Health Coverage in Low- and Middle-Income Countries

SCHOOL OF PUBLIC HEALTH

Health Coverage in Low- and Middle-Income Countries

Guest Lecture: Kristen Danforth, PhD
Date: March 5, 2026
Course: SPH 380 Public Health Principles and Practice

Lecture Objectives

  • Explore the path to Universal Health Coverage (UHC) in low- and middle-income countries (LMICs).

  • Describe challenges to healthcare delivery in LMICs.

  • Understand the ways that funding influences healthcare provision in LMICs.

Universal Health Coverage (UHC) Goal

  • Definition (3.8): Achieve universal health coverage, including:

    • Financial risk protection

    • Access to quality essential health-care services

    • Access to safe, effective, quality, and affordable essential medicines and vaccines for all.

UHC Components

Coverage Dimensions

  • Service Coverage Index (3.8.1): Captures the service coverage dimension of UHC.

  • Population Exposed to Financial Hardship (3.8.2): Measures catastrophic out-of-pocket health spending.

Audience Engagement

Interactive Polls

  • PollEv.com/kristen323

  • Activity Title:

    • True or False: The United States has achieved universal health coverage.

    • What are the reasons that the US has not achieved UHC?

Global Context

World Bank Classification (2023)

  • Income Levels:

    • High Income

    • Upper-middle Income

    • Lower-middle Income

    • Low Income

    • Not Classified

Progress Toward UHC

  • Variable progress observed across LMICs.

  • UHC-Service Coverage Index (2019): 51

  • Out-of-pocket expenditure (% of current health expenditure): 24.9

  • Hospital Beds per 10,000 Population: 75

  • Sample Countries and Data:

    • Bangladesh: 82

    • Brazil: 62

    • China: 61

    • Ethiopia: 59

    • Indonesia: 43.1

    • India: 35.2

    • Mexico: 38

    • Nigeria: 37.9

    • Pakistan: 34.8

    • Philippines: 54.8

    • Russian Federation: 70.5

    • United States: 44

Health Coverage and Access in LMICs

Urban Primary Care

  • Discussion around primary care access in urban settings within LMICs.

Breakout Session

  • Prompt: What surprised you most about healthcare systems and coverage in LMICs? Why?

Healthcare Coverage Models

Overview of Four Models of Healthcare Coverage

  1. National Health Service Model

    • Examples: UK, Spain, Cuba, New Zealand, Hong Kong

    • Coverage: Universal

    • Financing: Taxes

  2. Insurance Model (Single Payer)

    • Examples: Canada, Australia, Taiwan, South Korea

    • Coverage: Insurance

  3. Out-of-Pocket Model

    • Examples: Many LMICs; rural areas

    • Coverage: Supplemental only

  4. Mandated Insurance Model

    • Examples: Switzerland, Germany, France, the Netherlands

    • Coverage: Private insurance and supplemental options

Common Health System Arrangements in LMICs

  • Providers:

    • Low income: Public providers and external aid funded.

    • Middle income: Mix of public and private providers.

  • Financing Models:

    • Low income: Out-of-pocket, external aid, voluntary insurance, taxes.

    • Middle income: Taxes, mandatory insurance, out-of-pocket.

  • Social Contract: Government's obligation to ensure health of citizenry.

Case Study

Example 1: Uganda

Administrative Structure

  • Hierarchy:

    1. Central Health Administration

    2. Regional Health Units → Health Centers → District General Hospitals → Community Health Services

  • Services Provided:

    • Promotive, preventive, referral, and specialized curative services.

    • Highest staff cadre: Specialists, doctors, and comprehensive nurses.

Challenges in Uganda

  • System heavily privatized (95% of capital facilities are private).

  • Underfunding of government facilities leads to lack of services, commodities, and poor service quality.

Example 2: Colombia

Health Insurance System Overview

  • Public Sector Workers: Health insurance available.

  • Systems:

    • Contributory System (45%): Payroll taxes.

    • Subsidized System (51%): Payroll taxes + general government revenue.

  • Legislation:

    • Development of public health laws like "Law 100" and subsequent regulations.

  • Challenges:

    • Increased utilization post-COVID; underinvestment in service access especially in rural areas; inefficient healthcare workforce.

Breakout Session 2

  • Prompt: Discuss strategies to address challenges in Colombia's healthcare system across various levels: community, service delivery, health sector, and government policy.

Investment in Primary Healthcare in LMICs

Historical Development

  • Key Figures: Sidney Kark and Jack Geiger introduced community-oriented models.

  • Historical Milestones:

    • 1920: Foundation laid for primary health care (PHC).

    • 1978: Declaration of Alma-Ata emphasized global PHC agenda.

    • 2018: Declaration of Astana renewed commitment to PHC.

Importance of Funding

  • Current Issues:

    • Historical under-investment leads to rural inequities in access and quality of care.

Funding Healthcare Systems in LMICs

Global Health Spending

  • Nearly 80% of total health spending was in high-income countries in 2021.

  • Health Financing Sources by Income Group:

    • Low income: 90% out of pocket; 22% government financing.

    • Lower-middle income: Higher mix of private prepaid plans and public funding.

    • Upper-middle income: Variability, less reliance on out-of-pocket expenditure.

    • High income: Strong public insurance systems.

Out-of-Pocket Expenditure Trends

India Example (2018)

  • Categories of expenditure:

    • Non-medical: lodging, food, transportation.

    • Medical: doctor fees, diagnostics, medicines.

Health Insurance Strategy

  • Insurance viewed as a strategy to improve healthcare quality and access.

Coverage Trends in LMICs (2006-2016)

  • Coverage trends indicated variability across 56 LMICs.

Structural Improvements Needed

UHC 2.0

  • Key Issues:

    • Billions lack access to health services; high out-of-pocket expenses persist.

    • Traditional financial sources deemed unsustainable.

  • Necessary changes:

    • Adopt contributory culture, embrace preventative health models, and ensure accessibility in the healthcare system.