Friday 12 December is Universal Health Coverage Day. In advance of a conference at the London School of Hygiene & Tropical Medicine, Professor Kara Hanson shows how countries can strengthen health systems by mobilising domestic resources for health.
The Ebola crisis in West Africa has shown what happens when local health systems lack the resilience to respond to shocks. Acute shortages of health workers, poor infrastructure, and lack of trust in health systems have allowed the epidemic to spread rapidly and cost many lives.
Fragile health systems like those in Sierra Leone, Guinea and Liberia are exposed at times of crisis; but every day, in countries around the world, thousands of people die simply because they can't access essential live-saving interventions, or are impoverished as a result of seeking care. Strong health systems that are based on the principles of universal health coverage - that everybody, everywhere, has access to the health services they need without financial hardship - have the potential to contribute to poverty reduction, social cohesion and economic development, as well as save lives.
Even though the principle of universal health coverage has widespread international support, health spending in many countries is simply insufficient to ensure provision of adequate healthcare. It is estimated that the cost of providing a comprehensive package of health care is $86 per person (in 2012 terms). In the poorest countries, national resources are insufficient to finance this package - in Sierra Leone, for instance, government spending on health was just $US16 in 2012. In these settings, donor resources go some way to fill the gap. However, many countries could afford to spend more of their own domestic resources on health.
So how can poorer countries fund health for all? Pooled sources of financing, such as taxes and social health insurance contributions, that allow people to contribute according to their ability to pay, and to benefit according to their health need, are the most effective means of generating money to improve health. For example Thailand, which funds its Universal Coverage scheme through general taxation, has demonstrated the improvements in equity that can be achieved through health financing reforms.
Many observers dismiss the possibility of raising more tax revenue in low- and middle income countries. However, Recent evidence from South Africa, Kenya and Lagos State, Nigeria shows that it is possible to increase tax revenue without raising tax rates - which many may find surprising. This has been achieved through a combination of measures to expand the tax base and improvements in the efficiency of tax collection authorities.
What is more challenging, however, is to persuade Ministries of Finance to allocate more funds to health. Advocates for greater health spending need to make a stronger case, and more compelling evidence is needed about the economic benefits of better health, and that the health sector is able to efficiently transform money into health services. This requires wide-ranging reforms to health systems to ensure that money is well spent and that resources are distributed equitably throughout the country.
The Ebola-affected countries in West Africa face an acute shortage of resources. In contrast Nigeria, which mounted an effective public health response to its few imported cases of Ebola, has more than ten times the number of doctors and nurses proportional to population as Liberia and Sierra Leone. Wealthy nations need to step up their contributions not just to emergency relief, but to health system strengthening, which will save money and lives in the longer term. And in low and middle-income countries, a sustainable path to universal health coverage will require governments to establish a virtuous circle by mobilising more domestic resources for health and showing they can be well-spent.