Universal Health Coverage: Old Wine in New Bottles?
Professor Ajay Mahal discusses whether there is any value left to the UHC agenda.
The landscape of recent health sector policy and academic discussions is increasingly dominated by ‘Universal health coverage’ (or UHC) with its significance further underlined by its inclusion as goal 3.8 of the Sustainable Development Goals (SDGs) of the United Nations. Indeed, the vast recent health literature that either cites or draws its inspiration from UHC prima facie suggests a new paradigm for health policy formulation. A closer look points to the deflating conclusion, however, that the key questions and policy challenges facing the health sector are fundamentally not very different from those facing the health sector almost two decades ago.
As defined by the World Health Organization (WHO), UHC refers to an outcome whereby all people have access to the services they need, where the services are of good quality and the users of such services do not face financial hardship. These are useful goals, but as far as desired outcomes go these are certainly not novel, even in the context of low- and middle-income countries (LMICs). Many of UHC ingredients can be found in a framework document for the future development of India’s health sector in 1946, as also in its 1950 Constitution. Moreover, health sector policy in most high-income countries and countries of the formerly socialist bloc was motivated by considerations of population-wide health coverage well before the term UHC became fashionable.
It is also not obvious that reaffirming the goal of UHC (as a WHO resolution, or signing up to SDGs) implies a fundamentally new understanding of how to achieve it: namely the means, rather than an endpoint. A World Bank review (Giedion et al 2013, p.4) concluded that “when it comes to understanding how UHC is to be achieved, it becomes clear that it is a broad and somewhat vague concept…” What about the country agreements to UHC as a potential pathway for legal enforceability of their obligations to bring about affordable care to the most in need? In fact, access to legal redressal mechanisms is considerably lower for the poor, compared to the non-poor, and not just in the realm of health. And the wielding of the UHC baton is unlikely to be effective in challenging the existing resource allocation patterns in settings where Ministries of Health are weak.
Many of the major health policy challenges that occupied experts before the lexicon of UHC emerged on the scene, persist. Rural and remote populations continue to lack access to health services (and personnel) in many LMICs. I remember being at a workshop almost 20 years ago where Victor Fuchs (one of USA’s premier health economists) pointed out that even Stalin faced this problem and failed to make doctors’ work in rural areas in the USSR in the 1930s. Imperfect targeting of benefits of health sector programs is common, often with the marginally poor benefiting more than the very poor. And many countries are continuing to grapple with effective coordination in the functioning of public and private actors in the health sector. It is unclear that UHC has helped to better focus minds on these problems. If anything, there is the risk that short-term ‘UHC-solutions’ or strategic choices of indicators of progress towards UHC might sideline the heavy lifting required to address deeper health policy challenges. In federal structures, a push towards UHC by central governments can generate resentment and pushback by local governments, as occurred recently in India.
In short, the jury on UHC as a lynchpin for effective health strategy is still out. Is there any value then to the UHC agenda? Two possibilities suggest themselves. One area where the UHC approach does differ, at least when considered from a human rights perspective, is its focus on distribution of outcomes on the pathways to an end, and specifically the idea that no-one should become worse-off (only Pareto-superior options are acceptable) along the path to full coverage. In that sense, a human rights perspective on UHC imposes restrictions on the types of policies that can be introduced. Second, achieving improved outcomes in health in not just a technical matter but also a matter of politics. The lexicon of UHC can then serve as a rallying cry for groups placing a high priority on improved allocations to health.
References U. Giedion, E. Alfonso, Y. Diaz. 2013. “The Impact of Universal Coverage Schemes in the Developing World: A Review of the Existing Evidence” Universal Health Coverage Study Series No. 25. Washington DC: The World Bank.