The elusive goal of universal health coverage


As the world struggles to recover from the relentless coronavirus pandemic, the goal of universal health coverage (UHC) has become more relevant than ever. UHC means people have access to community-based services that promote healthy habits, disease prevention and early detection, quality medical treatment, and rehabilitation services without suffering financial hardship.

COVID-19 has highlighted how elusive CSU is. In the past 20 months, more than 5.2 million people have died from COVID-19 and many more have had their access to regular or urgent care restricted. More … than 114 million people lost their jobs and the health coverage that accompanies it, and a 97 million people fell into poverty and are now more vulnerable to catastrophic spending. The pandemic has also reduced tax revenues and diverted existing resources to other needs just as fresh health fund are the most urgent. Will we fail in our quest for UHC? It is too early to tell, but there is cause for optimism.

Mixed progress on UHC

December 12 marks both the 10the anniversary of the endorsement by all countries of the UN resolution to accelerate progress towards UHC, and 5 years since the UN formally designated the 12e of December as the International Day for Universal Health Coverage. We are rapidly approaching 2030, the deadline for meeting the sustainable development agenda, including the UHC global health goal. It’s a good time to pause and reflect on the progress made so far, what has worked well and what could have been done differently and how to go back, refocus, remove the barriers to access and accelerate progress.

Even before the pandemic hit, implementation of UHC was mixed and we were not on track to achieve UHC. Significant reductions in mortality, mainly linked to communicable diseases and maternal, newborn and child health, have been observed in most countries not affected by conflict for several decades. But the incidence of catastrophic health expenditure (defined as large direct expenditure relative to consumption or household income), continuously increased from 2000 to 2015, especially in the poorest regions of the world.

There are several reasons for this. More importantly, promises to accelerate progress have not translated into the necessary budgetary commitments. On average, overall health expenditure in low- and middle-income countries (LMICs) increased minimally from 5% to 5.4% of GDP from 2010 to 2018. In addition, rich donor countries decided to cut development assistance for health at critical times, particularly in three areas essential health care: 1) HIV, TB, malaria and other infectious diseases, 2) maternal, neonatal. and child health, and 3) family planning. Last but not least, population growth, aging and the introduction of new health technologies, for example COVID vaccines and treatments, continue to expand the reach and needs of essential interventions, making UHC a moving target.

It’s time to double down

The pandemic will leave important lessons behind. When health systems are under stress, they reveal their intrinsic strengths and weaknesses in rich and poor settings. An emerging consensus is that strong health systems help protect the economy. Countries that have responded early and decisively to the pandemic have also been successful in protecting their economies from undue disruption by protecting their workforce and properly communicating what works best to keep people safe. Where highly fragmented health care systems are the norm, it has also revealed the difficulties of an effective and coherent national response, whether it is preventative measures or access to scarce hospital services.

Supply chains and supply systems for essential services and products, such as oxygen, face masks or vaccines, have proven to be more fragile and less responsive than expected and the capacities of health systems to produce and to properly communicate basic statistics on health activities and timely mortality, a reliable and actionable means has become a major concern.

Getting back on track will be difficult but achievable. Political commitments should now translate into more concrete recommendations, and mobilizing more resources for health is the obvious starting point. Lost global economic output estimated at nearly $ 3 trillion for 2020 only. If the economic value of the lives lost is included, the figure is 3 times higher. This is only a fraction of what is needed to provide UHC for essential services to all countries of the world.

The main takeaway from the pandemic is that investing in health system strengthening for UHC not only saves lives, but also generates high economic rates of return. New and existing resources will not be sufficient, and smarter choices must be made about who should be covered and what should be offered. Prevent and control diseases with primary care was highlighted as the most cost effective way to combat rapidly emerging communicable noncommunicable diseases.

There is a strong likelihood that the poorest regions of the world will be left behind and that external assistance will be needed in a more consistent and systematic manner; targeted and sustained development assistance for health should be the third line of action.

And finally, financial protection will require a comprehensive reform of financial arrangements to effectively pool national resources, giving priority to interventions that bridge the access gaps between populations.

Universal health coverage will remain above all a political movement that must find its place creatively and effectively on national and local political priorities. There is still time to make the CHU a success story. We must not let a health crisis of this magnitude pass. The pandemic has been a stark reminder of the human and economic costs of not making bigger and smarter investments in health.

Eduardo Gonzalez Pier is Global Fellow at the Wilson Center and Senior Technical Director for Health Funding at Palladium and Health Funding Manager for the USAID-funded Health Policy Plus project.

Sources: Statistica, World Bank, World Bank Blog, World Economic Forum, World Health Organization.

Photo credit: Christianah Okunola, Deputy Head of Primary Health Care at Alekuwodo, takes care of a patient, used with permission from the Flickr user Health Policy Plus Project.


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