Investments in this strategy aim to reduce financial barriers to health services by introducing prepaid, pooled mechanisms for spreading risk across populations (e.g., insurance), fighting rising health care costs through innovative service delivery methods, and implementing new technologies to facilitate payment for services. The sections below include an overview of the strategy for achieving desired goals, supporting evidence, core metrics that help measure performance toward goals, and a curated list of resources to support collecting, reporting on, and using data for decision-making.
Each year, 10% of gross world product—USD 7.3 trillion—is spent on health by governments, individuals, corporations, and other actors in the health system (1). Despite this substantial global investment, people all over the world have difficulty covering the out-of-pocket expenditure (OOPE) required to purchase services at the point of care, which directly impacts health outcomes.
Evidence analyzed by the World Health Organization suggests that, in order to minimize household impoverishment due to healthcare spending, OOPE should be kept below 20% of total national health expenditure. However, OOPE in many countries exceeds this target; for example, only 10 of 47 African countries have OOPE below 20% of their total national health expenditures (2).
Higher OOPE can lead people to neglect needed care; one study associated a 10% higher share of OOPE with 11.6 more female deaths per thousand (13). The global health community’s vision of Universal Health Coverage (UHC) specifically means ensuring people can access the healthcare they need without incurring financial stress. OOPE is perhaps the largest barrier to realizing that vision.
A strategy to combat financial barriers to UHC can improve both financial resilience and health outcomes by:
Interested in understanding how gender relates to this strategy? Check out the gender lens summary and metrics created to complement this theme: Improving Health Systems through Gender Equitable Policies and Decision-Making.
According to a World Bank estimate, in 2010 808.4 million people worldwide (11.4% of world population) experienced catastrophic health expenditures (7). This indicator actually worsened compared to 2000, when 588.5 million (9.7% of world population) experienced catastrophic expenditures.
Below are some of the groups that could benefit the most from investments to reduce financial barriers to health services.
People Living in Poverty: By definition, financial barriers to health are the largest for individuals in poverty, who are also disproportionately affected by incidents of catastrophic health expenditure (7). Investments in this strategy could improve health outcomes, financial security, and even human capital.
People without Access to Formal Financial Services: The unbanked face particularly acute challenges associated with financial barriers to health care. Investments specifically in mobile payment platforms can reduce their financial barriers to care through easier access to health savings accounts, payments into health-insurance schemes, or other means (6).
Governments: The absence of pooled financial and health risk across populations strains government resources for health (7). Investments in pooled risk schemes can create flexibility for governments to target their citizens' most pressing public-health needs.
High-income countries comprise 16% of world population but 80% of global health spending, and they have made much greater progress to date toward UHC (1). Notwithstanding various financial barriers to health care in more developed markets, then, this strategy largely targets emerging markets in Africa, Asia, and Latin America.
Two main factors will probably contribute, without investment, to progress against the challenges this strategy confronts: (1) economic growth and (2) development toward UHC through social health insurance and other means aiming to decrease OOPE. Concerning economic growth, Brookings Institution economists estimated that, by 2030, the total global population living in extreme poverty will decrease by 200 million, but 438 million will remain impoverished (8). Notwithstanding expected economic growth and progress towards UHC, then, more effort to reduce financial barriers to health care will be needed both at present and in the future.
Investors can augment the potential impact of investments in this strategy by targeting areas experiencing slow growth or stagnant expansion of health coverage. Investments can also take advantage of synergies between these trends; for example, mobile platforms might enable the informal sector to contribute to and take advantage of health insurance.
A WHO report estimates that health expenses annually drive 100 million people into extreme poverty, all of whom would greatly benefit from investment in this strategy (7). Notably, financial distress caused by high OOPE is also frequent in developed markets, including the United States (9).
The amount of change this strategy can deliver for certain beneficiaries depends on their baseline income and health outcomes, as well as the degree to which the investment targets them specifically. MicroEnsure, for example, a social business offering innovative financial-protection products for the base of the pyramid, partnered with mobile provider Tigo to allow enrollees to purchase basic health and life insurance by making small mobile payments. After launching in 2013 in Dar es Salaam, MicroEnsure spread quickly to the rest of Tanzania; it was East Africa's fastest-growing health insurance product that same year (10).
Stakeholder-Participation Risk is the primary risk associated with this strategy, as patients and other stakeholders may require education and awareness regarding specific interventions. Especially for insurance and other prepaid, pooled schemes, terms of payment and other features can be difficult for stakeholders to understand. Jamii Africa, a microinsurance platform in Tanzania that allows users to pay using mobile phones, faced initial obstacles in this regard, which it overcame through extensive educational and outreach efforts (11).
Since Stakeholder-Participation Risk can dilute or even nullify the impact of the strategy, relevant parties should engage requisite stakeholders to ensure they understand the nature of the investment. For example, mobile insurance providers should take great care to inform clients of the basic uses and benefits of health insurance, whereas strategies aiming to reach the poor through innovative service delivery models will require more intensive engagement with providers.
AllLife, supported by a USD 13.9 million investment from Leapfrog Investments, provides affordable life insurance to patients living with HIV in South Africa. Integral to AllLife's model is an adherence program: under the terms of this program, which accompanies all of its products, clients must follow steps to ensure optimal health for those living with HIV, including anti-retroviral therapy and regular blood testing. (HIV-positive clients previously had difficulty accessing coverage, an important market gap that AllLife fills.) The company has grown substantially since its inception. Since then, by leveraging investment, it has also developed diabetes-related products (12).
Xu, Ke, Agnes Soucat, Joe Kutzin, Callum Brindley, Elina Dale, Nathalie Van de Maele, Tomas Roubal, Chandika Indikadahena, Hapsa Toure, and Veneta Cherilova. New Perspectives on Global Health Spending for Universal Health Coverage.WHO/HIS/HGF/HFWorkingPaper/18.2. Geneva: World Health Organization, 2018. http://apps.who.int/iris/bitstream/handle/10665/259632/WHO-HIS-HGF-HFWorkingPaper-17.10-eng.pdf.
Regional Office for Africa. WHO African Region Expenditure Atlas. Brazzaville: World Health Organization, November 2014. http://www.afro.who.int/sites/default/files/2017-06/who-african-region-expenditure-atlas_-november-2014.pdf.
Pearson, Mark, Francesca Colombo, Yuki Murakami, and Chris James. Universal Health Coverage and Health Outcomes. Paris: OECD, July 22, 2016. https://www.oecd.org/els/health-systems/Universal-Health-Coverage-and-Health-Outcomes-OECD-G7-Health-Ministerial-2016.pdf.
Giedion, Ursula, Eduardo Andrés Alfonso, and Yadira Díaz. The Impact of Universal Coverage Schemes in the Developing World: A Review of the Existing Evidence.UNICO Studies Series 25. Washington, DC: World Bank, January 2013. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/IMPACTofUHCSchemesinDevelopingCountries-AReviewofExistingEvidence.pdf.
Deloitte. "2016 Global Health Care Outlook: Battling Costs while Improving Care." 2016. https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-lshc-2016-health-care-outlook.pdf
Haas, Sherri, Marilyn Heymann, Pamela Riley, and Abeba Taddese. Mobile Money for Health. Bethesda, MD: USAID Health Financing and Governance Project, 2013. https://www.hfgproject.org/wp-content/uploads/2013/12/Mobile-Money-for-Health-Case-Study.pdf.
World Health Organization and the International Bank for Reconstruction and Development. Tracking Universal Health Coverage: 2017 Global Monitoring Report.Washington, DC: World Bank, 2017. http://documents.worldbank.org/curated/en/640121513095868125/pdf/122029-WP-REVISED-PUBLIC.pdf.
Kharas, Homi, and Wolfgang Fengler. "Global Poverty Is Declining, but Not Fast Enough." Future Development(blog), Brookings Institution, November 7, 2017. https://www.brookings.edu/blog/future-development/2017/11/07/global-poverty-is-declining-but-not-fast-enough/.
Brink, Susan. "What Country Spends the Most (and Least) on Health Care Per Person?" Goats and Soda (blog), National Public Radio, April 20, 2017. https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person.
USAID Health Financing and Governance Project. "Case Study 10: MicroEnsure Tanzania." 2014. https://www.hfgproject.org/wp-content/uploads/2014/06/HFG-Mobile-Money_CASE-STUDY-10-MICROENSURE-TANZANIA.pdf.
Peverelli, Roger, and Reggy De Feniks. "JAMII: Bringing Affordable Health Insurance to Low Income Tanzanians." Digital Insurance Agenda, May 4, 2017. http://www.digitalinsuranceagenda.com/100/jamii-bringing-affordable-health-insurance-to-low-income-tanzanians/.
“About AllLife.” AllLife. https://alllife.co.za/about/company.
Moreno-serra, R., & Smith, P. (2011). The Effects of Health Coverage on Population Outcomes : A Country-Level Panel Data Analysis, 1–35.
This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.
Joos O, Silva R, Amouzou A, Moulton LH, Perin J, Bryce J, et al. (2016) Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial. PLoS ONE 11(1): e0145238.
McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase healthseeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth. 2016 Jun 04;16(1):136.
Mitchell M, Hedt B, Msellemu D, Mkaka M, Lesh N. Improvement in Integrated Management of Childhood Illness (IMCI) Implementation through use of Mobile Technology: Evidence from a Pilot Study in Tanzania. BMC Med Inform Decis Mak. 2013;13:95.
Haberer JE, Musiimenta A, Atukunda EC, Musinguzi N, Wyatt MA, Ware NC, et al. Short message service (SMS) reminders and real?time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS. 2016;30(8): 1295.
Biering-Sorensen S, Andersen A, Ravn H, Monterio I, Aaby P, Benn CS. Early BCG vaccine to low-birth-weight infants and the effects on growth in the first year of life: a randomised controlled trial. BMC Pediatr. 15, 137 (2015).
Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, et al. (2015) A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS ONE 10(7): e0129545.
Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of training informal health care providers in India: A randomized controlled trial. Science2016;354:aaf7384.
Nyqvist, M. B., Guariso, A., Svensson, J., Yanagizawa-Drott, D. Effect of a Micro Entrepreneur Based Community Health Delivery Program on Under-Five Mortality in Uganda: A Cluster-Randomized Controlled Trial (CEPR Discussion Paper Series DP 11515). London: Centre for Economic Policy Research.
Sharma S, Van Teijlingen E, Belizán JM, Hundley V, Simkhada P, Sicuri E. Measuring What Works: An impact evaluation of women’s groups on maternal health uptake in rural Nepal. PloS one. 2016;11(5):e0155144.
Boston Consulting Group (BCG). The Advance market commitment pilot for Pneumococcal Vaccines: Outcomes and impact evaluation, 2015.
Ross, et al, 2013. A Low-Cost Ultrasound Program Leads to Increased Antenatal Clinic Visits and Attended Deliveries at a Health Care Clinic in Rural Uganda. PloS One. 2013.
Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.
(Price obtained by the producer/supplier from the organization for a good or service − Benchmark price of the good or service) / (Benchmark price of the good or service)
(Number of patients completing treatment within the clinically recommended time frame during the reporting period) / (Number of patients who started treatment and who were expected to complete treatment during the reporting period)