Advancing universal health coverage in Asia

Access to healthcare is a basic human need, but efforts to provide affordable public care in many developing
nations have had mixed results. EU-funded researchers sought to find out why through a landmark evaluation of
healthcare systems in six Asian countries. The conclusions highlight the influence of insurance schemes'
affordability, understanding what motivates people to take out insurance policies, and how public money is
spent.

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By using an innovative methodology to compare different public healthcare strategies in Cambodia, China, Indonesia, the
Philippines, Thailand and Vietnam, the researchers indentified key factors that influence how much of the population can
access healthcare, what kind of services they receive, and how efficiently the system is funded.
Their research, conducted within the HEFPA project with the support of the European Commission, has since fed into several
follow-up initiatives aimed at improving the accessibility and affordability of care in countries where low-income groups have
inadequate coverage and face financially crippling out-of-pocket expenses for treatment.
Universal health coverage is a big buzzword in the international community. Many countries have implemented initiatives to
provide care for their population, but there are big differences in the depth of care provided, how accessible it is and how it is
funded, explains Eddy van Doorslaer, a professor of health economics and coordinator of HEFPA at the Erasmus University
Rotterdam in the Netherlands.
Socio-economic, political and demographic factors all influence how universal health coverage can be implemented. But
without it, low-income families faced with large out-of-pocket expenses will often delay or forgo treatment, or if they seek
treatment they risk being pushed deeper into poverty by the financial burden. Social insurance schemes are part of the
solution, but as HEFPAs research shows, they are not all equally successful.
Among the countries studied in HEFPA, Thailands universal health insurance system stands out as the most effective.
However, it leverages Thailands pre-existing network of hospitals and medical facilities that many other developing nations
lack and is financed through tax revenues that many other nations with large informal economies cannot afford.
Other countries have taken alternative routes. Some, such as the Philippines and Vietnam, are attempting to combine tax-
financed coverage of low-income households with voluntary enrolment in social health insurance for wealthier groups not
covered through formal-sector employment. But succeeding in this strategy requires the acquisition and utilisation of a good
understanding of the factors that motivate people to insure themselves or not.
Two randomised studies conducted by HEFPA in Vietnam and the Philippines revealed that subsidisation of insurance
premiums by up to 25% and 50%, respectively, along with the provision of information on the benefits of insurance, was
insufficient to bring enrolment rates anywhere close to universal coverage.
Aligning supply and demand
Concerns about the affordability of insurance even with the subsidies scepticism about the benefits and difficulties of
completing forms and enrolment procedures appeared to be key factors in limiting uptake. In Indonesia, for example, the
deployment of a public insurance scheme has contributed to increased use of healthcare services, although many people only
enrol when they need treatment, resulting in the cost of claims far surpassing the revenue generated from insurance
premiums.
Where there is sufficient funding, the effectiveness of healthcare is determined by how the money is spent. In China, where
the HEFPA team looked at the staggered rollout of the New Cooperative Medical Scheme across different regions, the
researchers found that funding of inpatient care, but not outpatient treatments, led to many people being hospitalised
unnecessarily, while fee-for-service payments to providers created incentives to overprescribe drugs.
We found that access to healthcare is not only contingent on demand-side parameters, but also on how providers are paid
and managed, Van Doorslaer says.
Aligning demand and supply within the healthcare system, training professionals to manage coverage effectively, providing
incentives for enrolment in social insurance schemes, increasing awareness and educating people about the benefits are all
strategies that countries can use to effectively increase healthcare coverage, the HEFPA researchers found.
The projects results and recommendations have been disseminated to policy-makers in several countries with the aim of
improving the implementation of universal healthcare systems. The HEFPA results are also feeding directly into new
healthcare initiatives.
In Indonesia, a follow-up project has been launched to support the training of professionals in health insurance and finance
skills to support universal health coverage implementation. Erasmus University is also involved in several applications for
funding of similar research work in low- and middle-income countries.
Project details

Project acronym:HEFPA
 Participants:Netherlands (Coordinator), Belgium, Greece, UK, Cambodia, China, Indonesia, Philippines, Thailand,
Vietnam
Project Reference N 223166
Total cost: 3 849 138
EU contribution: 2 885 767
Duration:June 2009 - November 2013

http://ec.europa.eu/research/infocentre/article_en.cfm?&artid=35357&caller=SuccessStories