Financing UHC for adolescents
The way that health services are financed is central to progress towards UHC. For adolescents three aspects of financing are crucial:
- maximizing the number of adolescents covered by an effective prepaid pooling arrangement, which can take the form, for example, of an explicit insurance programme or access to facilities that are financed by prepaid pooled funds;
- reducing or removing out-of-pocket payments at the point of use;
- expanding the range of services covered by the effective prepaid pooling arrangement to include the services in the country’s package for adolescents.
Covered by an effective prepaid pooling arrangement?
Currently, there are a variety of prepaid pooling arrangements for adolescents. In high income countries particularly, adolescents are likely to be covered. Where a system provides explicit benefits to enrolees through a traditional insurance mechanism, adolescents may be enrolled as children within a family (many schemes cover children up to age five years and sometimes up to 18 years), as employees (when eligibility depends on employment status), or as students (in school-based schemes).149 This means that adolescents are less likely to be covered if they are not in school, older than 18, not employed or in low-income households, since poor families are less likely to be insured. But effective prepaid pooling arrangements can take other forms besides the traditional insurance system that links entitlements to contributions; for example, access to health-care providers in adolescent-responsive health services without financial hardship can be achieved by directly funding these providers through prepaid pooled funds (e.g. general tax funds). Many countries fund their general health services through effective prepaid pooling arrangements of this nature. Additionally, it is imperative that there is adequate subsidization from other groups for health care for vulnerable adolescents and their families. However, it is important to keep in mind that adolescents without birth registration or who are undocumented immigrants may not be eligible for any programme.150
multiple countriesPaying out-of-pocket?
Requiring direct payments generally decreases health services utilization.151-154 Additionally, paying out-of-pocket for health care can cause severe financial hardship. Worldwide, an estimated 100 million people are impoverished due to out-of-pocket payments for health care.155
For adolescents the impact is made worse by their limited capacity to access services independent of their parents156-159 and their limited access to cash, either their own or their family’s.160 Indeed, in the WHO global consultation very few (6%) adolescents indicated that they pay out-of-pocket for health services; many (45%) named their parents and/or family members as the principal payers of their health-care costs. Adolescents’ access to scarce family resources depends on the priority that is given to their health care. Depending on the culture, the family may consider care for a younger child more important.161-164
independent serviceFor adolescents responding to the WHO global consultation, cost and poor access were the top two reasons preventing them from using health services. In many countries, particularly middle and high income countries, existing schemes may make exemptions or reduce co-payments for children and adolescents.165-174 Facilities must be monitored to ensure that these policies are observed. Health-care vouchers given to adolescents can be another way to improve their access by reducing or eliminating out-of-pocket payment.175
payments on useAre priority services for adolescents covered?
From the UHC perspective it is important that prepaid pooled funding arrangements cover the services needed by adolescents. In reality, mainstream health services provide some but not all services important for adolescents. For example, antenatal care is usually covered, but abortion or contraception (for adolescents) may not be. Some services are covered only if the country recognizes their importance—for example, harm reduction programmes for users of intravenous drugs. Some other interventions that may be important to adolescents may not be seen as a priority for this age group (e.g. tobacco cessation counselling).176
Paying for contraceptionIt is also important that mechanisms for paying providers are aligned with the needs of adolescents. For example, any scheme that requires others (often parents) to pay for adolescents’ care risks breaching confidentiality. In the United States of America, even when adolescents are legally allowed to receive some services without parental consent, itemized bills sent to parents can breach confidentiality.177
Also, mechanisms for paying providers must align with defined standards of quality. Financial incentives to health-care providers are rarely linked to services to adolescents. For example, in the United Kingdom only four of the 128 Quality and Outcomes Framework indicators for additional financial incentives for general practitioners relate specifically to children and adolescents.178 Among the primary care providers in the WHO consultation who reported receiving financial incentives for certain services to the general population, only 13% indicated that services for adolescents are specified in the list of services for which they receive extra pay. At the same time, financial incentives to providers need to be designed in a way that limits perverse incentives (e.g. inadvertently discourage provision of the services).
I am scared of the gynecologist, I know I have to go one day, but the idea terrifies me.
female, 18-19, France
Adolescents on what stops them from using health services: Lack of financial resources and lack of access to good treatment.
male, 18-19, Morocco
There is a lack of information about how to reach health services. For example, I just recently found out that my school has a nurse - two years after getting there!
female, 18-19, Peru
Health risks are so high that services don’t have enough resources. Also the doctors are difficult to access. There are few doctors for many illnesses.
male, 18-19, Burundi
In order to have to see specialists, I would need my parents' approval. However, asking them to see a nutritionist or counselor would make them worry.
female, 15-17, United States of America
The only problem I really want to see anyone about is, ironically, my anxiety. I intend to seek therapy after leaving home as it's meant to be extremely good. That being said, I am surprised that the NHS doesn't offer general health check-ups - nobody has ever checked to see if I am suffering from symptoms unless I bring it up myself.
male, 15-17, United Kingdom
Adolescents on what can be done to improve health services: That there be more places that offer free services as it is very necessary.
female, 18-19, Mexico
Adolescents are not able to pay for themselves and have to be dependent on parents for consultations.
female, adolescent physician, India
Improve public education and the way in which health is taught. Improve public hospitals. To have a kind of place of care or assistance where youth can go without involving parents.
female, 15-17, Mexico
I use free healthcare services offered by the government. So nothing gets in the way of me using those services even if they’re not necessarily the best, I am just happy it’s an option because I don’t have the means to pay at a clinic.
female, 18-19, Mauritius
Long distance from the health center, lack of information on available health services and lack of money to pay for health services like STI's treatment.
female,18-19, Uganda
The demand for services at community health centers is far too high, which quickly becomes exasperating, and the services are terrible. The government spends more money on guns for the army than on the well-being of its population.
male, 15-17, Guatemala
If I want to go to the gynecologist for any given reason, I can't go because it would show up in insurance. I can't get birth control pills, for example, because it would show up on insurance, and there's no free clinics nearby.
female, 18-19, United States of America
Adolescents on what can be done to improve health services: Greater flexibility and efficiency during emergencies and routine appointments, of any kind in public hospitals. Better equipment, medications in schools, more efficiency when distributing medications in hospitals, and also warmth and patience with patients.
female, 18-19, Mexico
I may not be able to improve my sexual life (as I want to be a girl) because I live in a small town with a population of approximately 25,000, and there are no experts on this subject.
trans, 12-14, Argentina
Adolescents on what can be done to improve health services: Educate more doctors and reinforce their competences, construct more sanitary infrastructures and equip them with modern healthcare materials.
male, 18-19, Burundi
Education of adolescents is important - they don't know the services available to them.
female, general practitioner, Australia
Delays in public services, like at the hospital; often they attend to your needs but it’s already too late, and they can be very rude, which is psychologically damaging.
female, 18-19, Mexico
They usually scold me when I go to clinics, saying that I am too young to have sex or ask for condoms.
male, 15-17, Mexico
My mum would have to know, and I am not comfortable with that.
female, 12-14, United Kingdom
I am an adolescent clinical nurse specialist and work exclusively with adolescents. However I do not have the time or resources to see them all. System problems stop me from seeing all patients.
female, nurse, United Kingdom
Adolescents on what stops them from using health services: Fear, distance, not being aware that they are available in your region, language barriers.
female, 15-17, Switzerland
Adolescents on what can be done to improve health services: To be allowed access to health services without being judged.
female, 18-19, Mexico
Adopt a system of universal healthcare, because if society possess both systems, the private system will have the tendency to look at patients as though they were clients.
male, 15-17, Canada
Linking organizational and delivery of care to payment might raise the profile and lead to better care being offered. QOF drives care in the UK to a large extent and if youth health is absent from the QOF be default it is off the radar.
female, general practitioner, United Kingdom
Adolescents on what stops them from using health services: In my country, the high levels of disorganization, the lack of resources. The lack of time, as there are big lines for getting medical attention that start forming extremely early in the morning.
male, 18-19, Peru
Community people are conservative minded; services in the health centre are not sufficient.
male, community health worker, Bangladesh
Adolescents on what stops them from using health services: Time, because there are too many people in health clinics and few doctors, meaning the waiting times are long, and I honestly don’t have the time to wait.
female, 18-19, Mexico
The cost. Also the hours and availability. Calling only to find out you can have an appointment in six months, it’s discouraging.
female, 18-19, Switzerland
Adolescents on what can be done to improve health services: Make access to psychiatric services easier because in my opinion, it is vital to see a psychiatrist when you are an adolescent.
female, 18-19, France
Adolescents on what stops them from using health services: Negative and judgmental attitudes of health care providers, long waiting periods, lack of trust in diagnosis (especially for elective counselling i.e.: pill pushers due to pharmaceutical company endorsement), expensive.
female, 18-19, Romania
