how reliable is the electricity? It turns out that it’s the efficiency of the whole lighting system, not just of the bulb, that matters.
So it goes with healthcare resources, or inputs. Rather than focusing on the efficiency of individual components, we often look at facility-level capacity utilization using indicators such as bed occupancy by ward, equipment utilization, and staff-level optimization. The problem lies more in the outputs, which are reported in terms of numbers of screenings, procedures, tests, consultations, etc. carried out. These figures say nothing about for whom, nor why, the resources were used. Diagnostic machines could be put to use round-the-clock, but their value squandered if predominantly for unwarranted tests. How best then to measure efficiency? No doubt it should involve health outcomes, as opposed to the number of procedures and prescriptions.
Basing accountability on health outcomes is undoubtedly difficult and complex, and the way revenue is generated does not help. That payers are charged for procedures instead of health outcomes has a multitude of implications. Countries have experimented with several schemes to prevent over-servicing the patients who can afford to pay; from charging user fees and co-payments with insurance, to capitation, which allocates a capped amount to primary health providers based on the number of people in their service area. The incentives and consequences are tricky, and there remains a lot of room to improve.
But set that issue aside—let’s assume that health systems’ efficiency could be easily measured as the ratio of health outcomes produced versus total inputs, and that providers were incentivized to optimize accordingly. Even then, poor allocations could reverse apparent gains in efficiency. For instance, a health service that only treated knee injuries might excel in delivering health outcomes per dollar invested, but would be useless to anyone needing cataract surgery. This reflects another dimension of the efficiency puzzle: that resources must be allocated strategically across all kinds of diseases, conditions, injuries, etc. Still another dimension is the allocation across patient groups. A health system made up of very efficient hospitals that only admitted a fraction of prospective patients would be highly inefficient at a population level.
Ethics and politics become intertwined here, but from an economics perspective, it would be ideal if health systems could be evaluated by comparing total inputs against the number of disability-adjusted life years (DALYs) averted across the entire population. This would show which types of interventions, at which times, and for whom, would avert the highest number of DALYs at the lowest cost.
Looking through this lens, we are essentially bargain-hunting in health—and a lot of bargains are to be had by serving people who do not have coverage. The WHO CHOICE initiative (Choosing Health Interventions based on Cost Effectiveness) offers a standardized way to compare data. In Sub Saharan Africa and in Southeast Asia, interventions that reduce infant mortality are clearly good buys. Several themes emerge from the data: bulk interventions tend to be more economical than individualized care; efforts to prevent- rather than to treat- illness and injury win out (unsurprisingly); and relatively less complex, low-tech, and less intensive interventions appear more economical. Examples of high-value interventions include raising taxes on tobacco, offering skilled delivery and management of complications at birth, and reducing sodium consumption in the population (Bertram 2021).
To achieve UHC, health care systems need to do more with less, not less with more. But the inverse is also true (and less intuitive): that providing UHC is itself a good way to do more with less. Helping large numbers of young people (who have the most DALYs to lose) avoid becoming sick, injured, or addicted offers huge potential.
Perhaps that is why the most recent theme of UHC day included ‘healthy environments’. Health coverage is closely linked with efficiency, and many of the biggest opportunities to improve efficiency are in preventative public health measures. Indeed, the drive toward UHC should become self-amplifying through a positive feedback loop: expanded coverage generates opportunities for greater efficiency, which in turn frees up resources to expand coverage further. Put another way, improved public health measures are not just enabled by UHC, they are a path to it.
Among the unsung interventions that could be pivotal in enabling access to healthcare for all is handwashing. Not only does inadequate hand hygiene lead to adverse events in hospitals (including hospital acquired infections) and contribute to antimicrobial resistance, it is one of the most effective ways to prevent infectious diseases— especially those that contribute to under-5 mortality.
Perhaps it’s time to start thinking of interventions that enable handwashing (by the general population) as part of ‘healthcare’—at least in so much as handwashing is like a cheap vaccine against a wide array of communicable diseases.
Geoff Revell is a WASH practitioner with over 20 years in market-building and systems change in WASH. He’s based in Canada, and is also the founder of HappyTap.
2. Unwarranted use of diagnostic procedures accounted for an estimated 40% of all waste in healthcare in the US ($250-325 billion/year in 2009). Thomson Reuters. ‘Where can $700 billion in waste be cut annually from the US healthcare system?’ 2009.