Legal health coverage Universal coverage

8 Universal Health Protection Availability of quality health care The availability of health care relates to the physical existence of a set of essential health services, a health workforce to deliver these services, infrastructure allowing individuals to reach health facilities, and medical goods and products to provide care responding to needs. In the absence of one or more of these components, effective access to adequate care will not be possible. Globally, the availability of health care is distributed unevenly between low-, middle- and high-income countries, as well as frequently within these countries. This is mainly due to issues within health schemes and systems at the organizational and managerial levels. The unavailability of services also entails gaps in the scope of benefits that lead to exclusion from essential health care. Service delivery and an unequal distribution of the health workforce and infrastructure are also highly relevant to this discussion. Discrepancies in the availability of health care are particularly prevalent across geographic regions – specifically between rural areas, cities and slums – within a given country. Recent studies have shown that it is residents of urban slums in developing countries who may experience the greatest inequities in accessing essential health care at the national level. This is evident in Dhaka, Bangladesh see table 2.1, where only about 23 per cent of urban slum dwellers visited providers with skilled health workers as compared to 35 per cent of the sick from rural areas. The source of health care most used in urban slums was pharmacies, which accounted for 42.6 per cent of visits to health-care providers Khan, Grübner and Krämer, 2012. Table 2.1. Dhaka: Health-care utilization by residents in urban slums and rural areas, 2008─09 percentages Urban slums Rural areas Providers visited Pharmacy 42.6 30.1 Government hospitalclinic 13.5 8.9 Private hospitalclinic 2.7 22.6 16.1 35 Qualified allopathic practitioners 3.9 8.4 Paraprofessionals 2.5 1.6 Traditional health providers 1.4 3.1 Others 0.0 1.6 Source: Khan, Grübner and Krämer, 2012 Similar observations could also be made with regard to skilled attendance at births in the same areas of Bangladesh: in 2009, 19 per cent in rural areas but only 15 per cent in slums UNICEF, 2010. Health care that is available and affordable cannot fulfill its purpose unless it is at an adequate level of quality. Quality refers to various dimensions, including: compliance with medical guidelines or protocols as developed by WHO or other institutions, such as the guideline on natural ventilation for infection control in health- Universal Health Protection 9 care settings WHO, 2009a, and the WHO recommendation on screening donated blood for transfusion-transmissible infections WHO, 2009b; responsiveness to needs, including special needs such as those of people living with HIVAIDS PLHIV, the elderly or disabled; ethical dimensions such as dignity, confidentiality, respect of gender and culture, and issues such as choice of provider and waiting times; and administration and management of health protection systems and schemes, e.g. with accountability, transparency and participation. Quality is strongly linked to the availability of sufficient financial and human resources.

2.2. Financing mechanisms

There is no single right financing model for providing universal health protection. Countries use various resources generated from various tax schemes, income-related contributions and divers forms of risk pooling, among others, to create dynamic systems that evolve over years, often resulting from historical and economic developments, social and cultural values, institutional settings and political commitment. However, financing mechanisms should be developed in such a way as to foster solidarity and generate sufficient income for the health system. Thus, no individual in need of health care should face hardship or an increased risk of poverty when accessing essential health care Recommendation No. 202, para. II. 8a. It is usually the case that different financing mechanisms are combined into a pluralistic health financing system in order to generate sufficient income for the delivery of health care. The following principles need to be taken into account during this process: solidarity in financing, to ensure that those in need and with limited capacity to pay e.g. through co-payments, contributions or VAT are supported by those who are healthy and financially better off; consideration of the diversity of existing methods and approaches, including of financing mechanisms and delivery systems when aiming at universal coverage; transparent, accountable and sound financial management and administration; and financial, fiscal and economic sustainability, taking into account social justice and equity. Figure 2.5 provides an overview of the most important financing mechanisms funding health protection systems and schemes; these mechanisms should be coordinated with a view to achieving equity in access to health care. While OOP are frequently used as a financing rather than a control mechanism, the ILO does not consider OOP to be an acceptable method of generating income for health systems, given their negative impacts on equity and household income.