Universal Health Coverage is possible. We just need to focus on outcomes

Universal Health Coverage (UHC) has achieved broad support from leaders around the world, as reflected in the UN Sustainable Development Goals (SDG) and World Health Organization's global priorities. Yet analyses show that despite increased domestic financing for health and growing evidence of the positive impact of increased health spending on population health and economic productivity, countries continue to under-invest.

For example, health spending in low-income countries - including aid and out-of-pocket spending - averaged about $19 per capita in 2016, or roughly one-fifth of the estimated $100 cost of essential primary care coverage alone. Not only is domestic financing, donor aid and out-of-pocket spending falling way short; the gap in public sector spending as a proportion of GDP between low-income and high-income countries is also widening.

At the same time, there are significant deficiencies in the quality of coverage. Many countries that nominally provide UHC have serious access problems, inequalities and unmet opportunities for improving outcomes in practice.

Multiple recent studies, including reports by the US National Academy of Medicine and a special Lancet Commission, found widespread evidence of care that was inefficient and not person-centred, leading to millions of deaths and trillions of dollars in productivity losses annually in low- and middle-income countries.

It seems likely that closing this spending and health care gap – really a chasm – will become more difficult in the future through public and donor aid funding alone. Ageing populations, the growing burden of chronic disease and the potential for many more - and, at least initially, more costly - life-improving medical technologies all further threaten the financial sustainability of health systems that aim to provide universal access to effective, up-to-date care.

With these challenging trends, it is time to reconsider and potentially expand mechanisms for making progress towards the ultimate goal of UHC: ensuring that health resources are equitably distributed, and used efficiently.

To do so, we need to move beyond access and benefits packages to an emphasis on quality and health outcomes. This shift is already beginning, but will require rethinking the role of the private sector in achieving UHC – and will require a new level of private sector leadership from both non-profit and for-profit organizations.

First, achieving the goals of improved population health and financial sustainability will require new models of paying for health services and technologies that reliably deliver higher value for money – much of which will depend on encouraging low-cost innovation in delivering better health outcomes, supported by capital from the private sector.

Second, private spending can be better integrated with public spending on efficient care delivery systems. Separate public and private systems mean private spending is not being leveraged in a coordinated way to close access and quality gaps. People with low incomes need more subsidies to afford the higher-quality care preferred by those with more ability to pay.

Here are three ways to promote private-sector innovation and investment - to improve outcomes; to leverage private, voluntary spending on health services with public sector spending for better integrated care; and to ultimately help close the funding and quality gaps, towards achieving meaningful UHC.

1. Shift from paying primarily for health services and start paying for person-centred health outcomes

Many nations at all income levels have stated their desire to implement “value-based care” through payment and regulatory reforms. Global leadership communities, such as the World Economic Forum, OECD and G20, among others, strongly support this shift. Yet most countries still pay for and organize health care around providers and services – not around the outcomes that matter to people.

For all the United States’ efforts to move to “value-based” care, most payments are still based on the volume of services provided. The SDG target related to healthcare access still focuses on coverage of key services, not whether those or other innovative services are of high quality or are being put together effectively in practice for each person covered to achieve the SDG population health goals. The associated variation in quality and access across health systems shows that paying providers for traditional service delivery is not sufficient for meeting UHC goals.

Fundamental reforms towards payment for health rather than health services have been challenging for countries to implement. For example, in 2012, Ghana piloted a new payment model to gradually shift provider payments from fee-for-service and hospital diagnosis-related groups (DRGs), to a per-person payment model.

Despite early willingness and commitment, the government faced challenges, including boycotts by private sector providers, and other financial and operational hurdles to implement the reformed care models to go along with payment. But, with growing experience, there is now a much better understanding of the capacities, policies and innovations needed to support local capacity building for value-based care, beyond traditional pay-for-performance, or early results-based financing programmes.

2. Build capacity for reliable data capture and sharing to improve care

The ability to capture and exchange key health and social data related to personal and community risk factors, treatment, patient experience and outcomes enables better patient decision-making and is the foundation for monitoring results and rewarding organizations that are successful in improving health.

But data and measurement limitations remain serious barriers to faster progress towards value-based care, even in high-income countries that have made considerable investments in health informatics infrastructure and standards for reporting on performance.

Efforts by the WHO and the Institute for Health Metrics and Evaluation (IHME) track disease burden at the country and regional level, which helps identify opportunities and priorities for care reform. The International Consortium for Health Outcomes Measurement (ICHOM) and other quality improvement entities have established meaningful measures of outcomes of care for common conditions.

Success in value-based care reform requires extending timely data collection and measurement capacity to the local population level, to support care improvement, and to produce measures that can serve as benchmarks and as a basis for evaluating providers. Ministries can facilitate collection and access to key health and social data, in collaboration with local health and social service providers, including with the participation of local populations.

3. Scale and leverage effective value-based care models

Income-based subsidies can enable individuals and populations to participate in value-based care models. Health care organizations eligible for such subsidies can be determined initially on a pilot basis, with limited populations or limited shifts away from traditional financing.

Those that meet or exceed benchmark performance can expand, through opportunities to increase scale, more ability to attract participants (and thus more payments and subsidies), and further shifts in payment towards person-based payment.

For countries with a growing middle class that is increasingly buying their own private care, partial public subsidies for value-based care models can steer private investment towards value rather than fee-for-service models.

Larger subsidies for people with lower-incomes can help them participate in the same care systems. Such subsidies could help unify public and private spending in support of more innovative care models, helping to drive private investment to develop and scale models that have shown evidence of improving health outcomes.

The goal is to leverage the private funding that people with higher incomes spend on themselves and their families towards innovative capacity that can benefit the whole population, rather than driving private investments towards separate, often inefficient systems of care.

When facing regulatory conditions that enable sustainable business and growth around value-based care (including being paid for person-level outcomes), private entrepreneurs have shown the ability to provide access and reduce costs in ways that are simply not achievable in traditional heath financing models.

Looking ahead, the World Economic Forum’s Global Coalition for Value in Healthcare can be a mechanism for accelerating the shift to value-based care, and leveraging private resources to build public-private partnerships for better healthcare capacity that can benefit all, rich and poor.

It is time to expand the means of reaching the essential public health goal of universal access to high-quality care and better health outcomes for all - and the role of local private sector investment and participation in doing so.

The authors thank Osondu Ogbuoji and Gavin Yamey of the Duke Center for Policy Impact in Global Health and Justice Nonvignon from the University of Ghana for valuable comments, and Sarah Bond and Kathryn Lallinger for assistance in preparation of this manuscript.