At least 400 million individuals around the world – one in six people – are still without access to the most basic health services. Humanist and egalitarian principles were what prompted the World Health Organization (WHO) to develop the idea that universal health coverage (UHC) should be established. The aim was to ensure access for all human beings to the health services they need without the cost of such services placing them in financial difficulties.
The 74th session of the United Nations General Assembly in New York this September, attended by 143 heads of state and government, decided to launch a global plan to achieve UHC at a high-level meeting on the topic on 23 September 2019. The member states adopted a political declaration on health for all. It constitutes the most complete set of commitments ever adopted regarding health at an international level.
The goal of universal health coverage for 2030 (UHC2030) is one of the targets the countries of the world set themselves when adopting the sustainable development goals (SDGs) in 2015.
The goal had already been formulated in 2012 by the General Assembly, which had adopted, by a very large majority, and chiefly at the initiative of France, a resolution on global health and foreign policy, in which it invited countries to speed up their progress towards UHC. The goal was reiterated in September 2015 by the resolution Transforming our world: the 2030 Agenda for Sustainable Development, requiring countries to invest at least an additional one per cent of their GDP in primary health care to eliminate the glaring gaps in health coverage.
The WHO, a specialised UN agency created in 1948 with the mission of ensuring the highest possible level of health for all people, has long been developing ideas on how to achieve this goal. UHC has roots in the WHO’s constitution, adopted in 1948, which declared health a fundamental right for all human beings, and in the Global Strategy for Health for All, launched in 1979. In 2017, the United Nations proclaimed 12 December as International Universal Health Coverage Day.
Although universal health coverage does not mean free coverage for every intervention possible, it not only covers individual treatment services but also prevention and public health campaigns.
The ‘social protection floor’ objective
The WHO, which notes that 100 million people fall into poverty each year because they have to pay for care out of their own pockets, has called for a major redistributive effort from rich to poor countries to achieve UHC.
UHC is in line with the ‘social protection floor’ objective promoted by the International Labour Organization (ILO) with the support of the WHO since 2010. In her speech to the 65th World Health Assembly in May 2012, Margaret Chan, the then director-general of the WHO, described UHC as the “the single most powerful concept that public health has to offer”.
The WHO defines UHC as “ensuring that all people have access to the necessary health services (including prevention, treatment, rehabilitation and palliative care) of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”.
In May 2013, the then World Bank President Jim Yong Kim made a commitment to the World Health Assembly to work towards achieving UHC. The European Union also supports the UHC2030 target. But it is also, and above all, from the countries of the South that the push has come to work towards meeting it. Several governments are already heading in this direction: China, Thailand, South Africa and Mexico are among the first emerging powers to have substantially increased their spending on public health. And many other countries, such as Indonesia, India, Vietnam, Mali, Sierra Leone, Zambia, Rwanda, Ghana and Turkey, have included it in their national priorities and/or have established systems of free access to healthcare for a portion of the population, as a first step towards the establishment of UHC. Ecuador, in its new constitution, approved in 2008, establishes the right to health and to free public health services. And Senegal adopted UHC in September 2013.
How to finance UHC?
Whilst there now seems to be a consensus amongst all ‘global health’ stakeholders on the need to meet the UHC target, there is disagreement over how to fund it. There is a range of possible approaches: increased tax expenditure; social security contributions levied as part of a solidarity-based health insurance system; the establishment of mutual societies or private insurance bodies; or direct payment on the part of patients themselves, implying the payment of contributions that can be subsidised by the public authorities, leaving patients to cover a greater or lesser proportion of the direct payments, depending on the nature of the care and services required.
It should, however, be noted that most of the stakeholders in the UHC consensus, and within the OECD in particular, see private providers as essential to the system.
For some observers, it seems that the UHC target, a global, transformative and inclusive goal in itself, is being stripped of its progressive essence to fit in with a more neoliberal interpretation. As the French economist and diplomat Laurence Tubiana, chair of the French Development Agency’s board of governors, explains: “Unfortunately, under the guise of UHC, many states and donors are promoting and setting up voluntary private and community insurance schemes that in fact offer limited coverage, are expensive to manage and exclude the most disadvantaged.” Such schemes only help to reinforce inequalities.
UHC is thus widening the gaps. Some governments feel its definition is not clear and its scope uncertain. The resources to be deployed are left up to the individual state to determine (with advice and support from international organisations, as well as NGOs, foundations and business), in line with their national priorities and contexts. UHC thus seems to be a ‘variable geometry’ concept.
As the French sociologist Blandine Destremau and her colleagues observe, “the fabric of UHC, stretched to fit a market-based approach and a public good approach, is being torn apart”, coming under pressure from firms, private non-profit organisations, religious organisations, NGOs and foundations, which control large swathes of the health “market”, and some of which see UHC as a way of expanding it.
The WHO, for its part, seems to have a more progressive view of UHC, affirming that “there is no evidence that privately owned/financed service providers are any more or less efficient than government-owned/financed alternatives”, and that it is ultimately up to the public authority to give the health system its final shape.
It also asserts that making the user pay for care is the most inequitable way of financing health services. Yet again, in 2019, the United Nations Secretary General António Guterres stated that evidence shows universal health coverage contributes to economic growth for individuals, families, businesses and societies as a whole and that health is both a driver and a result of economic and social progress.
It is up to the WHO, now led by an African (the Ethiopian Dr. Tedros Adhanom Ghebreyesus) for the first time, and progressive forces, to shape the UHC concept around the principle of social justice. As noted by Destremau and her colleagues: “UHC could play a role in transforming the concept of ‘global health’ into a more positive one, by moving it towards a common goal of health coverage for all”. It would no longer be just a matter of tackling health problems that transcend borders, “but of promoting robust and efficient national health systems that integrate prevention”.
