Leaving nobody behind in bad health requires Universal Health Coverage

This post, written by Rob Yates, health consultant at Chatham House and former Senior Health Economist at WHO, is the third in our blog series which aims to explore how the Sustainable Development Goals can be drafted to include all social and economic groups.

How can we ensure that no one is left in bad health as the SDGs are implemented? Thankfully the global health community has rallied behind a health service goal, that by definition, means that nobody should be left behind. This goal is Universal Health Coverage (UHC), which means that all people receive the quality, essential health services they need, without being exposed to financial hardship.

It’s clear that the health sector has a vital role in improving health outcomes, which is achieved through people consuming effective health services. This involves a broad spectrum of services from the preventive that stop people becoming sick, through the curative that treat ill health, to palliative services that improve the quality of life for the terminally ill.

UHC is fundamentally about improving equity – both in terms of achieving an equitable consumption of health services and ensuring financial protection from the costs of health services. Firstly, UHC calls for people to receive the health services they need, which means that those with higher needs (the sick and vulnerable) should receive more health services than people in relatively good health. Secondly, eliminating the risk of financial hardship when consuming health services means that the health sector should be financed according to people’s ability to pay – with the rich contributing more than the poor.

Combining these two equity principles, UHC requires that healthy wealthy people to cross-subsidise health services for the poor and people with high healthcare needs. This has profound implications for the way health systems are financed, because private markets, with people paying voluntarily, will never deliver this outcome. The United States shows that even the wealthiest country in the world can’t reach full population coverage with a privately financed health system. Instead countries, such as China, Brazil, Thailand and Rwanda are learning that the only way to finance UHC is through public financing. In the last twenty years each of these countries has experimented with voluntary insurance systems but have now switched to compulsory public systems largely funded through tax financing.

UHC is also a good SDG goal for the global health community to choose because it can easily be measured using indicators of service coverage and financial protection.  In fact the World Bank and WHO have just produced the first global monitoring for UHC which estimates that 400 million people lack effective health coverage.

With all nations now committed to achieve UHC, after a UN General Assembly Resolution in 2012, the big question is: how does the world move from the current situation to genuine UHC, where nobody is left behind? Here a consensus is emerging that this should be achieved through countries publicly financing a package of health services available for everyone, free at the point of delivery.

Recent research has estimated that this would cost around $86 per capita.

Furthermore, in adhering to equity principles, countries should implement policies that reach UHC through “progressive universalism”, in other words, in moving towards universal coverage the needs of the poor and vulnerable should be met FIRST.  This can best be achieved through investing heavily in primary healthcare services at the district and community levels. Countries like Rwanda and Ethiopia have been very successful in using community health workers to cover even the remotest communities with these cost-effective services.

Achieving UHC in this way will deliver considerable health benefits to countries and is likely prove to be the world’s best strategy to build more resilient health systems against infectious diseases and hence strengthen global health security. Furthermore, reaching UHC will bring considerable economic benefits in stimulating economic growth and reducing poverty and inequality. Finally, UHC has proved extremely popular worldwide and can therefore deliver huge political benefits to governments and leaders that bring their people publicly financed UHC.

It’s well known that population health outcomes are affected by many factors outside the immediate health sector. These social determinants of health include factors relating to poverty, conflict, nutrition, education (especially for girls), sanitation and the environment. Therefore ensuring that nobody is left behind in bad health will involve improving indicators and reducing inequalities in each of these areas. Fortunately, the broad agenda of the SDGs means we can expect progress across all these other areas too.

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