New global momentum for universal health coverage

Young girl in hospital, Gambia

Editor’s note: I wrote this piece for publication in November’s edition of Al Jazeera Magazine, accessible through downloading on iTunes or other Apple (only) devices. Re-posted here for those, like me, who persist in using PC-based machines. 

Young girl in hospital, Gambia
Young girl in hospital, Gambia
Mike Urban, http://mikeurban.photoshelter.com/

The idea that every person should have access to affordable, basic health care is hardly new, but many believe there is new global momentum toward achieving this worldwide.

While U.S. politicians and pundits squabble over the relatively modest aims of Obamacare, policy makers in nearly every other country have either already adopted a system or embraced the goal of universal health coverage as a critical component of their economic, social and development strategy.

“I would say it is not just feasible, but unavoidable,” said Ariel Pablos-Méndez, a key player in this movement and assistant administrator for global health at the U.S. Agency for International Development (USAID).

“We’re in a fundamentally different place today,” agreed Tim Evans, director of health, nutrition and population at the World Bank.

“The demand for universal health coverage is not coming from advocates or from experts just saying this is a good idea. This is being driven by citizens at the country level, a phenomenon politicians ignore at their peril.”

Thailand has achieved universal coverage after instituting ambitious reforms that began in 2001. Mexico recently expanded its social protection system to beef up public health and expand its insurance coverage while keeping overall health spending relatively stable (about 6 percent of GDP). Rwanda, a poor country, has reached more than 90 percent of its citizens for about $55 per capita per year and, as a result, reduced maternal mortality by 60 percent, dramatically reduced deaths from HIV and malaria, and doubled life expectancy.

Nobody should be surprised by such statistics. The benefits of expanding fundamental health services to a population are obvious and well-documented.

Given the return on investing in health, there have been plenty of movements over the years aimed at making a reality of the rhetoric that basic health care is a right of all people. The Alma Ata Declaration of 1978 ordained ‘health for all’ as a key operating principle of the World Health Organization. Going back further, the first step aimed at universal coverage (though viewed more as a responsibility than a right) may have been in 19th Century Germany, when employers were required to insure their workers.

Despite the evidence and rhetoric, access to health care has not been an enforced right or guaranteed benefit for most citizens living outside of industrialized nations – until recently.

The U.S. still remains a notable outlier among rich nations, spending the most on health (about $8500 per person, or 18 percent of GDP) yet failing to provide coverage for one of every six Americans. To make matters worse, health indicators in the U.S. – such as maternal mortality, child health – often rank the world’s superpower in the same neighborhood as Bulgaria or even Bangladesh.

Uwe Reinhardt
Uwe Reinhardt
Princeton

“It’s just crazy,” said Uwe Reinhardt, a Princeton University economist widely regarded as one of the leading experts on health care systems and reform.

“Nobody wants to copy our system. It’s become an administrative monster full of ethical problems and massive inequities. I travel a lot and talk to ministers of health in other countries…. If anyone brings up the notion of adopting aspects of American health care, that’s the kiss of death for any further discussion.”

USAID’s Pablos-Méndez refrained from so colorfully characterizing the American health care system, but he did note that one of the obstacles to achieving universal health coverage in the U.S. is that the concept for many years was viewed as the first step on the road toward socialism. Universal health care was seen in the Cold War context as a Soviet idea (which may explain why U.S. politicians usually don’t talk of making health care ‘universal’ even today). But politics is losing out to economics, he says.

Ariel Pablos-Méndez
Ariel Pablos-Méndez
USAID

“What is driving change in the U.S. is mostly the cost,” said Pablos-Méndez. “I think the struggle over President Obama’s approach, glitches and all, is still helpful to the global conversation about achieving universal health coverage. The fact that Europe, countries like Mexico, Thailand and Ghana, can achieve universal coverage and also control costs is not going to be something we can ignore.”

Getting everyone into the pool, actuarially speaking, is how universal coverage is supposed to keep costs down. By reducing barriers to preventive care and including in the mix all citizens, the idea is that the financial risk is evenly spread, health services care can be done more efficiently and the potentially catastrophic financial impact of serious illness on the uninsured disappears.

Serious illness is the leading cause of bankruptcy in the U.S., just as it is one of the leading causes of poverty in poor countries.

Yet even some of the more established systems of universal health coverage, like Britain’s National Health Service, are hardly enjoying a smooth sail these days. The UK’s tax-based system of government-run health care is suffering from costs spiraling upwards (though not yet to American levels) even as Brits complain about declining quality of service and long waits.

The complaints are similar to the criticisms long leveled against Canada’s health care system, which differs from Britain’s in that the taxes go to pay for the insurance and the providers remain in the private sector. Health systems throughout the industrialized world are getting a bit creaky, due to rising costs of drugs or services and aging populations. Yet the momentum for universal healthcare coverage continues unabated. Why? What’s changed to make this such a juggernaut?

Robert Marten
Robert Marten
Rockefeller Foundation

“Part of it is due to the strong economic growth in emerging economics, in Africa and Asia,” said Robert Marten, with the ‘transforming health systems initiative’ for the Rockefeller Foundation. The philanthropy has been one of the leading private sector organizations working on this issue, along with Oxfam and Save the Children UK.

“All around the world we have a new, emerging middle class and with that comes demand for better access to health services,” said Marten. That’s what the World Bank’s Tim Evans is talking about, he said, when he explained that this push for universal health is coming from the ground up rather than, as in the past, from the top down.

Universal health coverage is not a single strategy or even a specific method of financing, Marten emphasized. It’s not necessarily about insurance, he said, which is why some still don’t like the word ‘coverage.’

“It simply means a system which provides basic, quality and affordable health care to all citizens,” said Marten, adding that there are any number of ways to achieve this – whether through a completely tax-based system like in Britain or through the use of compulsory private insurance like in Germany (or in Massachusetts, where a version of Obamacare got its start under Gov. Mitt Romney and now covers nearly all of that state’s population).

The World Bank recently published a report analyzing 22 countries (and Massachusetts) on their efforts to achieve universal health coverage.

Tim Evans
Tim Evans
World Bank

“What we’re trying to do is identify some common themes and lessons learned to find the right balance that both respects different approaches tailored to fit the specific needs of a country but without having to re-invent the wheel,” Evans said. “But what any approach has to incorporate are some means to move people away from paying out of pocket.”

Ghana is one of those emerging countries with a growing middle class and a demand for improved health services. Though it is frequently cited as one of the success stories of a nation moving toward universal health coverage movement, a 2011 report by Oxfam said Ghana’s approach may turn out to be an example of how not to do it.

Ghana has claimed significant expansion in health coverage for Ghanaians through a new insurance scheme that every citizen pays for through a national tax. But as anyone with a bargain-basement policy knows, having coverage does not by itself translate into access to health care. Oxfam claims that the insurance scheme has failed to improve access to services, especially among the poor, and that many still have to pay out-of-pocket to get care.

“This is one of the unfortunate trends we’re also seeing, along with economic growth,” said Pablos-Méndez. “In Africa, something like 50-60 percent of health spending is paid out-of-pocket for unregulated private services of low or mixed quality. In Asia, it’s more like 60-80 percent.”

Out-of-pocket spending is one of the most inefficient and regressive ways to pay for health, he said, in part because people don’t go in for early, preventive care and because when they do it’s often poor quality care. Another reason why so many governments around the world want to implement some kind of universal health coverage is to counteract this parallel growth of private, unregulated and out-of-pocket health care.

Over the last 15 years or so, the international community has seen remarkable progress in the global health arena. The Global Fund to Fight AIDS, TB and Malaria as well as Pepfar, the President’s Emergency Plan for AIDS Relief (launched by Pres. George W. Bush), got millions of people on anti-AIDS drugs, among other things. The Global Alliance for Vaccines and Immunization, the Bill & Melinda Gates Foundation’s flagship program, has prevented millions of deaths from mundane childhood diseases.

Now, say many, it’s time to pivot to a new phase in improving global health – a more comprehensive, or systems approach. And universal health coverage will need to be a fundamental part of this approach.

“I think we are entering a new era,” said Pablos-Méndez. “We’ve laid the groundwork for doing systems strengthening by all of these tremendously successful efforts focused on fighting a single disease. Now it is time to do more than focus on the next single disease.”

Marten agreed, noting that this is why universal health coverage has become central to the discussion of setting the next development agenda after 2015 when we reach the finish line for the Millennium Development Goals.

Those eight goals – reducing child mortality, halving the number of people living in extreme poverty, etc – were hatched by a handful of people 15 years ago and were somewhat arbitrary. But they compelled the international community to act, with clear targets in mind.

“They were fairly successful, but there’s growing recognition today that what we don’t need now is a new set of narrowly targeted interventions,” Marten said. “What we need now is a more holistic approach that focuses on equity and health, not just a disease du jour.

“Universal health coverage is about health equity and its time has come.”

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About Author

Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.