Moving towards universal coverage: access for all, with financial protection
There is a strong consensus that, even if all the right technical choices are made, maternal, newborn and child health programmes will only be effective if together, and with households and communities, they establish a continuum of care, from pregnancy through childbirth into childhood. This continuity requires greatly strengthened health systems with maternal, newborn and child health care at the core of their development strategies. It is forcing programmes and stakeholders with different histories, interests and constituencies to join forces. The common project that can pull together the different agendas is universal access to care. This is not just a question of finetuning advocacy language: it frames the health of mothers, babies and children within a broader, straightforward political project, responding to society’s claim for the protection of the health of its citizens and for access to care – a claim that is increasingly seen as legitimate. The magnitude of the challenge of scaling up services towards universal access, however, should not be underestimated.
Reaching all children with a package of essential child health interventions necessary to comply with and even go beyond the MDGs is technically feasible within the next decade. In the 75 countries that account for most of child mortality this will require US$ 52.4 billion, in addition to current expenditure, of which US$ 25 billion represents additional costs for human resources. This US$ 52.4 billion corresponds to an increase as of now of 6% of current median public expenditure on health in these countries, rising to 18% by 2015. In the 21 countries facing the greatest constraints and where a long lead time is likely, current public expenditure on health would have to grow by 27% as of 2006, rising to around 76% in 2015.
For maternal and newborn care, universal access is further away. It is possible to envisage various scenarios for scaling up services, taking into account the specific circumstances in each of the same 75 countries. At present, some 43% of mothers and newborns receive some care, but by no means the full range of what they need even just to avoid maternal deaths. Adding up the optimistic – but also realistic – scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers (some 73% of the expected births) in 2015, and to their babies. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but the reduction of maternal and perinatal mortality globally would be well on the way. The costs of implementing these 75 country scenarios would be in the region of US$ 39 billion additional to current expenditure. This corresponds to a growth of 3%, in 2006, rising to 14% over the years, of current median public expenditure on health in these countries. In the 20 countries with currently the lowest coverage and facing the greatest constraints, current public expenditure on health would have to grow by 7% in 2006, rising to 43% in 2015.
Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. The extra work required for scaling up child care activities requires the equivalent of 100 000 full-time multipurpose professionals, supplemented, according to the scenarios that have been costed, by 4.6 million community health workers. Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives – or their equivalents – as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care.
Without planning and capacity-building, at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment. Planning is not enough, however, to put right disruptive histories that have eroded workforce development. After years of neglect there are problems that require immediate attention: first and foremost is the nagging question of the remuneration of the workforce.
In many countries, salary levels are rightfully considered unfair and insufficient to provide for daily living costs, let alone to live up to the expectations of health professionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain-drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet – leading to competition for time, a loss of resources for the public sector, and conflicts of interest in dealing with their clients. There are even more serious consequences when health workers resort to predatory behaviour: financial exploitation may have catastrophic effects on patients who use the services, and create barriers to access for others; it contributes to a crisis of trust in the services to which mothers and children are entitled.
There is an urgent need to invent and deploy a whole range of measures to break the vicious circle, and bring productivity and dedication back to the level the population expects and to which most health workers aspire. Among these, one of the most challenging is rehabilitating the workforce’s remuneration. Even a modest attempt to do so, such as doubling or even tripling the total workforce’s salary mass and benefits in the 75 countries for which scenarios were developed, might still be insufficient to attract, retain and redeploy quality staff. But it would correspond to an increase of 2% rising, over 10 years, to 17% of current public expenditure on health, merely for payment of the MNCH workforce. Such a measure would have political and macroeconomic implications and is something that cannot be done without a major effort, not only by governments but by international solidarity as well. On the eve of a decade that will be focused on human resources for health, this will require a fundamental debate, in countries as well as internationally, on the volume of the funds that can be allocated and on the channelling of these funds. This is all the more important because rehabilitating the remuneration of the workforce is only one part of the answer: establishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication.
At the same time, ensuring universal access is not merely a question of increasing the supply of services and paying health care providers. For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, and particularly against the catastrophic payments that can push households into poverty. Such catastrophic payments occur wherever user charges are significant, households have limited ability to pay, and pooling and prepayment is not generalized. To attain the financial protection that has to go with universal access, countries throughout the world have to move away from user charges, be they official or under-the-counter, and generalize prepayment and pooling schemes. Whether they choose to organize financial protection on the basis of tax-generated funds, through social health insurance or through a mix of schemes, two things are important: first, that ultimately no population groups are excluded; second, that maternal and child health services are at the core of the health entitlements of the population, and that they be financed in a coherent way through the selected system. While it can take many years to move from a situation of a limited supply of services, high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection, the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms.
Financing is the killer assumption underlying the planning of maternal, newborn and child health care. First, increased funding is required to pay for building up the supply of services towards universal access. Second, financial protection systems have to be built at the same time as access improves. Third, the channelling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints – particularly the problems facing the workforce.
Channelling increased funding flows through national health insurance schemes – be they organized as tax-based, social health insurance, or mixed systems – offers the best avenue to meet these three challenges simultaneously. It requires major capacity building efforts, but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeconomic and poverty-reduction policies are decided. It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in a way that gives them long-term, credible prospects, which traditional budgeting or the stopgap solutions of project funding do not offer.
While the financing effort seems to be within reasonable reach in some countries, in many it will go beyond what can be borne by governments alone. Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required, to build the institutional capacity to manage them, and to ensure that maternal, newborn and child health remains at the core of these efforts. This decade can be one of accelerating the move towards universal coverage, with access for all and financial protection. That will ensure that no mother, no newborn, and no child in need remains unattended – because every mother and every child counts.