Universal health coverage refers to the idea that all people are able to receive the health care that they need, where and when they need it, without financial hardship. While the world aims to move toward providing health care to all, the reality is, there are still many people being left behind, including the nearly two billion low-income people living in low- and lower-middle-income countries (LLMICs).
In a new paper published in the journal Social Science & Medicine, Global Health Education and Learning Incubator Senior Faculty Scholar Professor William Hsiao and co-author Professor Winnie Yip of the Harvard T.H. Chan School of Public Health argue that a cooperative healthcare (CH) model could help make basic health care accessible to those people.
Universal health coverage is usually financed by either general tax revenue or mandatory social insurance. However, compared to wealthier countries, LLMICs do not have much tax revenue and are generally unable to allocate enough of it to finance health coverage. LLMICs also tend to have a large proportion of farmers and informal workers, meaning that mandatory social insurance through wage contribution is not feasible to finance universal coverage in these countries. Community-based models of financing show promise to deliver where funding through tax revenue or social insurance can’t. In their paper, Hsiao and Yip review several community-based health care financing schemes and identify one, which they call CH, that has the potential to be both feasible and scalable.
In a CH approach, residents of a community prepay into a risk-pooled fund for the delivery of basic health services and common drugs, often from local providers that residents are already using. The scheme is managed and governed by the community, giving communities the power to hold providers accountable. The approach leverages—in fact, it relies on—existing social connections within communities and residents’ willingness to cooperate and assist one another. Trust is the most crucial part to make CH feasible; the authors hypothesize that as long as there is strong social capital, a CH approach could work even if cost outweighs individual benefit.
Knowing this, could the CH model be scaled to cover a whole country? The authors argue, yes, so long as certain conditions are met. First, there needs to be sufficient social capital and trust. Second, the schemes need to deliver real value and be trusted by the communities they serve. Finally, the program has to be legitimized and supported by the state, but not run by it.
The authors believe that a scaled-up CH system could act as a transitional steppingstone to universal health coverage in the future. Members of a CH program may be more likely to accept universal coverage through taxation or contributions for social insurance because they will have become used to prepaying for health care. A CH program would also help lay the groundwork for universal coverage by organizing primary health care delivery so that good quality, accessible care is available from the get-go.
In the meantime, “we encourage LLMICs to start with experimentation,” write the authors. Experimenting with CH on a smaller scale could help identify where the model may need to be tailored to the local context. Although CH may not work for every community, scaling it up in the places where it can be feasible could be a worthwhile investment for making health care affordable and accessible to the many rural and informal workers in LLMICs. To learn more about health systems and health system financing, check out our resource pack on Health Systems and Universal Health Coverage.