Universal Health Coverage: Why health insurance schemes are leaving the poor behind

October 2013 Oxfam

Author: Ceri Averill, Health Policy Advisor, Oxfam GB with support from Anna Marriott, Health Policy Advisor, Oxfam GB

Universal Health Coverage has risen to the top of the global health agenda. At its core, Universal Health Coverage is about the right to health. According to the World Health Organization every year 100 million people are pushed into poverty because they have to pay in cash for medicines and treatment – that’s the equivalent of three people every second. Everyone – whether rich or poor – should get the health care they need without suffering financial hardship.

Unfortunately, in the name of Universal Health Coverage, some donors and developing country governments are promoting health insurance programs that exclude the majority of people and leave the poor behind. These programs may also reinforce inequality – by prioritizing people who are formally employed and excluding the most poor and marginalised who cannot afford to pay premiums, especially women.

However, a number of developing countries are rejecting this model and prioritize general government spending for health – on its own or pooled with formal sector payroll taxes – to successfully scale up health coverage. Funding through progressive taxation and international aid is the key to achieving Universal Health Coverage. Even the poorest countries can raise more revenue for health through taxes. Oxfam estimates that improving tax collection in 52 developing countries could raise an additional $269 billion – enough to double health budgets in these countries. Urgent action on global tax evasion and avoidance is needed to ensure that countries can generate and retain more of their own resources for health.

Key recommendations

Donors and governments should abandon unworkable insurance programs and focus on financing that delivers universal and equitable health care for all.

Developing country governments should:

Develop financing systems based on the four ‘key ingredients’ outlined by WHO. Rather than looking to adapt European-style employment-based social health insurance, build on the lessons from the growing number of low- and middle-income countries that are making progress towards Universal Health Coverage.
Make equity and universality explicit priorities from the outset and avoid the temptation to start with the ‘easiest to reach’ in the formal sector. Those living in poverty must benefit at least as much as the better off every step of the way.
High-income country governments and multilateral organizations should

Stop promoting inappropriate approaches in the name of Universal Health Coverage, especially private and community-based voluntary health insurance programs.
Take action on tax avoidance and tax evasion, which denies poor countries much-needed revenue for universal public services. Provide support for progressive tax reform in poor countries, including technical support to strengthen tax administration capacity.