World Health Day 2019 - Universal Health Coverage: Everyone, Everywhere
By: Tisa Barrios Wilson
Sofía is 20 years old and lives in a rural town in Northern Peru. She was recently married to Mattias and soon after was thrilled to learn that she was pregnant with their first child. Her family and community celebrated the good news and looked forward to welcoming the child with much enthusiasm. But when the day of the birth came, Sofía and her family were devastated to learn that her child was born with with microcephaly, a condition where the head is much smaller than normal because the brain has only partially formed, which is a manifestation of Congenital Syndrome associated with Zika (CSaZ). Aside from the concern they feel about the health and development of her child; she and her family must also grapple with the costs that incurred by families caring for infants and children suffering with CSaZ. Screening and diagnostic tests might require MRIs, EEGs, and other expensive examinations. Depending on the severity of the CSaZ, her child might need a breathing apparatus, feeding tubes to swallow, and wheelchairs for mobility. Sofía and her family will have to travel long distances to regional hospitals to seek specialized health professionals and equipment for physical therapy, paying out-of-pocket for transportation, food, and other incidental costs. Her child may also suffer from other associated complications that require additional medical attention and expensive medicines including seizures, hearing and vision problems, and increased susceptibility to pneumonia and infections. One study estimates that each case of microcephaly incurs USD 91,102 in direct medical costs per lifetime in Latin America. This financial cost in inconceivable to most families, and does not consider the added costs resulting from the loss of income and productivity due to full-time care of a child with developmental delays. Psycho-social costs take a heavy toll on families with high rates of male partner abandonment and the social stigma associated with microcephaly.
Luckily for Sofía and her family, Peru has been continuously working towards Universal Health Coverage (UHC) that will help address these devastating costs; but that is not the case for everyone.
Today, at least half of the world’s population does not have coverage of essential health services and an estimated 100 million people fall below the poverty line because they are subjected to financially crippling, out-of-pocket payments for health services. To address this issue, many countries in Latin America and worldwide have been implementing programs to work towards UHC. The aim of UHC, rooted in a human rights and equity based framework, is that everyone should be able to access the quality health care they need without suffering financial hardship. This year’s theme for World Health Day (April 7th) was “Universal Health Coverage: Everyone, Everywhere,” highlighting and celebrating the progress made around the world toward UHC.
The aim of UHC is to improve overall population health by increasing accessibility of health services while also protecting individuals and households from high, out-of-pocket health expenditures, usually accomplished by increased government spending on healthcare or through retooling insurance mechanisms. Under these protections, households can not only benefit in financial terms, but they can redirect the money they would have spent on healthcare elsewhere, boosting cash flow in the broader economy.
In Peru, the government has been making strides in covering their diverse population. Under EsSalud (the social security health insurance institution under the Ministry of Labor), the private health sector, and the publicly-funded Comprehensive Health Insurance Scheme (Seguro Integral de Salud—SIS), over 80 percent of the population is covered by health insurance, up from 53 percent in 2008.[6,7] In terms of health equity, health insurance affiliation is higher among the extremely poor and poor than among the nonpoor, and the five poorest regions of Peru have the highest share of their populations enrolled in health insurance. This reflects the success of SIS in covering more vulnerable populations.
While coverage is important, it’s also important to examine what kinds of essential services are covered. Initially, the SIS was focused on health prevention, treatment, and rehabilitation for children under 18 years and maternal health (including prenatal care, delivery, and postnatal care). More recently, the government has released the Essential Plan of Health Insurance (PEAS) which was designed to meet 65 percent of causes of morbidity. However, while the PEAS benefits package now includes a wide range of services, actual availability of those services, especially in poor rural areas continues to be a challenge. In the last few decades, the public and social security health systems have not invested enough in hospital infrastructure or ambulatory facilities, especially in poor areas. Despite these challenges, access to maternal and child health services has significantly improved with immunization rates above 85 percent, 96 percent of pregnant women receiving prenatal care, and 87 percent of births attended by skilled health workers.
While efforts working towards UHC appear to have had tangible benefits for the health of the Peruvian population, the evidence of economic benefits is less clear. Despite the growth of affiliation to health insurance programs, out-of-pocket health payments still total to 36% of total health financing.6 In 2013, 2.6 percent of the population were pushed below the poverty line due to catastrophic health expenditures, and that number has been stable in the period between 2008 and 2013. Out-of-pocket payments are not only required from those who are still uninsured but also from those who are insured but have no access due to geographic barriers or supply limitations. In addition, many people who are insured may choose to pay out of pocket if they feel that providers who are included in their insurance plan do not offer the quality or convenience of services that they require.
While UHC traditionally focuses on who gets covered, what health services are provided, and the cost of these services, another important dimension is ensuring quality of care. The success and value of UHC depends on the health system’s ability to provide safe, effective, people-centered and timely care for its population.4 Under USAID’s Applying Science to Strengthen and Improve Systems (ASSIST) Project, WI-HER partners with URC to support countries in the Latin America and Caribbean region to improve the quality of care by strengthening health care delivery and integrating gender-responsive programming in the face of the Zika outbreak. We are working with frontline health workers and health decision-makers to identify and address gender gaps, and improve their skills, protocols and practices to achieve more effective Zika prevention strategies, screening, counseling and linkage to care. Even as the incidence of Zika begins to decline, the health system is now better equipped to response to other mosquito-borne outbreaks; and the antenatal care, post-natal care and well-baby care systems are more efficient and effective in providing high-quality care.
Sofía and her family are lucky. While they live in a rural area, her family has a car and can drive her the health clinic where ASSIST works. She takes her child early stimulation sessions at the clinic every Thursday to learn different ways to help her child develop. Mattias also accompanies her so he can also learn how to be an engaged father. There are psycho-social support services available, so when Sofia and Mattias feel overwhelmed they can receive counseling. Best of all, Sofia and Mattias have health coverage so that they have access to all these services without fear of financial catastrophe.
Through ASSIST, we support health providers and strengthen the health system so families like Sofia’s can live a long and healthy life. We at WI-HER believe that everyone, everywhere has this right.
 Ellis EG. The price of zika? about 4 million per child. Wired. August 16, 2016. Available from: https://www.wired.com/2016/08/price-zika-4-million-per-child/.
 Salvador E. Diagnóstico de actores que integran o podrían integrar grupos de apoyo de familias con niños o niñas con Síndrome Congénito asociados al Zikavirus en la República Dominicana. Profamilia. Santo Domingo. 2019.
 Alfaro-Murillo JA, Parpia AS. A cost-effectiveness tool for informing policies on zika virus control. PLoS Neglected Tropical Diseases. 2016. https://library.biblioboard.com/viewer/564eea40-086f-4b2a-85e0-e5930b5430ee.
 WHO. Universal health coverage (UHC). 2019.
 World Health Organization. Arguing for universal health coverage. 2013. Accessible online: https://www.who.int/health_financing/UHC_ENvs_BD.PDF
 Vermeersch, C, et al. Universal Health Coverage for Inclusive and Sustainable Development: Country Summary Report for Peru. Health, Nutrition and Population Global Practice World Bank Group Report. 2014. Accessible online: http://documents.worldbank.org/curated/en/437741468076132999/pdf/912180W...
 Paving the Way for Universal Health Coverage in Peru. USAID. 2018. Accessible online: https://www.hfgproject.org/paving-the-way-for-universal-health-coverage-...