To date, every country in the world has been affected by the COVID-19 pandemic. Action is urgently needed, but the response must be coherent. It will do no good if the urgency of the moment leads to chaos in the response of both countries and the international community. To avoid this pitfall, it will be necessary to distinguish between what needs to be done (in terms of health service provision, financing systems and governance) and the health safety and UHC objectives to be achieved. It’s not a question of choosing between health security and CSU: investing in the core functions of healthcare systems is fundamental to both, and needs to be complemented by public policy measures that go beyond healthcare systems.
By the health financing systems team at WHO headquarters and regional offices
At present, the top priority is to plan, organize and reconfigure the provision of healthcare services to meet immediate needs. Measures relating to health financing systems can play a role in supporting a rapid and organized response to the pandemic. More specifically, the response of health financing systems needs to support the scaling up and delivery of relevant public and individual health services in two fundamental ways. These two objectives are those of health financing systems in the current situation and should be pursued simultaneously:
Guarantee adequate funding for health commons, i.e. public health functions such as extended health monitoring (including laboratories), data and information systems, regulation, communication and information campaigns. Financing these “health commons” helps to ensure that the public health functions needed for crisis preparedness and response are in place. Unfortunately, in many countries, investment in epidemic preparedness has not been sufficiently prioritized in recent years, or even in the last few weeks since the outbreak. However, this problem can be corrected to strengthen the response to COVID-19 and be better prepared for future challenges.
Remove financial barriers to accessing healthcare services to enable COVID-19 diagnosis and treatment for all those in need. It’s vital that people have a good understanding of the disease, and can act on health authorities’ guidance on when and where to seek care. The decision to seek care should in no way be influenced by concerns about the costs to be borne by individuals and families, particularly during a pandemic.
The main actions to be taken by health financing systems to support the achievement of these objectives are identified below.
Increase the allocation of public funds to the appropriate health system response, including funds from international donors where these exist, to achieve both objectives. This will require the implementation of budgeting and public finance management actions to prioritize and expand the budgetary space allocated to the response to COVID-19, as well as new processes to coordinate, ensure complementarity and alignment of funds (national and donor) for a comprehensive response, including all government actors and involving both health and finance authorities, national and decentralized levels, any other healthcare purchasing agencies (eg. national/social health insurance) and healthcare providers.
a) Increase the priority given to the health sector in public budgets, particularly when funds from national sources and external donors are channeled into the response. This could be facilitated by activating exceptional public spending procedures during the first phase of the crisis, then formalizing them in corrective budgetary legislation.
b) Rapidly reprogram allocations to guarantee relevant, stable and sustainable funding for Public Health Assets (PHAs). While additional allocations will not by themselves be enough to guarantee the supply of medical goods, surveillance systems, contact tracing, water and sanitation, public health communication, testing and laboratory capacity, channelling sufficient funding to these activities is essential. Constraints blocking the level or disbursement of funds should be removed as quickly as possible.
c) Reprogramming budget allocations so that service providers can cope with the increase in demand both internally and among the population, incorporating the need for additional inputs and overtime pay for health workers, as well as improving access to testing and treatment for the hardest-to-reach populations.
d) Create a specific program budget for the response to COVID-19 in amending budgets to facilitate the execution and monitoring of expenditure.
e) Give greater flexibility and decision-making capacity to front-line healthcare providers, so that they can rapidly counter shortages of essential inputs (soap, small equipment, medicines).
f) Set up transparent reporting mechanisms on the use of funds at all levels.
g) In countries receiving funds from external donors, involve these donors in dialogue around needs not covered in national response plans and alignment with national public finance management procedures.
Modify the orientations of healthcare financing systems to remove financial barriers to access to care, by making services free when they are used. Co-payments (paid by users) should be suspended as a complement to health care supply strategies to cope with the pandemic, including for home care and teleconsultations where possible.
This measure should not be understood as an encouragement to bring everyone to care providers, but rather to remove any financial consideration from the decision to use care, because the evidence base clearly demonstrates that co-payments do not selectively limit “unnecessary” care, but reduce the use of all health services, particularly by the poor. When people think they’ll have to pay, or are uncertain about the financial aspect, they may postpone or avoid seeking care, making the pandemic harder to control and inducing additional risks for society as a whole. This is why people requiring medical treatment or quarantine/isolation should not have to pay for these services, including treatment of comorbidities, as the anticipation of payment even for services not directly related to COVID-19 could prevent people from getting the care they need.
A simple statement that services will be free of charge is unfortunately not enough, especially in countries where unrecorded payments (for medicines or healthcare staff) for officially free services has been the reality experienced by the population, or where people face high transport costs or other barriers to accessing care.
a) Suspend all co-payments (users’ financial participation) for all patients regardless of insurance, nationality or residential status for all health services provided at provider level or in the home, and those related to quarantines or isolation. This message should simply be communicated to the entire population.
b) Compensate care providers for income losses linked to co-payments as part of the general public spending measures mentioned above, to enable them to cope with increased demand.
c) Develop or simplify frameworks for integrating and contracting private service providers, including payment terms, pricing and reporting obligations.
d) Enable the disbursement of cash advances to public and private service providers to enable them to cope with increased demand. This can be achieved by advance payment of the global budget, by capitation calculation or by pre-financing corresponding to the volume of invoices normally paid retroactively.
e) Adapt pricing and payment arrangements to reinforce changes in the location and mode of delivery of services during the response, including homecare, teleconsultations and other forms of digitized health services.
f) Consider deploying multi-purpose cash transfers for households, including those that conventional mechanisms have difficulty targeting such as refugees, displaced persons, migrants and the homeless, using digital platforms where feasible. Cash transfers could be particularly important in the poorest regions of countries and in fragile contexts or conflict zones, including specific situations such as refugee camps, to enable people to stay at home as needed while having access to food and other essential goods and eliminating the indirect costs of seeking care such as transport or income lost through interrupted work; cash transfers should not, however, be used as a justification for leaving co-payments in place. Implementing cash transfers is likely to involve targeted social assistance schemes, in partnership with the competent authorities in this field (ministry in charge of social protection or similar agency).
As with other elements of the healthcare system, healthcare financing mechanisms must rapidly adapt and support the current pandemic context. They also need to be ready to face the period at the end of the crisis, when people will come looking for the services they put off during the response to the COVID-19 wave. More than anything else, funding mechanisms need to be simplified and harmonized, and this needs to be accompanied by clear communication messages to the public about rights and the expected pathways to healthcare. The actions highlighted in this text provide a roadmap in times of reconfiguration and scaling up of health services, but can also serve as a solid foundation for health financing systems that are better prepared to support health security and CSU in the future.
This document is the result of a collective effort by WHO
The health financing systems team at headquarters and in the six WHO regional offices. Specific contributors include Joseph Kutzin, Susan Sparkes, Agnès Soucat, Hélène Barroy, Matthew Jowett, Camilo Cid, Peter Cowley, Jonathan Cylus, Valeria de Oliveira Cruz, Fahdi Dkhimi, Alexandra Earle, Tamás Evetovits, Xu Ke, Awad Mataria, Inke Mathauer, Bruno Meessen, Diane Muhongerwa, Juliet Nabyonga, Claudia Pescetto, Tomas Roubal, Sarah Thomson, Tsolmongerel Tsilaajav, Prosper Tumusiime, and Hui Wang. French translation: équipe de coordination P4H.
