Costing universal health coverage

The sustainable development goals (SDGs) are audacious and clear. SDG 1 aims to eliminate poverty in all its forms everywhere, meaning that no one is to be left behind. SDG 3 focuses on health and well-being and targets to achieve universal health coverage (UHC) by 2030. However, health – and development interventions in general – must reach everyone if these goals are to be achieved. To ensure that no one is left behind, we need to reach the hardest-to-reach: the poorest of the poor, the geographically isolated, the administratively invisible, those without identification documents or an address, and the marginalized. Achieving UHC requires meeting the challenge of delivering services to those most in need and more specifically to those who are hardest-to-reach.1 The Reach Project at the University of Toronto is investigating how reach can be achieved.2 The project is a collaborative and multidisciplinary research programme, in which faculty researchers from the social sciences, management, medicine, public health and engineering, work together with students to examine how health and development interventions have successfully reached the hardest-to-reach in lowand middle-income settings. Over the past four years, researchers in the project have conducted archival research and fieldwork in several countries, looking at a range of important case studies including vaccine delivery to rural populations in India and Rwanda; the implementation of birth registration schemes in South Africa; the delivery of cash transfers in Brazil, Jordan and West Bank and Gaza Strip; the elimination of mother-to-child-transmission of human immunodeficiency virus in remote areas of Thailand; and many more.2 The case studies offer important insights for governments, nongovernmental organizations, firms and international donors. These studies include: the pivotal role that effective monitoring plays in reaching the hard-to-reach; creative efforts to accurately identify and locate the poorest of the poor; the generation of political will to overcome legacies of mistrust and marginalization among certain population segments; the importance of mobile units and digital platforms to actively reach those who live far from urban centres; the interaction of computer mapping technology and local knowledge to facilitate route optimization for cold-chain delivery of essential medicines; and the critical role played by community health workers, and specifically the balance between coordinated protocols with adaptive local knowledge so that frontline workers can deliver interventions in local contexts. Reaching the hard-to-reach demands innovative delivery mechanisms, but also attention to the economic and financial cost of reaching the previously unreached, an observation raised by the World Health Organization (WHO) in its 2014 Making Fair Choices on the path to universal health coverage report.3 Distance to travel and time, for example, dramatically affect the cost of delivering health interventions to remote places. Personnel and training costs of delivering health interventions to sparsely populated and distant regions can be extremely high. Maintaining an accurate registry of poor households, which is often used in targeted health programmes, is difficult and costly.4 In other words, ensuring no one is left behind is expensive. Indeed, if the costs become too high, such initiatives become prohibitively expensive, in which case governments fail to generate the political will to reach the hard-toreach and nongovernmental organizations cannot devise a feasible delivery model. The challenges of making a case to reach the hardest -to-reach are compounded further when we consider the difficulties of estimating the economic returns generated by reaching the hardest-to-reach especially in terms of the impact of health interventions. Simply put, when costs become too high and when returns are unclear, many will remain unreached and thus be left behind. Cost is an important variable and health and development research has a relatively good handle on aggregate cost data. Governments, development agencies and nongovernmental actors should know how much it costs to deliver health and development interventions. A good example is the United States Agency for International Development Deliver Project in United Republic of Tanzania. The Medical Stores Department of the country, a semi-autonomous public agency that oversees the procurement and distribution of medicines, uses mapping software to optimize routes for transport trucks to deliver vaccines and medicines to over 5000 clinics.5 Route optimization involves calculating the most effective (accurate and on-time delivery) and cost–efficient (distance and time travelled) delivery routes, affecting the programme’s total cost. Total cost is an important measure because we can assess the overall amount of resources needed to deliver, for example, vaccines and medicines to all clinics. Total cost also allows a calculation of the average cost to deliver on a per-capita (or per-clinic) basis. However, we contend that it is more important to know the marginal cost than total cost to deliver interventions as coverage expands. Marginal cost is the additional resources required to deliver an intervention to an additional beneficiary or clinic. In general, we expect that as coverage rates expand marginal cost will rise more steeply compared to average cost. This increase is opposite to the conventional wisdom that costs should decline as markets expand because of the economies of scale.6 Marginal costs rise as we reach the hardest-to-reach because populations become sparser, the terrain becomes more difficult to travel, distances become longer and personnel Costing universal health coverage Joseph Wong & Kimberly Skead