Universal Health Coverage (UHC)
The World Bank places a large emphasis on UHC: "All people aspire to receive quality, affordable health care. Universal health coverage (UHC) is about people having access to the health care they need without suffering financial hardship. UHC aims to achieve better health and development outcomes, help prevent people from falling into poverty due to illness, and give people the opportunity to lead healthier, more productive lives."
A paper from the World Bank and others Moving towards universal health coverage: lessons from 11 country studies "...showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls—but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context."
However, the World Bank's view on UHC is not shared by most public interest civil societies, and social movements oppose this view, as it favours private insurance for 'those who can afford it' and basic packages for the poor - literally first and second class medicine.
Is it health care alone, or does the movement have to include addressing the social determinants of preventable ill health, malnutrition and deaths?
We have recommended reading General Comment 14 on the right to health by the UN Committee on Social, Economic and Cultural Rights (CESR) before in the Introduction - it includes the following statement: “health is an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health”, but as discussed in "Is universal health coverage the practical expression of the right to health care?" Universal Health Coverage (UHC) is more often restricted to health care, and omits the factors leading to preventable ill health including the social and political determinants of poverty. Please think about this as we discuss UHC further.
The World Health Organisation in What is universal coverage?, seems to focus on health services: "Universal coverage (UC), or universal health coverage (UHC), is defined as ensuring that all people 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.
This definition of UC embodies three related objectives:
- equity in access to health services - those who need the services should get them, not only those who can pay for them;
- that the quality of health services is good enough to improve the health of those receiving services; and
- financial-risk protection - ensuring that the cost of using care does not put people at risk of financial hardship."
The statement goes on to set this in the context of Human Rights:
"Universal coverage is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma‑Ata declaration in 1978."
A Lancet Commission on Investing in Health also restricts the topic to health services: "Universal health coverage (UHC)—the availability of quality, affordable health services for all when needed without financial impoverishment—can be a vehicle for improving equity, health outcomes, and financial wellbeing. It can also contribute to economic development. In its Global Health 2035 report, the Lancet Commission on Investing in Health (CIH) set forth an ambitious investment framework for transforming global health through UHC. The CIH endorsed pro-poor pathways to UHC that provide access to services and financial protection to poor people from the beginning and that include people with low income in the design and development of UHC health financing and service provision mechanisms. The CIH argued that pro-poor UHC offers the most efficient way to provide health and financial protection, and proposed pathways through which pro-poor UHC could be achieved." The emphasis, however, is clearly on pro-poor pathways to services rather than addressing disparity reduction and poverty alleviation which are key to improving the health of the poor.
Is it all about the health insurance industry?
UHC is included as target 3.8 of the Sustainable Development Goals "Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". However there is debate about how to monitor achievement of the target through indicators which include health insurance. A group of concerned organisations has said that "Insurance is not a measure or guarantee of financial risk protection – in a number of countries the introduction of insurance schemes has not reduced out of pocket payments or provided protection against catastrophic health expenditure; There are numerous examples where insurance can widen inequalities". This in the context of a proposed change in the indicator from: “Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure” to: “Number of people covered by health insurance or a public health system per 1000 population”
On its web site, the Global Coalition for Universal Health Coverage headlines: "Universal health coverage improves how health care is financed and delivered – so it is more accessible, more equitable and more effective."
Cheng argues: "As a rule of thumb, the more egalitarian a UHC system is, the more heavily government will have to be involved in the financing of care. It requires social health insurance. A health system that relies purely on private, commercial insurers cannot ever achieve access to health care on egalitarian principles. The market constraints faced by commercial insurance makes it incompatible with equitable access to health care and, in fact, quite natural lead to inequality."
The People’s Health Movement argues that it “recognises the importance of UHC, but its endorsement is qualified, because of ambiguities associated with the different interpretations of UHC. PHM endorses the need for equality and efficiency in the allocation of resources for health care and population health programmes and the need for appropriate priority-setting methods to be part of any UHC policies. For PHM, health system design (funding and delivery configuration) is the major determinant of equity, equality and efficiency in resources allocation for health care delivery. PHM endorses the importance of capacity building for priority setting noting that, as well as technical capacity, it includes community/ rights holders capacity and norms and structures to support dialogue and accountability. PHM is particularly concerned that the marketisation of UHC (driven by the World Bankand accepted by WHO) undermines the implementation of comprehensive primary health care. Reducing PHC to arbitrarily defined ‘interventions’ limits and distorts the analysis of needs and priorities; it ignores community action on the social determination of health; it also prevents best use of limited resources. PHM insists on recognising that health policy debates around UHC are framed by macroeconomic instabilities and the neoliberal policies being put in place to manage those instabilities. TNCs and foreign direct investment are driving a race to the bottom with respect to tax policies (tax competition) with increased restrictions on public funding of health care as a consequence. Moreover, unethical pharmaceutical marketing practices are a major cause of inefficient resources allocation; but Big Pharma (supported by host governments) resists appropriate regulation of marketing”. You can read the PHM's full 28 page Position paper on Priority Setting for Universal Health Care.
Health system reform
Whatever the motivation, health system reform will be required in order to attain universal health coverage. Here is a set of educational activities which you might be interested to explore "The Joint Learning Network is a forum for countries to share knowledge and co-develop new tools, guides and resources that address the practical challenges of health systems reform to achieve universal health coverage."
UHC and Human Rights
Sacks has nicely summarised the underpinning of Human Rights to UHC: "The goal of universal health coverage is deeply embedded in politics, ethics, and international law. Article 25 of the 1948 Universal Declaration of Human Rights states that everyone has the right to a standard of living adequate for health, including medical care, and the right to security in the event of sickness or disability. Motherhood and childhood are to be afforded special care and assistance. In the same year, the Constitution of the World Health Organization came into force, declaring that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Sacks goes on to say "Health outcomes are the result of many complex factors inside and outside the health system. Poverty affects health outcomes not only through access to the formal health sector but through nutritional adequacy, safety of the home environment, quality of water and sanitation, environmental exposure to toxic substances, limitations of knowledge about health-seeking behaviours (eg, because of a lack of literacy and schooling), and the direct effect of low social status on physiological stress and psychosocial wellbeing...In a low income economy, many households so not have means to pay for any health care at all... Even with such multidimensional linkages from poverty to poor health, the health care system can make a major difference, especially if public provision is also made for basic infrastructure including safe drinking water, sanitation, electricity, and local environmental protection."
Chapman cautions in relation to Human Rights and the Sustainable Development Goals: "although the preamble to the Agenda affirms the importance of the Universal Declaration of Human Rights and other instruments relating to human rights, the document does not frame any of the goals as human rights. Nor is the international obligation of affluent countries to provide the necessary financing for poor and lower-middle income countries otherwise unable to pursue the goals specified".