Investing in equitable societies

In Sweden, publicly-funded services are designed to respect privacy, dignity and quality of care. As a result, the country has one of the highest life expectancy rates in the world.

By Gunilla Carlsson, UNAIDS executive director, a.i.

Life expectancy in Sweden is among the highest in the world. The Swedish healthcare system is anchored in the values of human dignity and solidarity and is explicitly committed to ensure the health of all citizens. The system is designed to respect everyone’s rights, regardless of their status. It is largely financed by taxes – about 80% of all health investments are public investments.

My siblings and I were raised to value and cherish a social contract based on equity and redistribution whereby part of our income would go to the state and, in exchange, the most underprivileged in society would access free, quality public services, including health care. One day, we might need it too. And that day, the system would take care of us. Such was our luck.

Not everyone today is that lucky. Globally, every year, 100 million people fall into poverty because of healthcare-related expenditures. The risk of impoverishment is much higher in poorer countries and the most marginalised communities. That is also where fiscal space is most constrained and compulsory contributions into redistributive risk pools are virtually non-existent. There we see health inequities weakening society as a whole and leading to despair.

Universal access to high-quality, affordable health care is key to a healthy, prosperous and cohesive society. The economic case for universal health coverage is strong. The Lancet Commission on Investing in Health found that 24% of income growth in developing countries between 2000 and 2011 resulted from health improvements. Access to care reduces workers’ absenteeism and boosts productivity.

Expanding universal health coverage can also reduce overall inequalities and thereby bolster social and political stability. Greater health equity can narrow inequality in income, wealth and education through better school attendance, higher educational attainment, capital accumulation and use of family planning. These are the determinants of a person’s ability to escape the poverty traps that can affect life chances for families across generations – and are particularly significant factors to create opportunities for women and girls.

Group declarations

Recent declarations from the G7, the G20 and the United Nations General Assembly reiterate countries’ commitment to universal health coverage. This is definitely the smart political choice – the right to health is a pillar of equitable development – a building block to enable all people to participate in the political, social and economic life of society as full-fledged citizens. Providing people-centred, rights-based, gender-equitable universal health coverage systems requires countries to develop new models of healthcare delivery and financing.

Here are some of the essential elements to collectively chart the path towards universality, inclusion and keeping people healthy:

To leave no one behind, leaders need to understand the barriers to equitable health outcomes

Service coverage without access will not lead to better health. Geography, cost, stigma, inequality or harmful laws can leave people behind. Implementing the principles of universality means eliminating all forms of discrimination against vulnerable and marginalised people. This demands, among other things, gender equality and eradicating gender-based violence as well as working across ministries to tackle the social and other determinants of health.

To deliver results, leaders need to encourage inclusive governance of universal health coverage

Communities and civil society have historically fulfilled key and often unique roles to improve health equity. Doing so includes promoting and defending health as a rights and social justice issue, monitoring and tracking political health commitments, and addressing service gaps for people most excluded. Community organisations contribute as demand creators, agents of change, and implementers and demanders of accountability. Universal health coverage needs a whole-of-society approach, one that includes the meaningful engagement of communities and civil society, from the clinic to the health policymaking table. By establishing inclusive monitoring mechanisms at all levels of health systems, everyone can play a role in holding governments accountable for universal health coverage.

To scale up from millions to billions, leaders need to support new delivery models

Among the myriad of lessons learned from the AIDS response is that remarkable achievements would not have been possible without the contribution of communities to bringing testing, treatment, peer counselling and prevention to scale. Expanding health coverage must not mean lower quality. Community groups need more resources to deliver impactful results. Investments in community health workers will create new jobs and economic opportunities, which are key to promote gender equality and decent paid work. Overall, communities need to be better supported, equipped and recognised as the heart of primary health care.

At a time when humanity faces crises ranging from climate change to gross inequalities of opportunity and wealth, it is time to recognise the limits and pitfalls of political short-termism. A healthier future requires bold leadership. One place to start is to take the needed tough decisions to ensure that everyone realises their right to health and well-being.