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Universal Health Coverage Simulation Manual IFMSA 2019

IFMSA Imprint Executive Board Batool Al-Wahdani Nebojša Nikolic Ahmed Taha Ivan Fabrizzio Canaval Diaz Georg Schwarzl Marian Sedlak José Chen Coordinators Tanya Zebrova Katja Cic Idil Kina Omnia El Omrani Kanchana Bali Maha Rehman






Students’ Associations (IFMSA) is a non-profit, non-governmental



associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 136 National Member Organizations from 126 countries across six continents, representing a network of 1.3 million medical students. IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so to shape a sustainable and healthy future. IFMSA






organization within the United Nations’ system and the World Health Organization; and works in

Publisher International Federation of Medical Students’ Associations (IFMSA) International Secretariat: c/o IMCC, Norre Allé 14, 2200 Kobenhavn N., Denmark

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collaboration with the World Medical Association. This is an IFMSA Publication


© 2019 - Only portions of this publication may be reproduced for non political and non profit purposes, provided mentioning the source.

All reasonable precautions have been taken by the IFMSA to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material herein lies with the reader.

Disclaimer This publication contains the collective views of different contributors, the opinions expressed in this publication are those of the authors and do not necessarily reflect the position of IFMSA. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the IFMSA in preference to others of a similar nature that are not mentioned.

Some of the photos and graphics used in this publication are the property of their respective authors. We have taken every consideration not to violate their rights.


Foreword Page 4

What is a UHC Simulation? Page 5

What is a Health System? Page 6

UHC at a glance Page 7

Structure of a UHC Simulation Page 8

Settings Page 9

#1 Home #2 Healthcare Facility

#3 Pharmacy #4 Insurance Company #5 Miscellaneous Settings Participants Page 14

Action Cards Page 16

General Organisation Page 17

Materials Page 17

Evaluation Page 18

Foreword One of IFMSA Global Priorities for the upcoming years is Universal Health Coverage (UHC). To answer the two main questions: “What is UHC?” and “How can we bring this idea to our members and generally to the students?”, we came up with an idea; we decided to create an interactive game which will help members understand the complex details that make up the aspects of Universal Health Coverage. It will additionally teach them the social determinants of health and healthcare systems of different countries, how they affect access to healthcare and how they can meaningfully contribute to UHC implementation. We hope that by providing you with a real-life simulation with your own experience yourselves via role-playing, we can bring UHC closer to you. Whether you’re a facilitator or a participant, we hope this simulation will inspire you to create solutions for achieving UHC worldwide. In this manual, you will find all that you need in terms of materials and guidelines on how to use them and facilitate each setting. We hope you will find them useful! Feel free to improvise a little bit, the more you act, the better it feels! And don’t forget to fill in the pre- and postevaluation forms. Also, feel free to give us your feedback; we are here for improvement and development, so let’s make this simulation better together! Your SWG coordinators, Omnia, Kanchana, Maha, Katja, Tanya and Idil


UHC Simulation Manual

What is a UHC Simulation? UHC Simulation is an interactive game aimed to explain the different components of UHC to participants through real-life situations encountered on a daily basis by the population. There are 4 basic aspects of the simulation: 1. Situation of the country 2. Settings 3. Roles of the participants and their current status 4. Action Cards: daily responsibilities and unexpected situations To ensure that you make the most out of our manual and effectively conduct the UHC simulation, we aim to: ● Guide simulation facilitators through all the steps of implementation and accomplish the objectives of each phase of the simulation; ● Explain all the tips and tricks of the simulation, what facilitators should be aware of and what participants should be informed of; ● Provide all the materials needed for the simulation as an annex to the manual, such as: ○ Handouts for participants, ○ Resources for facilitators. The UHC Simulation has 4 standardized phases: 1. Introduction: Explain the steps of the game and situation of Country X. Lead participants to their 1st starting point: Home. 2. Home: Participants receive their roles (i.e. mother and 2 children) and receive their first action card. (i.e. child broke his leg and needs to go to the hospital) Participants go to the relevant setting and then go back to their home setting for a new action card. 3. UHC Bill: After 30-45 minutes, the main facilitator will stop the session to make an announcement: “Country X just passed a new Universal Health Coverage bill, where the government will provide citizens with quality health coverage funded by the taxes paid by them, as not to put citizens through any financial hardship.” 4. Repeat: Participants will go back to the Home setting to start and get their first action card and then repeat the same cycle for another 30-45 minutes.


UHC Simulation Manual

What is a Health System? The main goal of this simulation is to explain what a health system is and give participants an idea about different models of healthcare systems. Here is a brief overview of the structure of a health system and its different variations. The World Health Organization defines health systems as follows: "A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health." This includes efforts that have a direct impact on health improvements (e.g. a mother taking care of her sick child at home) to influencing determinants of health (e.g. insurance and safety legislation). A good health system delivers quality services to all people, when and where they need them. Simply put, it is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations. Characteristics of a good health system: 1. Delivers quality services to all people 2. Robust financing mechanism 3. Well-trained and adequately paid workforce 4. Reliable information to base decision-making 5. Well-maintained facilities and logistics There are four main types of different healthcare systems: 1. The Beveridge Model This is where the government is responsible for financing and providing health care through taxes. Examples of this include the National Health Service (NHS) in the UK. 2. The Bismarck Model This system is financed by funds paid partly by employers and partly by employees through a payroll deduction using mainly private hospitals and private working doctors. It uses private insurance agencies, also known as “sickness funds�, and are run as nonprofits. This model can be found in France. 3. The National Health Insurance Model This system combines aspects of both Beveridge and Bismarck, with healthcare primarily paid through higher taxation. An example of this can be found in Japan. 4. The Out-Of-Pocket Model This system is essentially market-driven, in which individuals are either covered by their employers or themselves or they go without coverage at all like India. This system can be found in places with too few resources to set up mass medical care.


UHC Simulation Manual

Facilitator Tip #1: Involve participants by asking them to define a health system and to identify which model do they think that their country adopts.

UHC at a Glance This simulation aims to introduce and explain the concept of universal health coverage to the participants and how that can be achieved through a health system so here is some information that you need to know. What is Universal Health Coverage (UHC)? Universal Health Coverage (UHC) means "all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship." UHC is firmly based on the WHO constitution of 1948 declaring health as a fundamental human right and on the Health for All agenda set by the Alma Ata declaration in 1978. UHC cuts across all of the health-related Sustainable Development Goals (SDGs) yet Over 800 million people (almost 12% of the world’s population) spent at least 10% of their household budgets to pay for health care. What are the objectives of UHC? 1. Equity in access to health services. 2. The quality of health services should be good enough to improve health. 3. People should be protected against financial risk. Can UHC be measured? Yes! It can be done by looking at two aspects: 1. The proportion of a population that can access essential quality health services. 2. The proportion of the population that spends a large amount of household income on health.


UHC Simulation Manual

UHC does not mean free coverage for all possible health interventions, regardless of the cost, as no country can provide all services free of charge on a sustainable basis, UHC enables everyone to access the services that address the most significant causes of disease and death, and ensures that the quality without financial burden. Facilitator Tip #2: Ask the participants 1) What is UHC and 2) What do they know about it

Structure of a UHC Simulation


UHC Simulation Manual

Settings In this simulation, the participants will rotate between different settings where they will be given different choices and must make decisions, taking into consideration their circumstances explained in their role cards. The first and most important setting is “home”. At home, participants will be receiving action cards, which serve as the backbone of the simulation. Each action card asks the participants to do something (e.g. getting insurance, buying food, going to the doctor etc) and the actions take place in different settings. (e.g. the insurance office, grocery shop, hospital etc).

Setting #1 - Home This setting is the starting point for the participants. Here they have to decide on many important issues that affect their health and well-being. They will have to decide what kind of food to get for themselves and their family, how and where they want to live, how they should get to work or what school their kids should go to. If you as a facilitator want to go further and make the game a bit more realistic, you can include ‘Immunization Points’. These points get rewarded to the participants when they make a choice that benefits their health and well-being. For example, buying food for a well-balanced diet is more expensive, but will earn them immunisation points. Those points, in turn, can protect them from dangers (e.g infections) that they might have to face in the action cards. If you would like to implement the immunisation point system, and have a more detailed breakdown of how you, as a facilitator, can make this simulation more realistic, you can find it in the outline here.


UHC Simulation Manual

Setting #2 - Healthcare Facility A: Hospital Admission The participants will come to this setting after they leave home. In the first round (Country A), the facilitator in the admission should not be very kind and cheerful. They have to pay expensive registration fees for procedures and have to wait for a long time before going elsewhere, such as emergency room, pharmacy, the insurance company or home back. If the participants don’t have enough money, they will not be able to reach health care services in the hospital. In the second round (Country B), the facilitator in the admission tries to help as far as possible and they should be kinder. The participants don’t wait very much to reach the doctor and they don’t need to pay very much for registration/ procedures; therefore, the participant will be satisfied in this round. Even if they don’t have enough money they can reach health care services, because most of the services are free in this country with universal health coverage. In both rounds, the facilitator directs the participants according to action cards.

B: Emergency Department The participants come to this setting with emerging cases. In the first round (Country A), the facilitator in the emergency room makes the patients/ participants wait and, in some cases, they even cannot reach these services. In this health system, patients have to pay much money to reach emergency services, even if they have an urgent situation. In the second round (Country B), the facilitator in the ER tries to help them as quickly as possible, and avoids making the patients wait. Participants/patients don’t need to pay any money for emergency care services because Country B has universal health coverage. In both rounds, the facilitator directs the participants according to action cards.

Setting #3 - Pharmacy The participants will have to come to this setting if they need medication or other medical supplies. The setting is very different in the two scenarios when it comes to waiting time and stock of medicines. Without UHC, antibiotics might not be available and the waiting hours tend to be longer. Participants have the choice to buy antibiotics for example - if they choose not to, they will fall ill and miss work for several days. They can also get vaccinations in the pharmacy to stay protected from infections that wait for them in the action cards.


UHC Simulation Manual

Setting #4 - Insurance Company The participants will come to this setting from home or the hospital. In the first round (Country A), the facilitator in the Insurance Company should not be very kind and cheerful and offer them expensive insurance services which the participants can buy only if they have enough money. In the second round (Country B), the facilitator in the Insurance Company will be helpful and they don’t need to sell insurance services because participants who are people of the country with universal health coverage already have insurance for health care services. They only pay a little in hospitals and it’s just for the procedure. In both rounds, the facilitator directs the participants according to action cards.


UHC Simulation Manual

Setting #5: Miscellaneous Settings A: Immigrants Office The participants will come to this setting from different countries as refugees. In the first round (Country A), the facilitator in the Immigrants Office should not be very kind and cheerful. They should explain the health system of Country A but don’t help them very much about reaching health services and getting health insurance. In the second round (Country B), the facilitator in the Immigrants Office will be helpful. They should explain the health system of Country B and help them about reaching health services and getting health insurance. In both rounds, the facilitator directs the participants according to action cards.

B: Grocery Shop Participants, like every human being, will need to eat throughout the simulation. It is well known that locally produced, ecological and healthy food is more expensive than fast food. Fruit





Scenario A

10 €

20 €

10 €



Scenario B


10 €





UHC Simulation Manual

C: Job Office for Unemployed In the job office for unemployed participants will have to pick from different options in both scenarios the earnings will be the same. In the first round (Country A), we encourage facilitators to be more hostile, to have long waiting queues, to explain poorly the jobs and to add drama to their acting. In the second round (Country B), we encourage the facilitators to be friendly, easy-going and helpful and to solve all the doubts and questions the participants might have. Job



Construction worker at the new tunnel project outside the city

The working hours are irregular with high noise and lifting but the salary is high. One great benefit is that you will have medical insurance since it is a risky job.


Part-time at the ice cream store in the neighbourhood

The manager is very flexible with the working times and the income is average. We can plan around your studies and make a schedule that will work for you.


Bus boy at a local restaurant nearby

They can’t offer that many working hours and the salary is not that high but at least you get some income and you can start work in this place to improve your CV for future opportunities.


Facilitator Tip #3: We recommend you to establish criteria at the beginning and just go with the flow of the simulation. Some frequently asked questions include: ● Whether they can combine two jobs ● Whether infants can work ● Whether people who are not unemployed can have jobs Anything is allowed, don’t be afraid of letting the participants have two part-time jobs or children working, as well.


UHC Simulation Manual

Participants After the introduction to the simulation, participants will go to their first setting “Home”. Each home setting has a facilitator, who will give each group of participants one of the roles mentioned below - Feel free to create your own! Each role (i.e. single dad with two children) can have up to 6 participants, and will act as one ‘unit’. In each role, there’s a short description of the role which includes; employment, savings, education and living conditions. After the participants receive their roles, the home facilitator will give them an action card. They always need to consider the information and circumstances in the description of their roles while making decisions, as they proceed through the simulation. They also need to decide on it as a group and then move together accordingly. They are given a standardized amount of money (i.e 1000 €) to start with. Hence, they have to keep count of their payments on a common paper as they move along different settings. After finishing their first action card, each group goes back to their home setting to receive another action card.





Living Conditions

Humble family; you are aware of your limitations and don’t tend to exceed You've got some 2 full-time jobs them. However, you live a happy, savings in your with normalcomfortable life as long as you don’t 2 parents and bank accounts, Both parents have low pay have to pay for social services 2 children but they are middle education (barista and (education and healthcare). You are invested in stockplumber). used to paying the rent, food and bills exchange and normally you don’t have problems in doing so.

Married Immigrant Couple


You just You have some arrived in the savings. You could country live with them for and have no two more months job. only.

High education

High class in your home country. In the new one, you are marginated, without a job or a place to stay. Your mental health state is low and you are exhausted. You are irregular immigrants.

UHC Simulation Manual

You (dad) left school when you Poor living conditions. It’s usually You (Dad) are a were 15 to start difficult for you to cover the rent, food hairdresser as Savings to subside working. You have and bills with the salary. All the Single Dad a part-time job for a month poor health economic related inconveniences break with 2 Children with no without any education; You the structure of the family. Being a insurance income don’t recognize at hairdresser carries health problems. coverage all when You are used to having back pains. healthcare is needed You've got savings of $20000. Faculty of You started You received a Commerce your own loan from the Received courses A pair of private digital bank to start in English, ICDL, entrepreneurs marketing your project, so Entrepreneurship company you pay to the and other soft bank $500 every skills month. A pair of doctors

You work in a private hospital

You have no savings yet.

You tried to work in several Unemployed shops, but the man seeking a You have $5000 salary was too job and a as savings from low, so you young sister your parents didn’t stay in who passed away any of them. a year ago. You're now NO INCOME! seeking another job

High-class lifestyle and one of the partners is a smoker for 30 years and hypertensive.

Fresh medical graduates

Long working hours and poor mental health. At least four 24-hour shifts per week

Not well educated. Just finished high school and could not enrol into college

You use part of the savings on paying for your sister's education and expenses. You are of low class and never waste money on useless stuff.

Facilitator Tip #4: You can adjust the roles according to the number of your participants, it is better to cut down from each similar category so you can keep the diversity of the roles. even if you have a small number of participants we encourage that you let them work in groups as assigned to encourage discussions, debates and brainstorming among group members.


UHC Simulation Manual

Action Cards The action cards that describe the tasks the groups of participants might be assigned to from the facilitator embodying the “Home”. There are different types of cards, some specific for some groups’ age (e.g. some only for kids, some other for adults or the elderlies) or groups’ activity (e.g. some more related to students' lives, other parents life,..) and others that can be more or less used for every type of participant. You can find the full list of Action Cards here (LINK). The action cards describe events that may occur to the participants (e.g. you broke your leg, you have asthma, etc.). For each action, you will find also the following steps (e.g. go to the hospital, go to the ER, call an ambulance, etc.) and therefore you need to give the participants the options (sometimes instead there is only one option and therefore you have to tell the participants what to do next. In a few cases, you also have to send the participants simply to the pharmacy, bank, job office or to buy some glasses. Besides, every month-time you would have to ask for rent and bills payment. Depending on the number of participants you might prefer to keep note the action cards you already give to the different groups or not, but just be mindful and try to keep varying the type of cards you give to the participants so they can experience all the services and different types of illnesses and emergency. You will have people coming and going from your house and sometimes - depending on the action card - they should wait a certain amount of time in the “Home” to recover from their illnesses. Remember to be creative and try to act a bit instead of just giving orders, this will help to involve the participants in the activity and add some drama and emotions that can make the simulation more realistic.


UHC Simulation Manual

General Organization The simulation game can be easily organized in any setting: university room (for at least 100 people capacity). There is also an opportunity to organize the activity outdoors. You will need at least 10 (But better around 20) facilitators, 1-2 of whom should be main facilitators. The materials (roles and action points) should be printed and there should be at least 1 online and 1 face to face (all together) training of facilitators. You might need a time-keeper and 2-3 observers checking if everything is ok in the settings and explaining lost participants where they should go. A debrief is a very crucial part of the simulation game. Make sure to not only present the theoretical part, but also to have an open conversation with the participants about their feelings, doubts and questions. Make sure to perform Pre- and Post-Evaluation, which will also help you to assess the impact of the simulation game you are performing.

Materials Please, find below the materials you might need in order to organize the Simulation 1. Printed description for the roles: - Role; mother and two children, a brother and a sister, refugees couple. - Starting salary; 1000 euros. - Job Description: mother is ‌ - Etc. 2. Printed action cards 3. Physical settings: home, healthcare facility, pharmacy, insurance company and miscellaneous settings. You might be interested to use some decorations to make the settings more realistic. 4. Paper and pens for the participants to keep track of the money they earn and lose 5. Projector, screen and laptop for performing the explanation and debrief powerpoint 6. Pre and post evaluation forms (either printed or in the google form format) 7. Any costumes, tools, devices, instruments in order to make your simulation brighter and more realistic


UHC Simulation Manual

Evaluation As for any activity, the evaluation is an essential part and it is fundamental to measure the impact and improve the activity from time to time. The SWG has developed an impact assessment consisting of a pre- and post-evaluation form to be filled by the participants. The questionnaire questions refer both to the new knowledge and information that participants can acquire from the simulation itself but also from the final debrief and PowerPoint Presentation speaking about more theoretical concepts regarding Health Systems. Therefore, it is really important to follow all the steps of this manual while organizing and delivering the activity to reach significant and relevant results. If you are an external (not IFMSA) party using this manual, please contact in case you want to take part in general impact assessment process and to get the results of your activity performed. IMPORTANT Those NMOs that will be organizing this activity during 2019-2020 should notify the SCOPH/SCOPE/SCORP ITs when they deliver this activity for them to get access to the results of the impact assessment. We are going to process the impact assessment data in order to further improve the activity and to share the results in abstracts, conferences and articles if we are going to take part in any.

Here below you can find the link to the Evaluation form both as a prepared Google Form - in this case we will also be able to have a look at the results, this data is needed for us to learn how this activity is working out around the IFMSA and non-IFMSA world and the impact it has - and as Google Doc in case you want to create your own Google Form or to perform evaluation any other way. Link to the Pre-Evaluation Form: - Google Form 2XWM/edit?usp=drive_web - Google Doc s-0LE/edit Link to the Post-Evaluation Form - Google Form UUpUzHI/edit?usp=drive_web - Google Doc


UHC Simulation Manual

The Pre and Post Evaluation Forms help you to see the difference in knowledge and the impact the activity had considering the quantitative and qualitative difference seen between the answers of both forms confronting both singularly and globally the participants’ performance.

We would like the following creators for contribution to this manual: Aina Maria Gomila Terrasa - AECS - Catalonia, Spain Blanca Paniello Castillo - AECS - Catalonia, Spain Emine Konaç - TurkMSIC, Turkey Giorgia Solda - SISM Italy Idil Kina - TurkMSIC, Turkey James Janani - UMSA, Ukraine José Chen - ANEM Portugal Kanchana Bali - NMSS, Nepal Katja Cic - SloMSIC, Slovenia Maha Rehman - IFMSA Pakistan Mathew Siu Chun CHOW - AMSAHK, Hong Kong, China Mohamed Mamdouh - IFMSA Egypt Omnia El Ormani - IFMSA Egypt Shahd Rasheed Sayed Rasheed - MedSIN Sudan Suzie Kratzer - bvmd, Germany Tatiana Zebrova - HCCM, Russia


UHC Simulation Manual


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UHC Simulation Manual  

UHC Simulation Manual, developed on August 2019.

UHC Simulation Manual  

UHC Simulation Manual, developed on August 2019.

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