Universal health coverage for the poorest billion: justice and equity considerations

The Lancet NCDI Poverty Commission report by Gene Bukhman and colleagues makes a compelling case that the needs of people affected by non-communicable disease and injury (NCDI), and poverty have been largely neglected.¹ The Commission report lays out crucial evidence and health sector interventions, and calls for increased solidarity and development assistance to redress these health inequities. However, what will it take to convince global actors and national governments to act on this issue?

We believe that the call for solidarity offers an opportunity to also tackle the underlying structural determinants that cause and perpetuate poverty. These structural determinants facilitate the neoliberal world order, including international corporate tax avoidance, the accumulation of extreme wealth, and macroeconomic policy making that reduces government revenue and shrinks policy space.

In 2013, international tax avoidance in low-income countries resulted in government revenue losses that exceeded domestic public health expenditures.² Oxfam reported that numerous multinational pharmaceutical companies appeared to dodge US$112 million per tax year across seven low-income and middle-income countries—an amount that would have paid for the human papillomavirus vaccine for 10 million adolescents.³ Approaches to curtail corporate tax avoidance could generate income to spend on universal health coverage.²

Global inequality has worsened during the COVID-19 pandemic, while billionaires have increased their wealth.⁴ One of these billionaires is Bill Gates, whose foundation has used its outsized power to dictate global health and development priorities.⁵ Although the role of power is not explicitly mentioned in the Commission report, implicitly, it offers insight on how institutions, epistemic communities, and high-income countries have exercised their power to shape global health policy. All the while, countries and individuals most affected have had little influence on setting priorities. NCDI advocates can show solidarity with social movements like the People's Health Movement, which works towards a more equitable distribution of wealth, power, resources, and fair and inclusive decision making processes.

Although we agree with Elizabeth Zuccala and Richard Horton⁶ that non-communicable diseases should be reframed as a matter of justice and equity, these frames and the people most affected are currently silenced in the dominant context of neoliberal ideology. For example, outside of the health system, governments are guided by neoliberal thinking in signing trade agreements that have constrained regulatory space and reduced government revenue from tariffs, especially impactful for low-income countries. What is needed is not just reframing but a collective reimagining of a new global political economy that prioritises justice and equity first and foremost.

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