Universal health coverage: time for an ambitious call for equity in health

Blog post by Winnie Byanyima

Oxfam International, Executive Director
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People want dignity, people want rights

In the global survey World We Want 2015, health was the first priority of people living in poor countries. This was not surprising. Every year in Africa, nearly a quarter of a million children under five die because their parents cannot afford to pay for treatment. According to the World Health Organization, 150 million people face catastrophic healthcare costs every year, while 100 million are pushed into poverty because of direct payments. Increasingly, poor people are protesting the denial of their basic right to access healthcare when they need it. 

The situation can afford no band-aid, but needs transformative solutions. It is time for universal health coverage.

Universal health coverage: a simple and unifying concept

Some people argue that the Universal Health Coverage (UHC) concept is not easily understood or defined. In fact, it is very simple. At its core UHC is about ensuring the right to health. It means that all people - whether rich or poor – are able to access good quality health services without fear of falling into poverty. No one should live in daily fear of falling ill because they cannot afford the healthcare to survive. As President Kim said last week, there's now overwhelming evidence that health user fees actually worsened health outcomes - and we cannot agree more with him. 

There is also now overwhelming evidence that more public budget dedicated to healthcare is a key investment. Twenty years ago, in its major World Development Report on ‘Investing in Health’, the World Bank showed that health expenditures are an investment in economic prosperity. The Lancet report ‘Global Health 2035’ launched a few months ago went one step further in gathering evidence of the impact on economic growth of investing in health. 

That UHC is needed is self-evident.  Now we need an ambitious plan to get there. 

A realistic and right-based goal means ambitious targets

When President Macky Sall in 2013 launched a plan for national universal health coverage in Senegal with a target of half the population covered by 2015, it was ambitious. When Nigerian President Goodluck Jonathan set a target of 30% by 2015, it was ambitious as well. As we embark on discussions of what the sustainable development goals will look like after 2015, now is the time for us all to be ambitious. 

Nelson Mandela said “it always seems impossible until it’s done.”

In fifteen years, we can achieve universal health coverage.  It is an ambitious goal, but it is an achievable goal. Everywhere in the world, ambitious targets can unite the international community to improve people’s access to healthcare and make the financial barrier disappear. 

The data needed to measure health service coverage and financial risk protection are not routinely collected by all governments, making indicator measurements problematic. That is precisely what a UHC goal agreed by the international community could change. The World Health Organization and the World Bank worked intensively to propose a monitoring framework for UHC. The framework now exists and it shows that yes, we can measure UHC. 

To measure progresses towards UHC, there are three areas where the international community has to show the ambition needed to answer to what we – the people – want, and leave no one behind:   

1. Access to health services and medicines

A focus on UHC provides an opportunity to accelerate progress on the health-related Millennium Development Goals, and address the burden of non-communicable diseases, and improve sexual and reproductive health. There is no reason why the poorest shouldn’t have access to hospitals. Public policies of equitable financing of healthcare should be put in place to ensure this. The package of services covered by UHC policies should therefore be comprehensive, ambitious and universal.

2. Strong and equitable public financing mechanisms

UHC should be based on the principle of social solidarity in the form of income cross-subsidies – from rich to poor – and risk cross-subsidies – from the healthy to the ill – so that access to services is based on need and not ability to pay. This means that health services must be provided free at the point-of-use. Health user fees are the most inequitable way of paying for health care – they prevent poor people from accessing lifesaving treatment and push millions of them into poverty each year.

Scaling up health care services to achieve UHC requires a strong public health sector paying and providing the majority of services. Governments should therefore ensure that adequate proportions of national budgets are allocated to public delivery of healthcare. 

3. Measure equity

Finally, to ensure equity and universality it is critical to set specific targets to ensure that people living in poverty benefit at least as much as the better-off every step of the way toward UHC. Focusing on 40% of the poorest as proposed by the World Bank and WHO in their monitoring framework on UHC is a good start. But it is not enough. The framework must measure progress across different income groups and in particular the poorest and most vulnerable bottom 20% and not just the bottom 40%. 

The UHC goal is an opportunity to move towards a more comprehensive approach to deliver on the right to decent, affordable, and equitable health care coverage for all. The measurement of UHC should reflect what we all want: universality and equity. It means making progress towards removing user fees, developing strong public services and targeting all the population in universal policies. No-one should be left behind.

We can be at the same time ambitious and realistic. We have to be. It is what the world wants. 

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