As COVID-19 spread across Europe earlier this year, many countries moved quickly to address gaps in health coverage by extending entitlement to migrants, suspending the payment of health insurance contributions for low-income self-employed people, adding teleconsultations to the benefits package and offering free access to testing and treatment of the virus.
These actions demonstrate widespread acceptance of the need to ensure that everyone has access to health care and protection from out-of-pocket payments in a pandemic. On Universal Health Coverage (UHC) Day – 12 December 2020 – WHO releases new analyses that underline the importance of extending this principle to all needed health services on a permanent basis.
Financial protection and the Sustainable Development Goals (SDGs)
A new factsheet sets out how failure to address common gaps in health coverage before the pandemic was already undermining national and regional ability to meet targets to reduce poverty (SDG 1.1) and income inequality (SDG 10.1), and move towards UHC (SDG 3.8).
Two coverage gaps have even greater resonance now, in the context of COVID-19 and its economic impact.
First, countries that base entitlement to publicly financed health care on payment of health insurance contributions (rather than residence) find it hard to cover the entire population at the best of times, particularly if the informal economy is significant. This challenge grows in an economic crisis, as people lose jobs or suffer a drop in wages and can no longer afford to pay contributions.
Ensuring that everyone living in a country has health coverage is a precondition for UHC, not an optional extra.
Second, just being covered is not enough. User charges (co-payments) for covered services are a key source of financial hardship in health systems in Europe. Countries can reduce access barriers and alleviate financial hardship by exempting poor households and people with chronic conditions from co-payments. Redesigning co-payment policy allows the health system to target those most in need of protection.
Cyprus fixed its roof while the sun was shining
New WHO analysis of financial protection in Cyprus shows how health budget cuts and coverage restrictions introduced in the wake of the 2008 global financial crisis were associated with a rise in unmet need for health and dental care and a doubling in the number of households with catastrophic health spending. Before the economic crisis, Cyprus already had one of the largest gaps in population coverage because entitlement was linked to income and citizenship. This gap grew from 15% to 25% of the population during the years of the economic crisis, as new rules linked entitlement to payment of social security contributions.
Cyprus has recently redesigned its coverage policy. The new General Health System implemented in 2019 changed the basis for entitlement to residence, allowing all legal residents to be covered for the first time. It also reduced user charges, particularly for low-income people. As a result of removing many financial barriers to access, Cyprus was better prepared to meet the health and economic challenges of the pandemic.
The Republic of Moldova makes progress during the pandemic
Over 10% of the population in the Republic of Moldova lacks health coverage because entitlement is linked to payment of health insurance contributions and the informal sector is significant. Reforms introduced in the last ten years have led to greater use of health services and fewer people reporting unmet need due to cost, but better access to care has also increased people’s exposure to out-of-pocket payments – for example, through heavy co-payments for outpatient medicines and informal payments in hospital. New WHO analysis finds that poor households are at high risk of being uninsured, facing financial barriers to access and experiencing catastrophic health spending.
In working to control the pandemic, the Republic of Moldova has used reserve funds to guarantee free hospital treatment for everyone, regardless of health insurance status. As the longer-term economic disruption caused by COVID-19 becomes more evident, this short-term measure could be turned into a permanent feature. De-linking entitlement to all health services – not just hospital care – from payment of contributions would ensure people do not lose coverage when they need it most. Redesigning co-payment policy will also help to reduce financial hardship.
From crisis response to sustained progress towards UHC
UHC is one of the three priorities in the WHO European Programme of Work. “COVID-19 has caused enormous disruption and devastation, but it has shown us the importance of accessible and affordable health services. No one should be denied the fundamental right to health care,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe. “A commitment to universal health coverage is at the heart of our work at WHO/Europe. We need to mobilize the public and political will to make sure it remains a priority.”
Two policy responses to the pandemic stand out as candidates for permanent change in European health systems: breaking the link between entitlement to health care and payment of contributions, and exempting poor people and people with chronic conditions from co-payments. WHO/Europe will support the efforts of Member States to put universal health coverage at the core of recovery from COVID-19.