Making Fair Choices on the Path to Universal Health Coverage: Applying Principles to Difficult Cases.

Abstract-Progress toward universal health coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the World Health Organization (WHO) Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases, and how should one adjudicate between them when their demands conflict? This article by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three key dimensions of progress toward UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to prepayment with pooling of funds. Our cases are simplified to highlight common trade-offs. Though we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC.

Comparison of maternal health services and indicators in three districts of the Volta Region, Ghana.

BACKGROUND: Ghana's maternal mortality ratio continues to decline, but is not expected to meet the Millennium Development Goal (MDG) 5 target. The Ghana Health Service and Ministry of Health have displayed a high commitment to the improvement of maternal health in the country. One of the most recent partnerships directed at this is with the Korea International Cooperation Agency. METHODS: This study was conducted among women between ages 15 and 49 resident in Keta Municipal, Ketu North and Ketu South districts in the Volta Region of Ghana who were pregnant or who had children aged less than five. Ethical approval was obtained from the Ghana Health Service Ethical Review Committee. Data were collected using questionnaires, entered into Stata version 12 and analyzed using frequency distribution and assessment of means. Comparisons among districts were conducted using chi square test and one way analysis of variance (ANOVA). RESULTS: The study covered 630 women whose mean age was 28.4 years. Almost all participants (99.1%) from Ketu North knew where to obtain family planning services. Use of modern contraception was highest in Ketu North with 31% of respondents using a modern method. Delivery in a health facility was highest in Keta Municipal (62.3%) with overall institutional delivery being 57.6%. Delivery by a skilled birth attendant (SBA) was also highest in Keta Municipal. CONCLUSION: Indicators used to assess maternal health services show a coverage of over 50% but we need to improve institutional delivery, use of modern contraception and education about danger signs in pregnancy. FUNDING: This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2013S1A5B8A01055336) and the Korea International Cooperation Agency(2013).

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage.

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

Reproductive age mortality survey (RAMOS) in Accra, Ghana.

BACKGROUND: Maternal mortality remains a severe problem in many parts of the world, despite efforts to reach MDG 5. In addition, underreporting is an issue especially in low income countries. Our objective has been to identify the magnitude of maternal deaths and the degree of underreporting of these deaths in Accra Metropolis in Ghana during a one year period. METHODS: A Reproductive Age Mortality survey (RAMOS) was carried out in the Accra Metropolis for the period 1st January 2002-31st December 2002. We reviewed records of female deaths aged 10-50 years in the Metropolis for the whole year 2002 using multiple sources. Maternal deaths identified through the review were compared with the officially reported maternal deaths for the same period. RESULTS: At the end of the study, a total of 179 maternal deaths out of 9,248 female deaths between the ages of 10-50 years were identified. One hundred and one (N = 101) of these were reported, giving an underreporting rate of 44%. The 179 cases consisted of 146 (81.6%) direct maternal deaths and 32 (17.9%) indirect maternal deaths and 1 (0.6%) non maternal death. The most frequent causes of direct maternal deaths were obstetric haemorrhage (57; 32%), pregnancies with abortive outcome (37; 20.8%), (pre) eclampsia (26; 14.6%) and puerperal sepsis (13; 7.3%). The most frequent indirect cause was sickle cell crisis in pregnancy (13; 7.3%). CONCLUSION: A Reproductive Age Mortality Survey is an effective method that could be used to update data on maternal mortality in Ghana while efforts are made to improve on maternal death audits in the health facilities. Strengthening the existing community based volunteers to report deaths that take place at home and the civil registration systems of births and deaths is also highly recommended.

Maternal mortality in the Greater Accra region in Ghana: assessing completeness of registration and data quality.

OBJECTIVE: To assess the completeness of registration of maternal mortality by comparing various data sources and to review the quality of information pertaining to individual cases. DATA SOURCE AND METHODS: Female deaths aged 10-50 years in the Greater Accra region in Ghana from January 1, 2000 to December 31, 2000 were recorded. Identified maternal deaths (International Classification of Diseases, 9th revision) in four major hospitals in the region were compared with those registered in the civil registers. RESULTS: During the study period, 148 maternal deaths were identified and a total of 21,183 live births were recorded in the study hospitals, yielding a maternal mortality ratio of 699/105 live births. This ratio is more than six times the officially reported maternal mortality ratio for the whole region in the same period. Ninety-two percent of the deaths were due to direct obstetric causes and 8% to indirect causes. One hundred and twenty-one of the cases were correctly classified and registered. By using the multiple source approach, 27 new cases were identified, an under-registration of 18%. The sources of error were misclassification (n=25) and error in registration (n=2). CONCLUSION: The process of registration of deaths in this region is incomplete. Enhanced registration systems (including routine linkage of death and birth certificates) on a regular basis could be used in Ghana.