A Call for Global Discussion on Universal Coverage

During the last three decades, national economies became increasingly more intertwined, social inequality increased, environmental threats scaled up, international travel became increasingly common, and so did the spread of emerging infections diseases, and violence, famine and poverty forced mass migrations in many parts of the world. These health determinants operate on a global scale, do not respect country boundaries, and require actions at the same level. Global Public Health is a relatively new academic label for the enterprise of understanding and proposing solutions to the health problems that arise and operate from such large-scale events.

AJPH is setting a platform for debates about such issues its new Global Public Health Forum. Universal Health Coverage was chosen as a first subject. Scholars from all over the world who have contributed to that discussion have been invited to submit their contribution to this section.

MILESTONES TO UNIVERSAL COVERAGE

Access to health care was acknowledged as a human right by the United Nations General Assembly in 1948. International agencies, particularly the World Health Organization (WHO), have historically proposed expanding access to health care. The International Conference in Primary Care that took place in 1978 in Almá Atá, Kazakhstan, under the sponsorship of the WHO and the United Nation’s Children’s Fund (Unicef) was an important landmark. It produced an official statement that, invoking the Universal Declaration of Human Rights, proposed assuring access to care for all of humankind by the year 2000, using primary care as the strategic approach to that goal.

Although that conference did help to spark primary care initiatives all over the world, the results where nowhere near the proposed goal of granting access to everyone. Soon after the conference “selective primary health care” was proposed as an alternative, restricted to interventions to reduce mortality among those younger than five years in developing countries.¹ A global recession further restricted funds for health and at the same time increased the number of people who became ill as a consequence of its effects on jobs, wages, and social safety nets, especially in Latin America and Africa. At the same time, other health challenges emerged, such as the Aids epidemic, further stressing already compromised national health budgets.

Amid this difficult conjuncture, another landmark document emerged: the World Bank’s World Development Report for 1993, subtitled “Investing in Health.” It made the case that a population compromised by poor health would not be able to adequately contribute to economic growth, so it made economic sense for States to develop public policies to expand access to health care. But States were to provide only a “package” of basic services that would not be profitable enough for the private sector to invest, whereas more complex and expensive procedures should be left to the supposedly inherently superior efficiency of the free market. A few years after that, Gro Harlem Bruntland, then director of the WHO, took a more nuanced approach, to some extent undermining the more extreme reading of the WB proposal. In the 1999 WHO Global Health Report,² Bruntland stated that market-oriented approaches ran contrary to human rights and were inefficient. But she also declared that competition in the provision of services was welcome, and since not all services could be provided for all, most cost-effective services should come first. This seemed to leave the doors open to previously criticized “market-oriented approaches,” while glossing over the complexities of assessing cost-effectiveness and setting up the necessary mechanisms for funding health care.

This logic fueled a number of attempts at reforming (or structuring) health care systems, especially in low-income countries, with mixed results.³ At the same time, the threat of new pandemics (SARS, avian influenza, hemorrhagic fevers) made clear the global aspect of the challenge of developing effective, equitable health care systems.

A new push can be traced at least to the 2008 WHO Global Health Report, which once again emphasized primary care, and pushed for the expansion of access to health care, once again invoking the Universal Declaration of Human Rights. This issue was also at the forefront in the 2010 WHO Global Health Report, which explicitly mentioned “universal coverage,” as a means to reach the Millenium Development Goals. Universal coverage was subsequently endorsed at the 64th World Health Assembly in 2011, and finally it was the object of a resolution of the 67th UN General Assembly,⁴ which urged the inclusion of universal health coverage as an important element of the international development agenda, a proposal that has been receiving widespread support.⁵

REMAINING OBSTACLES

It would seem that a global consensus on universal coverage has been reached, and it will soon become a reality. Not so.

The widespread use of the expression “universal coverage” does not imply a broad consensus on its meaning. Each term of the expression is polysemic⁶; absent proper definitions it may be taken to mean entirely different things, with very concrete consequences in terms of policy making.

There seems to be an assumption that, given the widespread consensus on the merits of the proposal, it will be established by default.⁷ This ignores the necessary political negotiations that have to take place before ideas become public policy. The mere fact of having universal coverage as an item in the political agenda is already a political victory, but obstacles lie ahead in its path to implementation. For example, the right to health, a historical linchpin of the proposal, was recently the object of criticism by the US State Department.

Not all proposals on the table fully incorporate the notion that evening out the negative health consequences of extreme socioeconomic inequality requires universal access to all kinds of effective interventions. The constant development of new—and costly—medical technologies compounds the problem, rendering health care increasingly more complex and expensive, placing certain interventions beyond reach for entire population segments and even countries, increasing inequality within and between nations in that regard. Roughly speaking, we can identify two polar positions on the argument: on the one hand, the “cost-effective health care package” that should be provided by states and not compete with the private sector; on the other, the strong version of the right to health that states that every person is entitled to necessary treatments. In the first case, health care has to fit into whatever budgetary allocation has been created for it; in the second, budgets have to be built around the premise of the right to health. Criticism directed at the first position claims that it leads to “poor quality medicine for a poor population,” whereas the second position is denounced as leading to spiraling increases in health expenditure and overuse of resources.

The argument so far considers intranational aspects; how to deal with inequalities between nations is yet another thorny issue. Finally, the debate about access to care should not obscure the causal nexus linking standards of living and general health status of a population; no matter how excellent a health care system is, it will always be doing Sisyphus’s work if social inequalities that lead to diseases at a population level are not adequately dealt with.

AN AJPH FORUM

Despite these questions, or perhaps because of them, the ongoing argument about universal coverage offers a window of opportunity for the public health community to contribute in the unfolding debate and its political ramifications. Global comparisons can provide a rich laboratory for observing different approaches to universal coverage and its implementation. With this, we hope to provide a significant contribution in accordance to the goals of the American Public Health Association and its journal.