Universal Health Coverage: A Political Struggle and Governance Challenge

Abstract

Universal health coverage has become a rallying cry in health policy, but it is often presented as a consensual, technical project. It is not.

A review of the broader international literature on the origins of universal coverage shows that it is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics.

On one hand, a variety of comparative research has shown that health coverage is associated with democratic political accountability. Democratization, and in particular left-wing parties, gives governments particular cause to expand health coverage. On the other hand, governance, the ways states make and implement decisions, shapes any decision to strive for universal health coverage and the shape of its implementation.

Universal health coverage (UHC) has become a focal point in global health conversations. In the spirit of previous unifying concepts such as Health for All, basic health needs, and the Alma-Ata declaration, it presents a vision in which all citizens will enjoy (1) a strong and efficient health system that spans preventive and curative medicine, (2) affordable access to that health system, (3) access to relevant medicines, and (4) sufficient human resources for the health system. The 2010 World Health Report presented UHC as an objective and a strategy for its member states to reform, or design, their health systems.¹ UHC has been the focus of much research and policy prescription since then. Various authors have shown its implications for the health workforce and its governance,^2,3 health financing,⁴ and management.⁵

But is UHC likely to be attained? We draw on political science and public health literature to argue that politics and governance have been undervalued as key drivers for universal health coverage.

UNIVERSAL HEALTH COVERAGE IS POLITICAL

It is a political victory that UHC is discussed at all, and still more so that it has any veneer of consensus. UHC is a highly political concept. In the world of global health governance, it is part of an ongoing debate about the relative importance of “vertical” priorities such as disease eradication and broader “horizontal” system-strengthening proposals.^6,7 Given the momentum behind disease-specific interventions and the appeal of solving particular problems (e.g., antiretrovirals or polio eradication), it is always difficult to argue for more amorphous health system goals that are part of UHC or predecessor agendas.⁸

The contentiousness of global health politics is nothing like the domestic politics of UHC or universal health care access by any other name. The US State Department has even objected to a World Health Organization fact sheet on the right to health.⁹ Observation of politics in the United States,^10,11 or reading about the history of health politics anywhere, supports this point. UHC is expensive and redistributive; that is enough to make it contentious.^12,13 As if that were not enough, UHC also builds in additional contentious goals such as efficiency or access and medicines.^14–16 It is unwise to assume that UHC goals are entrenched in the countries that have broadly achieved them, to overstate the influence of health ministries or advocates committed to UHC, or to overstate the degree of consensus among governments that have adopted them on paper.^17,18

If any generalization about UHC holds, it is that democratization promotes it. Middle-income countries can broadly afford to aim for UHC, but they are most likely to enact access expansions when they have governments that are accountable to the population.^19–21 The effects of widespread democratization from the 1970s to the late 1990s help to explain the expansion of UHC in middle-income countries today.^22–25 Authoritarian regimes, by contrast, are less responsive to the broad population, can discourage or repress organized challenges, and therefore often focus benefits on a narrower set of people who are part of the regime or who can threaten it (e.g., by striking or staging a military coup). The result has been the historical pattern of segmentation that southern Europe and Latin America have had to confront, in which a few crucial sets of workers (especially the public sector and key strategic industries) enjoy extensive health and other benefits and groups without the capacity to threaten the regime receive less.^19,26–28

Partisan politics are one of the most promising avenues for explaining UHC. In particular, left-wing parties are more likely to enact redistributive policies such as UHC.^27,29–31 Socialist parties enacted universal health care across southern Europe when they came to power after democratization,³² despite major recessions that might be expected to block health access expansion, and later it was the left that universalized health care in Latin American countries such as Brazil and Chile.^33,34 Conservative parties have also at times expanded health coverage for their own political purposes.^20,35 Otto von Bismarck created the first social health insurance in response to socialist challenges, Japan’s health insurance expansion came about as a response to a left labor challenge to the dominant conservative Liberal Democratic Party, and the expansion of health care access in Mexico was partly a strategy to maintain the popularity of its once-dominant Party of the Institutional Revolution.^36,37

Democracy and partisanship do not automatically produce UHC; UHC still needs organized support and faces organized opposition.^38–40 Unorganized voters are unlikely to have their preferences reflected in any political system. The complexities of organization, political coalitions, and parties, a long-standing issue in comparative politics, therefore demand attention; the relationship between left-party success and UHC policies is not simple,³¹ and part of the reason is the interaction between politics and governance.

GOVERNANCE

“Good governance” is a widely supported goal, but there is great disagreement about what it is and how it is to be attained.^41,42 Governance discussion often mixes governance as a phenomenon (how decisions are made) with normative policy advice (how decisions should be made and implemented, i.e., good governance). Governance as a phenomenon is the institutional framework of the decisions and policy implementation.⁴³ A review of components of governance in the health and broader policy literatures by authors associated with the European Observatory on Health Systems and Policies found that diverse authors focused on the same five areas in which governance can affect health systems: transparency, participation, accountability, integrity (management and anticorruption measures), and policymaking capacity.⁴⁴

Governance shapes the likelihood that UHC will be adopted and actually implemented for three reasons. First, it is a prerequisite for some policies. Just as policies for UHC can cost too much for a given state, they can also demand a level of expertise, accountability, and good public administration that is not always available. In particular, elaborate public–private, market-based, and personal insurance schemes can overwhelm the capacity to design, regulate, and operate them.⁴⁴

Second, governance, particularly political institutions, can shape the likelihood of pro-UHC forces winning in politics. Veto points at which a policy can be blocked include bicameralism, referenda, strong supreme courts, and some forms of federalism; they are correlated with slower increases of expenditure, less redistribution, and less programmatic coherence, although they also slow retrenchment.²⁹ Among the rich countries, the United States and Switzerland stand out for the expense, slow development, and inegalitarianism of their health systems and for their particularly high number of veto points. Their many veto points make opposition easier, demand larger political coalitions, and allow interest groups to extract a higher price for their support.^45–48

Third, governance affects the likelihood that programs will be entrenched by affording programs greater or lesser real effectiveness and greater or lesser political defenses. Although the post-Communist states have shown that it is politically very difficult to take away UHC,¹⁹ their experiences also show that a system that only formally delivers UHC can engender effective privatization through exit from the system (into private provision) or informal payments. Ineffective programs engender less loyalty. Alternatively, governments can lock in UHC achievements by making the systems transparent and accountable to affected groups who will in the future be able to ward off efforts to reduce government commitments or undermine achievements.⁴⁹ A well-crafted policy includes governance changes that promote its own political survival by biasing policymaking toward groups who defend UHC. Just as Latin American's military regimes left institutional safeguards for their interests,⁵⁰ UHC advocates should pay attention to ways they can create institutional safeguards for a right to health. “Policies create politics,” after all.⁵¹

CONCLUSIONS

There is a strong tendency to discuss UHC as though it were a settled goal that only requires technical follow-up. This approach contradicts or at least underplays a large body of evidence suggesting that UHC is potentially transformative and intensely political, and depends on the features of a country’s governance. Without support in domestic politics, a redistributive policy such as UHC is unlikely to happen. Without political support in the international arena, it can be undermined by advocates of other attractive goals such as programs focused on single diseases. Decision-making and implementation—governance—can support or hinder UHC advocates and deserve attention for the ways in which they can bias decisions and improve or hinder implementation.

For researchers, this means that we need to apply ourselves to better understanding the mechanisms connecting governance, political forces, and UHC decisions; although studies have pointed to the interplay of parties and institutions under democratization, much still remains to be understood about the coalitions and political strategies that shape UHC politics. For UHC advocates, this means that technical skills and advice should be regarded as resources to be used in what are ultimately political fights within countries, that the commitment to UHC by member states is a resource for political argument rather than a binding obligation, and that attention to health governance should come with an explicit objective of strengthening those who seek UHC.