Universal health coverage alone won't radically improve global health
This Sept. 23, the United Nations General Assembly invites world leaders and delegates to converge for a meeting about universal health coverage (UHC) that's expected to result in a political declaration.
Since 2012 UHC has become a policy framework through which the UN has pledged to improve global health. Getting countries to implement UHC globally is also a now a sub-goal in the larger global aim of ensuring healthy lives and promoting well-being for all at all ages (Sustainable Development Goal 3) by 2030.
The important place of UHC in the UN's agenda means that countries such as Canada, for example, are assessing their international development partnerships partly by considering how much "progress" Global South nations are making with UHC. Meanwhile, health researchers are holding Canadian leaders accountable for whether Canada's oft-touted universal health care is truly sufficient to realize population-wide health.
The World Health Organization (WHO) first proposed UHC, defining it as a goal "to ensure that all people obtain the health services they need without suffering financial hardship at the point of receiving them." The WHO also recognizes that primary health care—not just being able to access services when sick—must be in place to realize healthy societies. Last year, the UN affirmed that primary health care is the foundation for achieving UHC.
As a researcher in the area of public health and health systems, I hope that any global meaningful standard for universal health coverage will include benchmarks for primary health care including patient participation in health systems. These are necessary to enable countries to effectively evaluate the true impact of health investments.
The UN's current 2012 policy on global health doesn't address this concern. A new political statement supporting UHC should.
If countries only pay lip service to a commitment to primary health care (PHC) as a means of investing in people's wellness, the world will be working with global health goals focused on responding to illness and disease management.
Much to be desired
Right now, there isn't a single country in the world with 100 percent universal health coverage. All global health systems have room to improve. But UHC as it has been held up as a UN goal leaves much to be desired.
In 2012, the former director-general of the WHO, Dr. Margaret Chan, said that "universal health coverage is the most powerful unifying single concept that public health has to offer, because you can realize the dream and the aspiration of health for every person …."
In ideal terms, UHC would cover as many people as possible with an essential package of health-care services without making them pay upfront.
But right now countries define this differently, making it easy to mask how effective health services are and how many people they're actually reaching.
Many countries report having implemented universal health coverage—but each country offers quite different levels of services and financial protection, to different portions of the population.
Dubious access, inadequate coverage
For example, when governments design health services, they can assign a health clinic or a hospital to cover larger or smaller catchment areas, without much focus on who can actually access or use the services.
Afghanistan, for example, claims 60 percent of its population is covered with basic health services within two hours of walking distance. But people's true access, and how they can actually use these services, not to mention their quality, is dubious.
The set of services can also be dramatically comprehensive or narrow or limited to a certain ceiling.
Canada, for example, globally known for its publicly funded health-care system, covers all people with "medically necessary services." But many Canadians understand all too well what is not covered: out-patient medications, home and community care and institutional long-term care.
Three main goals of a health system are improving health, financial protection and responsiveness.
A new vision for UHC must hold countries accountable for responsiveness towards patients' medical and non-medical needs and preferences. Health systems are inherently social institutions in which the power dynamics between providers and recipients affect how they work. Health systems must consider how patients are treated as persons, and the environments where patients find treatment.
Besides patients' need for technically competent services, patients need to exercise their agency in making decisions about their care. And collectively, patients as citizens need to participate in health-care policy, planning and provision.
Primary health care
A meaningful statement about UHC must address the fact that ensuring health is beyond the scope of ministries of health and the health-care sector alone, and that social factors impact health and community participation.
David Sanders of the School of Public Health, University of the Western Cape, South Africa, and an international team of health, epidemiology and public health researchers summarize priorities of PHC to include: universal and equitable access to health coverage; individual and community participation in health policy and planning; collaboration across sectors to address determinants of health; using appropriate technology and resources in a cost-effective way.
For the sake of better global health, UN decision makers should realize a vision for people to lead healthy lives, not just create policy that responds to illness.