Universal health system and universal health coverage: assumptions and strategies

Giovanella, Ligia; Mendoza-Ruiz, Adriana; Pilar, Aline de Carvalho Amand; Rosa, Matheus Cantanhêde da; Martins, Gabrieli Branco; Santos, Isabela Soares; Silva, Danielle Barata; Vieira, Jean Mendes de Lucena; Castro, Valeria Cristina Gomes de; Silva, Priscilla Oliveira da; Machado, Cristiani Vieira

doi:10.1590/1413-81232018236.05562018

person Ligia Giovanella

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Adriana Mendoza-Ruiz

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Aline de Carvalho Amand Pilar

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Matheus Cantanhêde da Rosa

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Gabrieli Branco Martins

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Isabela Soares Santos

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Danielle Barata Silva

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Jean Mendes de Lucena Vieira

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Valeria Cristina Gomes de Castro

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Priscilla Oliveira da Silva

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

person Cristiani Vieira Machado

schoolEscola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil. giovanel@ensp.fiocruz.br

Collaborations

L Giovanella, IS Santos, Mendoza-Ruiz contributed with the conception, the analysis and the writing; ACA Pilar, MC Rosa, GB Martins, D Barata, JML Vieira, VCG Castro, POS Faria contributed to the analysis and writing; CV Machado contributed to the critical review.

Characteristics	UHC	Universal System
Conception of health	Health as a commodity.	Health as a universal right.
Role of the state	Minimal. Restricted to the regulation of the health system. Explicit separation of financing/purchasing and service functions.	Social welfare. Responsible for the funding, management and delivery of health services.
Funding	Pooling of public and private funds (insurance premiums, social contributions, philanthropy, taxes).	Publicly funded via tax revenues (general taxes and contributions for social insurance).
Emphasis of reforms	Subsidy of demand for health insurance purchase. Packages of services›selectivity and focalization on the poorest	Subsidy of supply to guarantee equitable access.
Eligibility/ Entitlement	Segmented access depending on affiliation to some form of insurance (private or public).	Universal access as a condition of citizenship.
Efficiency of system	Increased operational and administrative costs. Higher total expenditure on health.	Lower operating and administrative costs. Reduced unit costs due to economies of scale. Lower total expenses due to greater regulation of supply.
Design of service system	Fragmented services without territorialization.	Networked, territorialized, PHC-orientated services.
PHC approach	Selective	Comprehensive
Service provision	Services provided mainly by the private sector.	Services provided mainly by the public sector.
Package of services	Restricted (basic/minimum packages). Explicit	Comprehensive (comprehensive care). Implicit
Integrality	Focused on individual care and biomedical services. Dichotomy between individual and collective care.	Integration between individual care and public health actions. Integration of health promotion, prevention and care.
Social determinants of health (SDH)	Does not incorporate the SDH approach. Restricted possibility of intersectoral action.	Incorporates the SDH approach. Facilitated possibility of intersectoral action.
Role of citizen	Consumer/object	Protagonist/individual
Citizenship	Residual	Full
Solidarity effects	Restricted	Comprehensive
Equity	Crystallizes inequalities of access and use according to income and social insertion. Access dependent on individual’s ability to pay.	Guaranteed access to, and use of, health services between social groups for equal needs, regardless of ability to pay
Ideology	Liberal	Social-democrat
Target countries	Low and middle-income countries	All countries

Characteristics	Germany	UK	USA
Denomination	Social Security for Illness Gesetzliche Krankenversicherung (GKV)	National Health Service (NHS)	Private healthcare
Founded	1883	1948	1965 (Medicaid and Medicare)
Entitlement	Compulsory social insurance traditionally linked to the labor market; progressive inclusion of populational groups.	Universal access as a condition of citizenship.	Targeted coverage based on ability to pay. Workers in the formal labor market contractprivate health insurance. Medicaid: population below the poverty line. Medicare: people aged 65 and over.
Scope of universality	1970s	1948	No. Obamacare (2010) aimed to expand coverage, but did not achieve universality.
Insurance institutions	Institutions controlled by public legislation with autonomous administration. The Krankenkassen (Disease Boxes), managed by representatives of workers and employers (113 Boxes in 2017), regulated by the state.	Not applicable	Private insurers of various types (from insurance to managed care companies). Medicaid: managed by states. Medicare: operated by private insurers hired by the federal government.
Funding	Predominantly public via compulsory social contributions proportional to salary (15%) paritary between employers and workers (70% social contributions, 7% fiscal resources).	Predominantly fiscal and public (68% fiscal resources, 15% social contributions).	Predominantly private (51%). Private insurance premiums. Medicaid: state fiscal resources and federal subsidies. Medicare: Compulsory social contributions during active life.
Basket of services	Implicit. Comprehensive and uniform. Guaranteed outpatient and hospital care at all levels of care; pharmaceutical assistance.	Implicit. Comprehensive and uniform. Guaranteed outpatient and hospital care at all levels of care; pharmaceutical assistance.	Differentiated according to ability to pay and insurance contract. Medicare does not cover all services and most beneficiaries need to pay for private insurance to supplement the basket.
Populational coverage	GKV social security: 90%*. Private insurance: 10% substitute (4.4% civil servants).	100% Citizens and permanent residents.	Medicaid: 19% Medicare: 17% Private insurance: 68% Uninsured: 11%
Service providers	Wide range of services supplied by public and private providers accredited to the GKV at all levels.	Public supply** 84% public beds. Specialized outpatient care in public hospitals. PHC: national contract with general practitioners exclusively working for the NHS.	Wide-ranging service provision by predominantly private, profit-making and non-profit providers.
Design of system	System is not territorialized or organized in networks.	Integrated, centralized structure. Regionalized organization of services and resource allocation based on populational health needs and regional specificities.	System is not territorialized or organized in networks. Some insurers organize their own networks.
PHC	Weak PHC. Tradition of care by general practitioners who do not exercise gatekeeper function.	Robust PHC. Obligatory registration of citizens in a general practitioner’s surgery with gatekeeper function.	Weak PHC. Managed care organizations require a first consultation with generalist with gatekeeper function as a method of reducing costs. Community health centers cover less than ١٠٪ of population.

Indicators	Year	Brazil	Colombia	Mexico	USA	Germany	UK
Population (millions)^a	2015	205.962	48.229	125.891	319.929	81.708	65.397
GNI per capita ppp	1990	^b6,510	^b4,620	^b5,840	^b23,730	^b19,740	^b16,800
GNI per capita ppp	2014	^c15,570	^c12,910	^c16,840	^c56,116	^d47,500	^d43,350
Population coverage %^e*	2002	100.0	65.4	48.3	84.8	99.8	100.0
Population coverage %^e*	2014	100.0	96.6	83.0	88.5	100.0	100.0
Population without coverage % (millions)^e	2002	0.0	34.6 (14,229,772)	51.7 (53,467,054)	15.2 (43,719,030)	0.2 (164,977,000)	0.0
Population without coverage % (millions)^e	2014	0.0	^a3.4 (1,625,000)	17.0 (21,000,000)	^a11.5 (36,538,000)	0.0	0.0
Total health expenditure as % of GDP^e	2002	7.1	5.7	5.4	14.0	10.1	6.6
Total health expenditure as % of GDP^e	2014	8.3	7.2	5.7	16.5	1.1	9.9
Public expenditure on health as% of GDP	2002	^e3.2	^e4.6	^e2.3	^e6.3	^d8.2	^d6.0
Public expenditure on health as% of GDP	2014	^c3.8	^c5.4	^c3.3	^c8.3	^d8.7	^d7.6
Public expenditure on health as % of total health expenditure^e	2000	40.3	79.3	42.7	44.2	79.4	79.3
	2014	55.2 (2013)	76.3	51.8	49.3	84.3	79.6
Public expenditure on health per capita in US $ ppp^e	2002	307	317	238	2.403	^d2.328	^d1.757
Public expenditure on health per capita in US $ ppp^e	2014	549 (2013)	724	532	4.457	^d3.990	^d2.808
Out-of-Pocket (OOP) expenditure as % of total health expenditure	2002	^e38.8	^e12.2	^e54.4	^e14.3	^d12.1	^d10.8
	2014	^c25.5	^c15.4	^c44.0	^c11.0	^d13.2	^d9.7

Characteristics	Colombia General System of Social Security in Health (SGSSS) 1993 – present	Mexico Popular Health Insurance (SPS) 2003 - present
Emphasis of reforms	Subsidy on demand. Radical reform of the health sector with the creation of health provision and health insurance markets. Total separation of the functions of funding, intermediation and provision of services by specialized agents. Social security was transformed by the reforms.	Subsidy on demand. Reforms aim to create a market for healthcare provision and health insurance but the separation of the funding and provision has not materialized. Co-exists with social insurance.
Elegibility/ entitlement	Those who are unable to pay and who are not part of the formal labor sector are affiliated to the Subsidized Regime (RS) depending on the availability of resources. Workers in the formal labor sector, or who are able to pay, are obliged to join the Contributory Regime (RC).	People who are not part of the formal work sector (open or uninsured population). Voluntary affiliation.
Funding	RS: combination of national and sub-national fiscal sources, with solidarity contributions equivalent to 1.5% of the mandatory contributions of the RC and of the Armed Forces model, (Ecopetrol). RC: mandatory contributions from workers (4%) and employers (8.5%) in terms of salaries; 12.5% of income of self-employed or those who are able to pay. In 2014 the employer’s contribution for employees earning up to ten minimum wages was replaced by a tax on profits. Co-payments for RC and RS users by income ranges, with exemption for vulnerable groups.	Combination of fiscal sources from the national government (83%) and states (16%), with mandatory contribution per affiliated family (1%) according to socioeconomic conditions, except for deciles I to IV. No co-payment for services included in the basket.
Buying function	Insurance companies (Health Promotion Enterprises – EPSs) perform financial intermediation and manage risks. In 2014, in the RC there were 17 ICs (15 private and two public), and in the RS there were 35 ICs (24 private, two mixed and nine public). Unit of payment by capitation (UPC), differentiated by RC and RS with gradual equalization. In 1994 the UPC-RS was equivalent to 60% of the UPC-RC, which reached 89% in 2017.	No insurance providers were established. The intermediation/purchase function is performed by government agencies.
Segmentation of social protection (% of populational cover)	Contributory regime: 46% Subsidized regime: 45% Special schemes: 5% Total population covered: 96% (2016)	Popular insurance: 49.9%, Social insurance: 46.9% 17% remain without health coverage (2015)*
Basket of services	Obligatory Health Plan (POS): explicit baskets of benefits differentiated for RC and RS. POS-S basket with restricted content and differentiated costing. From 1995-2013 the average RS per capita expenditure corresponded to 33% of the RC expenditure. From 2008-2012 there was gradual equalization of the explicit baskets of RS and RC benefits; however, differences in use and costing persist. From 2015 the service basket became implicit, with a list of exclusions.	Universal Catalog of Health Services (CAUSES): restricted, explicit basket with 287 interventions (2016); 91% individual and 9% collective. Of the individual interventions 50% were hospital and 40% outpatient. Protection Fund for Catastrophic Spending (FPGC): 61 interventions included only eight types of cancer, HIV/AIDS treatment, treatment for acute myocardial infarction for those aged under 60, and hepatitis C treatment for patients aged 20-50. Complete coverage for care for children up to five years (“Medical insurance for a new generation”). Services not included in the baskets are only accessible through direct payment.
Design of the service system	Does not include a proposal to organize service network; provides for competition between providers. Fragmented services, without territorialization as a result of IC contracts with public and private providers. The supply from public providers is the only one available to the population in dispersed areas	Does not include a proposal to organize service network. Segmentation and fragmentation of provision of services. Population in dispersed areas with difficulty in accessing services.
Health service providers	Private and public service providers. Transformation of hospitals and public health centers into state-run social enterprises, aiming at revenues from billing services to insured individuals (subsidized demand) and elimination of public on-lending (subsidized supply) with closing of public providers.	Mainly public service providers from the Health Department (autonomous hospitals and health centers). Contracts are allowed with social and private insurance providers.

[1] Source: the authors, using^23,25,26_.

[TFN1001] * Social insurance coverage is not 100% because since its foundation civil servants do not participate and high-income workers can opt for private insurance. A total of 1-2% of the population are covered by social assistance, which pays for the services used by beneficiaries or their contribution to the GKV. ** From the 1990s onwards, new forms of management in public hospitals, as well as the separation of the functions of funding and supply with the internal market, have resulted in commodification.

Universal health system and universal health coverage: assumptions and strategies

Abstract