HEALTH ECONOMICS

MASTER OF PUBLIC HEALTH

OPEN UNIVERSITY OF MAURITIUS
LEARNER’S NAME: MUNGUR MANISHI
LEARNER’S ID: 202107599
TUTOR’S NAME: Dr HARRIS NEELIAH
DATE: 10/07/2023
ASSIGNMENT QUESTION

‘’ Universal Health coverage means that all people have access to the full range of
quality health services they need, when and where they need them, without financial
hardships. It covers the full continuum of essential health services, from health
promotion to prevention, treatment, rehabilitation and palliative care.’’ Definition from the
World Health Organization
What are the challenges facing Mauritius in delivering its UHC?
Word Limit: 4000
 TABLE OF CONTENTS

CONTENT PAGE
NUMBER

Introduction………………………………………………………………………. 1
Literature Review ……………………………………………………………….. 2-3
Health Care financing & Financial Risk Protection…………………………… 4-6
Strengthening Primary Health Care Systems…………………………………. 7-8
Challenges in the face of a pandemic………………………………………….. 9-10
Governance & Leadership………………………………………………………..11-12
Challenges to building resilient health systems……………………………… 13-15
Epidemiological & Demographical Challenges………………………………….. 16
Conclusion & Recommendations…………………………………………………..17-18
References……………………………………………………………………………19-20
Introduction

The foundation of Universal Health Coverage (UHC) is based on an egalitarian view of

health care as a fundamental human right, in the spirit of earlier unifying concepts such
as Health for All and the Alma-Ata declaration. According to Ranabhat et al (2019),
UHC presents a vision in which all citizens enjoy a robust and efficient health system
that spans preventive and curative healthcare, affordable access, access to medicines,
and sufficient healthcare human resources.  Efficient delivery of these services requires
capable healthcare systems and healthcare workers with optimal skill mix, equitably
distributed and adequately supported with sustained financing and resilient healthcare
infrastructure. Mauritius, a small-island developing state, has made considerable
progress towards achieving universal health coverage post-independence. The three
pillars of UHC namely health financing, health service delivery along with political
economy and process have been given due attention. Nevertheless, despite being
exemplary and having accomplished noteworthy health indicators, Mauritius still faces
certain challenges, which include finding the fiscal space to finance UHC policies and
programs, the growing burden of Non-Communicable Diseases (NCDs), the complex
health needs of the ageing population and the rising expectations of patients for more
patient-centered and improved quality of care. In addition, there is the need to ensure
the maintenance of health infrastructure and improving implementation rate of new
infrastructure projects in order to enhance the capacity of the health workforce and to
expedite the digitalization of health services to meet the new demand of the public
health sector.
 1

Literature review

In recent years, there has been an increased push for universal health coverage (UHC)
at the global level. UHC is defined by the World Health Organization (WHO) as
“ensuring that all people obtain the health services they need, of good quality, without
suffering financial hardship when paying for them”. This concept was initially created in
1883 after Germany introduced public health coverage to ensure the health status of its
young population. Later, after many countries also began to offer national health
insurance, the World Health Assembly adopted the term “UHC” starting in 2005, and in
2010, the World Health Report focused on financing health systems so countries could
build platforms for UHC. Mauritius is one such country that recognizes the perennial
importance of UHC. Since independence in 1968, successive Governments have
sustained the provision of free health care services and included Universal Health
Coverage (UHC) in their socio-economic development program. However, in the wake
of the 21st century, innumerable roadblocks are hindering the paths of not only Mauritius
but virtually all countries towards achieving UHC.

A systematic review conducted by Darrudi et al (2022) concluded that a lack of

administrative coordination related to stewardship, insufficient human resources related
to creating resource, a lack of financial support related to financing and unregulated
along with fragmented healthcare delivery systems related to delivering services were
the most common challenges on the road toward worldwide UHC. However, the 3 most
frequently mentioned challenges were inconsistencies within the structures of the health
ministries and their related facilities, insufficient human resources and a lack of financial
support. Results of this study are on the same lines with those of other studies and are
applicable even in the Mauritian context. In addition, a review carried out by Ranabhat
et al (2020) found that a strong governance and leadership, a resilient health system,
adequate healthcare resources along with a strong financial risk protection are sine qua
non for achieving UHC.

UHC is multidimensional and encompasses legal, political, health, and socioeconomic

systems and agendas. Laying the blame on one or two reasons behind the poor

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coverage of UHC is futile. What is critically important is the examination of challenges
related to UHC from various angles. Then only would we be able to grasp the issue
entirely and take resolute steps towards tackling any impedance with regards to
achieving UHC.

Health-care financing and financial risk protection

Health care financing and financial risk protection form the core of UHC upon which lies
the ability of health systems to respond to peoples’ legitimate demands for quality health
and care services along with improving outcomes. Financial risk protection (FRP),
defined as the ability to consume needed quality healthcare services without
experiencing undue financial hardship, is one of the critical components of (UHC). In
Mauritius, General government health expenditure (GGHE) accounts for approximately
2% of GDP and 10% of general government expenditure. Notwithstanding free
healthcare and relatively hefty government health expenditure there are major areas of
concerns. According to a 2021 WHO report, Mauritius is witnessing a relatively high
amount of out-of-pocket (OOP) expenditure on health, ranging from 49% to 52% as a
share of current health expenditure. In absolute terms, OOP expenditure on health per
capita rose from US$205 in 2012 to US$293 in 2017. Secondly, incidence of
catastrophic health expenditure due to OOP (at 10% of household total income)
increased from 6.52% in 2006 to 8.85% in 2012. This trend was also noted among the
two poorest quintiles of the population (rising from 2.08% in 2006 to 3.24% in 2012 for
the poorest quintile and from 2.95% in 2006 to 5.46% for the second poorest quintile). In
addition, Nundoochan et al (2019) argue that impoverishment due to OOP based on
international poverty line of US$3.1 daily among the poorest quintile has risen from
1.01% in 2006 to 1.45% in 2012. According to Musango et al (2020) a significant
proportion of OOP spending is linked to the purchase of pharmaceuticals from the
private sector as there is a general wrong perception that generic drugs in the public
sector are substandard. Generic medicines in the private sector are generally sold at
4.87 times their international reference price. Furthermore, a 2019 WHO report states
that innovator brand medicines are generally sold at 10.25 times their international
reference price, thus posing a challenge to progress towards UHC by 2030. In light of
the above, more stringent regulatory mechanisms with regards to pricing of medicines in
the private sector become a pressing priority to counter future detrimental impacts on
the poor of our country. The policy announcement made by the Mauritian government to
consider the introduction of a voluntary health insurance scheme for public employees,
where the Government will pay 50% of premium in favor of civil servants, is a positive
step towards financial risk protection. However, in order to ensure that our population as
a whole do not face any financial hardships, more solid steps are a necessity.

Increasing public financing through tax reforms, prioritizing allocation to health and
exploring innovative financing mechanisms (including ring-fencing tobacco and alcohol
“sin taxes” for health) for the health sector with a special focus on ensuring progressive
coverage with quality and affordable health services are much needed. Ensuring the
monitoring of financial risk protection as part of the SDG reporting framework requires
reliable and periodic household surveys that contain information on health-specific and
other expenditures. While household budget surveys have been institutionalized and
are conducted every 5 years in Mauritius, an important lacuna, however, is that not
much provision is made for analysis of health expenditures and utilization of health
services in both public and private sector. The country should take necessary actions by
increasing investments in ensuring the availability of data and strengthening analytical
capacity for monitoring financial risk protection. Then only would robust economic
analysis be possible and consequently informed budget allocations and wiser resource
allocation decisions would be made. Promoting and implementing policy, legislative and
regulatory frameworks to enable adequate, predictable, and timely flow of resources to
the front-line/service delivery level where they are most needed is yet another crucial
component of health financing and financial risk protection. Where appropriate,
duplication across resource pools should be limited so as to maximize efficiency and
ensure equitable allocation of health spending to deliver cost-effective, essential,
affordable, timely and quality health services. Intersectoral action to promote increased
social protection in our country with health insurance coverage implemented as part of
the broader social protection frameworks should be prioritized. Mandatory health
insurance schemes should be given due importance as they can raise adequate pools
and ensure risk sharing. Improving the targeting of benefit packages to meet the health
needs of elderly and multigenerational households would be another critical step in
reducing financial hardship, especially for the poorest and most vulnerable segments of
elderly populations. Moreover, in order to ensure that Mauritius achieves success in
protecting its people financially, WHO should continue to provide its support in
strengthening institutional capacity of the national government authorities to design,
implement and monitor health financing reforms for UHC consistent with national
sustainable development strategies along with monitoring progress of these reforms
using country-specific analytics and intelligence.

According to a report from the Ministry of Health and Wellness (2020), in a post-Covid-
19 environment marked with bleak economic growth prospects and rising healthcare
costs, health budgets are increasingly stretched to their limits in order to reconcile
competing needs, thus the key objectives to promote equitable and sustainable
financing for health as well as improve efficiency in the allocation and utilization of
resources. At the core of the pursuit of efficiency in health spending is ensuring value
for money through priority setting processes. However, according to WHO, value for
money is not the sole panacea as what is equally important is understanding and
addressing what patients and the population at large consider most important in relation
to health-care. Adopting a shift from value for money to that of a value-based health
services approach will imply health improvements at the patient level. Responsiveness
of the health system to patient needs, financial protection, efficiency and equity would
ultimately lead to achievement of UHC objectives namely equitable access to quality
healthcare and financial protection.

Healthcare financing and financial risk protection are integral aspects of UHC which
cannot be neglected at any cost. A comprehensive approach should be adopted with
respect to these pivotal components, without which the path towards UHC becomes
even more arduous.
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Strengthening Primary Health Care Systems

Primary Health care (PHC) is at the heart of achieving UHC. As discussed by a WHO
report (2022), PHC itself is estimated to account for more than 75% of the projected
health gains associated with attaining SDGs and more than 90% of health services
under comprehensive UHC. Evidence gleaned in sub-Saharan Africa of limited pro-poor
distribution at the PHC level prompted to conclude that health reform undertaken to
bolster PHC has not influenced service utilization by the poor. As PHC system of
delivery may not respond to the real needs of the poor, the latter resort either to hospital
services, turn to private providers or, worse, refrain to request for healthcare. According
to Rockers et al (2010), investment in PHC in many sub-Saharan Africa countries falls
well behind that of hospital services. Mauritius is no exception. Nundoochan et al (2020)
state that government hospital services expenditure, including investment, represented
almost 70% of general government health expenditure in [Link] promote greater
value for money, from an equity and efficiency perspective, a fundamental shift in the
allocation of government resources in favor of PHC is critical. Musango et al (2020)
argue that PHC needs to be better designed to meet the needs of the poor. An
assessment of health systems performance in Mauritius revealed that inefficiency
inherent to the PHC in Mauritius hampers provision of preventive services, early
diagnosis and treatment for those living with NCDs, as reported by an NCD survey in
2018. Wagstaff et al (2008) further add that several dysfunctions with the referral
system were also flagged. These included patients with non-complicated NCD ailments
circumventing the PHC providers to head straight to secondary or tertiary health
facilities for care, inadequate consultation time in PHC centers and paucity of preventive
services for a significant segment of the population in pre-diabetes and hypertensive
stage. Ensuring availability of health services is not a panacea on its own. The solution
lies in tackling the factors that impede the quality of healthcare with people-centered
health services as this will ensure that sufficient benefits are delivered to the poor.
Moreover, an integration of evidence into practice, the use of explicit priority-setting
approaches, efficient utilization of information & technology along with population
empowerment and adequate distribution of human resources would further strengthen

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the Mauritian population’s trust in our PHC. Should the PHC system in our country
undergo changes in the positive direction, achieving UHC in its integrality would no
longer remain an unattainable objective.

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Challenges in the eventuality of a pandemic
The Covid-19 pandemic has shown the world that a fundamental change in health
systems cannot wait, lending even greater urgency to the quest for universal health
coverage. In the space of two years, this deadly virus has spread to more than 190
countries affecting more than 800 million people worldwide and claiming nearly seven
million lives. It has also brought home the importance of basic public health, strong
health systems ,emergency preparedness along with the resilience of a population in
the face of a new virus or pandemic. Moreover, the probability of a pandemic with
similar impact to Covid-19 is set to increase three-fold in the next few decades due to
increasing risk drivers such as urbanization, climate change, land-use changes, fragility
and conflict along with zoonotic spillovers, thus considerably undermining herculean
efforts made during the last decades across nations. Mauritius is one such country that
has not been spared by Covid-19 and whose effects are still being felt by the nation’s
health system. Ensuring adequate supply of protective equipment, laboratory testing,
therapeutics, mechanical ventilators, isolation of confirmed or suspected cases, contact
tracing and treatment for severe illness and just dealing with the sheer number of
COVID-19 cases have been a daunting experience for Mauritian authorities. The
additional patient load caused by COVID-19 have disrupted the provision of other
essential health services. As a matter of concern, those who missed out on essential
health services were mostly those belonging to poor and disadvantaged groups with
poorer access to services. Moreover, this pandemic has negatively affected outcomes in
people with noncommunicable diseases through delays in diagnosis of
noncommunicable diseases, such as cancers and heart disease among others,
resulting in more advanced stages of disease. Delays in seeking care for heart attack,
stroke and cancer have also been reported in some countries including Mauritius.
UHC cannot not take a backseat in the event of a future pandemic similar to Covid-19.
National health plans should be updated in light of COVID-19, to ensure that
preparedness and response capacities are integrated into health systems’ support as
well as government preparations. Key global donors should be actively involved in
supporting Mauritius’ efforts to strengthen its health system so as to achieve health
security and sustain progress toward universal health coverage. Moreover, to minimize
morbidity and mortality, Mauritian officials should ensure that priority health services are
delivered during the acute phase of any pandemic. Investing in core health systems
functions that are fundamental to protecting and promoting health and well-being,
known as “common goods for health” is another aspect of UHC upon which the
Mauritian government should start taking concrete actions. Having these functions in
place is integral to the commitments that Mauritius made in the Political Declaration on
Universal Health Coverage in 2019 which include policy coordination, surveillance,
communication, regulation for quality products, fiscal instruments, and subsidies to
public health programs. COVID-19 has once again reinforced the importance of taking

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on-board local communities, affected populations, relevant stakeholders and
organizations, civil society along with the private sector. Should the above measures be
implemented, the day when the Mauritian health system would be able to face any
major health threat without jeopardizing UHC is not far.

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Governance and Leadership
Governance and leadership are at the helm of sustaining adequate healthcare
financing, building resilient healthcare systems and strategizing ways to provide
equitable healthcare access. As of 2017, only 38% of the WHO member nations passed
legislation on UHC, reflecting a limited leadership commitment. Without effective
political, economic, and administrative governance, the resiliency of health systems
cannot be enhanced especially in the post-pandemic context. Specifically, as countries
struggle with climate change, economic downturn, energy crisis, global uncertainties,
and internal issues, a sustained political commitment is essential to continue
investments to strengthen health systems. As per the latest data available, the countries
such as Bangladesh, India, Pakistan, Ethiopia, and Nigeria spend less than 5% of the
general government expenditure on health. According to WHO (2021), General
government health expenditure (GGHE) in Mauritius accounts for approximately 2% of
GDP and 10% of general government expenditure. The need for a sustained strong
leadership in Mauritius is over-riding. UHC is a long-term goal. Though the Mauritian
government has displayed a strong leadership and is taking concrete steps towards
achieving UHC, the latter is a goal upon which long-term actions have to be taken and
not limited to a span of five or ten years. Successive governments have to give equal
importance to UHC. In addition to financial investments into healthcare systems,
mechanisms are required to ensure efficient use of the available resources. Corruption
in the governance architecture and healthcare systems is a significant challenge
hindering UHC. According to Transparency International’s 2022 Corruptions
Perceptions Index, Mauritius scored 50 on a scale from 0(Highly corrupt) to 100(very
clean). This score is not flattering at all. The onus of annihilating corruption lies first and
foremost on our political leaders.  Lack of accountability, poor health resource
management and unequal power in healthcare decision-making, which negatively
impacted progress toward UHC in numerous countries, cannot be tolerated and should
be severely condemned by local authorities. Moreover, another significant challenge to
achieving UHC is an unequal distribution of healthcare services to socially and
economically vulnerable populations. Despite the longstanding awareness about the
impact of social inequalities in influencing individual health status and access to

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healthcare, the priority given to social determinants should have been much more, in
light of the post covid-19 situation. Social protection nets should have been continued
for a longer period to allow better recovery of poorest households. Moreover, a multi-
sectoral perspective should be adopted with regards to numerous determinants of
health and tackle each one individually.

Without a strong political leadership, achieving UHC would be a far-fetched dream.

Good governance strategies, including but not limited to leveraging technology, inter-
sectoral coordination, context-specific health policy, equitable financing modalities and
increased transparency are needed to improve progress toward UHC. Moreover,
creating quality leadership within healthcare human resources would be an added
bonus in improving healthcare systems’ long-term resilience and facilitate achieving
UHC.

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Challenges to Building Resilient Health Systems

Health systems are at the core of achieving the target of UHC by ensuring equitable
access to essential healthcare services. Resilience can be defined as the health
system’s ability to anticipate, absorb, adapt, and recover from significant shocks and
health emergencies. According to Abimbola et al (2021), climate change, emerging and
re-emerging diseases, natural disasters, epidemics, and human-caused disasters
highlight the need for resilient health systems which can withstand and adequately
respond in-face of crisis events. Building resilience requires investments in the health
workforce, infrastructure, processes, leadership, and governance backed by sustained
healthcare financing. Developing countries in Africa and Asia need more health
workforce in terms of trained doctors, nurses, specialists, pharmacists, and other
healthcare professionals. Karan et al (2021) state that India, with close to 18% of the
world’s population, has less than 11 qualified doctors and nurses per 10,000 population,
far below the WHO threshold of 44.5. The majority of African countries have a health
worker density less than 1/3rd of the WHO threshold. Mauritius, according to a 2023
WHO report has a ratio of 30 physicians for 10,000 persons. This is a result which
needs immediate remedial actions. The chronic shortage of the health workforce in the
country is argued to be a stumbling block in achieving UHC. Investments in recruiting,
training, and retaining trained health workforce become essential to building resilient
healthcare systems. Healthcare infrastructure, policies, and processes are another
important aspect in ensuring health systems’ resilience. Eight of the 12 major countries
with a population of 100 million or more have less than 11 hospital beds per 10,000
population. Despite the awareness that a chronic shortage of hospital beds could be a
challenge in a primary health emergency, most healthcare systems are underprepared.
Most African countries including Mauritius depend largely on importation of essential
medical and pharmaceutical supplies. In addition, though progress is being made, more
needs to be done in improving accessibility, availability of technology and built space in
the Mauritian health sector. In view of the above, building self-reliance in healthcare
capacities, essential medical supplies and consumables along with enhancing

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accessibility and technological use become essential components for the Mauritian
health system resilience on which more actions need to be taken if positive strides
towards UHC are to be made.

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Epidemiological and Demographic Challenges

There has been a paradigm shift in the disease burden with NCDs, injuries, and mental
health issues accounting for the majority of the disability-adjusted life years (DALY)
globally. The epidemiological transition is more rapid in developing countries,
characterized mainly by a substantial rise in chronic noncommunicable diseases. A
2020 WHO report states that Mauritius is currently at an advanced stage in its
epidemiological transition with the demographic status being marked by a rapid ageing
population while total fertility rate is below replacement level. On the other hand,
noncommunicable diseases (NCDs) and Injuries in Mauritius are estimated to account
for 84% and 7% respectively of total burden of disease. CVDs are the main cause of
death (33.2%) followed by Diabetes (predominantly of type 2) and Cancer responsible
for 23.5% and 12.8% of total deaths, respectively, in 2016. An intersectoral
coordination, consolidation of Primary Health Care as a hub for NCD care, community
empowerment, continuity of care, coordination across providers, patient centered care
and putting in place mechanisms for prioritizing public health budget allocation become
a must. Furthermore, a formal sector-wide approach mechanism in place to align and
harmonize technical and financial support between the government and all the
development partners in the health sector should be worked upon by Mauritian
authorities. Rising per capita income, coupled with favorable health indicators, has
impacted on Mauritius’ eligibility for external aid, especially for the health sector.
Presence of development partners in Mauritius remains limited. External resources as a
percentage of total health expenditures accounted for an average of 2.4% for the period
2007-2011. As a result, sources of technical assistance and grants to the health sector
which come currently from WHO and other UN Agencies along with the Global Fund to
fight AIDS, TB and Malaria, should be increased. A successful implementation of the
above-named measures would prepare Mauritius for any epidemiological and
demographic challenge and as a result, set our country on the right path towards
achieving UHC.

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CONCLUSION
In the words of former WHO Director-General Dr Margaret Chan, ‘’Universal Health
Coverage is the single most powerful concept that public health has to offer. It is
inclusive. It unifies services and delivers them in a comprehensive and integrated way,
based on primary health care’’. Mauritius, by putting UHC high on the priority list, has
made huge strides in the health sector and is often cited as an example on the
international arena. However, several challenges have come to light which threaten to
wash away efforts made during decades. Saying that a collaborative approach is
required would be an understatement. At this particular moment not only the health
sector but the Mauritian society as a whole, should come forward and take concrete
actions to vanquish any potential threat. Then only would we succeed in sustaining
UHC irrespective of the magnitude of the challenge.

RECOMMENDATIONS

1)Sufficient revenue should be raised for health system financing, and the efficiency of
revenue utilization should be improved. Coverage for the very poor should be provided,
and the proportion of the population that is underinsured should be reduced. Access to
quality healthcare in rural areas should also be improved.

2)Policymakers must develop and adopt national health financing systems to provide
financial risk protection.

3)Government stewardship, stakeholder support, and fair contribution and distribution of

resources by appropriate health financing modalities should be undertaken.

4)General revenues should be used to fully cover the informal sector, or a combination
of tax subsidies, non-financial incentives, and contributory requirements should be
devised and implemented.

5)An integrated dynamic UHC system that is adaptable to a rapidly developing society
should be developed to provide an affordable and sustainable path toward healthcare
for all.

6)Movement toward UHC should be established as a long-term policy engagement

requiring both technical knowledge and political know-how.

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7)UHC schemes should be designed to cover the entirety of a country’s population,
including those in poverty in addition to those with higher income levels using special
strategies.

8)The role of strategic purchasing when working with powerful private sector entities,
the effects of federal structures, and the implications of investment in primary healthcare
as a foundation for UHC should be explored

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