Much progress has been made in the universal health coverage movement by developed and emerging economies alike, proving that political will is the key driver to achieving the seemingly impossible
By John Kirton
Universal health coverage, as the essential foundation for attaining health for all, has long been seen as an issue for national or even subnational governments. At the international level, it has largely been left to the World Health Organization, its regional affiliates and the members’ health ministers that govern these bodies to provide the necessary encouragement and practical support.
This has now changed. Universal health coverage is rapidly rising to become an integral part of global governance as a whole. It has become a key political choice at the highest level, and one of the most important ones of all.
This publication thus takes the message about the power and promise of universal health coverage beyond the health community to global governance as a whole, and all the actors that shape its work. Yet the key component of implementation remains at the national and local levels. It must be met by building comprehensive health systems at home, based on local talents, to address in an integrated way all the health harms that people face.
The propellers of universal health coverage’s global governance ascent
Several urgent, unstoppable forces are propelling universal health coverage’s rapid global governance ascent.
The first force is globalisation in its many forms, starting with climate change, biodiversity, ecological loss and human migration. They bring escalating harms to human health and ensuing demands for health care on a global scale, anywhere at any time in a complex, often unpredictable, fast-moving world.
A second force is the return to global economic growth from the great global financial crises of 2008. This brings shifts in the political focus from finance to health, new wealth to meet the needs for health and new digital technologies and scientific innovations to make large, if disruptive, leaps ahead.
A third force is the planet’s growing population, which is rapidly ageing in many places. This brings a new scale and type of burden to health systems often already struggling to cope with existing demands.
A fourth force is pressure from people who see governments delivering wealth, health, security and other things for the rich rather than in improved living conditions for all and in particular to those economically struggling individuals whose sudden, spiking healthcare costs could make them poor at any time. With so many people lifted out of poverty in recent decades, the threat of plunging back due to the lack of universal health coverage is a major political driver.
The phases of UHC’s global governance ascent
These forces have driven universal health coverage upwards and outwards to the very top of global governance writ large. The launching pad was built long ago, on 10 December 1948 when the United Nations General Assembly, meeting in Paris, created the Universal Declaration of Human Rights. Article 25 declared health to be a human right: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family … including medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability.”
It was reinforced in Alma-Ata, Kazakhstan, on 12 September 1978 when the International Conference on Primary Health Care affirmed in the opening of its declaration that health “is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose full realisation requires the action of many other social and economic sectors in addition to the health sector”.
The current lift-off came at the historic UN summit in New York on 25–27 September 2015. World leaders launched the 2030 Agenda and its 17 Sustainable Development Goals. SDG 3 on health contains, for the first time at a UN summit, a target to provide universal health coverage. SDG 3.8 promises to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.
In making universal health coverage an integral part of the 17 SDGs and their 169 targets that bind all countries poor and rich, global leaders recognised that it does not belong in a self-contained health silo, even one supported by related social and economic sectors. Rather, it is an integral, intimately connected part of the sustainable development of everyone in every way. It has thus become a political choice for the whole of governance, for all who live on the precious, precarious planet we share.
To implement this visionary promise, the key institutions and leaders of the UN and Bretton Woods bodies started work in a focused, energetic synergistic way.
Description John Kirton, professor of political science, the director and co-founder of the G7 Research Group and co-director and founder of the G20 Research Group
At the centre stood the World Health Organization, as the central custodian of SDG 3 and target 3.8. It boldly aimed to lift one billion people out of poverty by providing them with universal health coverage by 2030. Under the leadership of Dr Tedros Adhanom Ghebreyesus, on 6 March 2019, it reorganised itself to more effectively reach this goal.
Dr Tedros also declared that WHO would work more closely with the global summits of the G20 and G7 in this cause. He aimed “to strengthen our role in international political fora like the G7, G20 and multilateral negotiations that we were not really exploiting”.
In doing so he was wisely choosing as allies many of the most powerful leaders of many of the most powerful countries in the world, whose summits and ministerial meetings have recently begun to promote universal health coverage.
At their Hamburg Summit in 2017, all G20 leaders declared: “We recall universal health coverage is a goal adopted in the 2030 Agenda and recognise that strong health systems are important to effectively address health crises. We call on the UN to keep global health high on the political agenda and we strive for cooperative action to strengthen health systems worldwide.”
At their Buenos Aires Summit in December 2018 they added: “We encourage the activities of World Health Organization, together with all relevant actors, to develop an action plan for implementation of health-related aspects of SDGs by 2030. …We reaffirm the need for stronger health systems providing cost effective and evidence-based intervention to achieve better access to health care and to improve its quality and affordability to move towards universal health coverage, in line with their national contexts.”
For the G20 summit that he will host on 28 – 29 June 2019, Japanese prime minister Shinzo Abe has made health a priority and put universal health coverage at the core.
The smaller, older summit of the world’s major market democracies is acting too. At the Ise-Shima Summit, hosted by Prime Minister Abe on 26 – 27 May 2016, G7 leaders promised: “We commit to take concrete actions for advancing global health as elaborated in the G7 Ise-Shima Vision for Global Health, highlighting that health is the foundation of economic prosperity and security. We commit to promote Universal Health Coverage (UHC) as well as endeavor to take leadership in reinforcing response to public health emergencies and antimicrobial resistance (AMR) which could have serious impacts on our economies.”
In 2019, French president Emmanuel Macron has put health on the agenda as part of his central theme of fighting inequality for the G7 Biarritz Summit he will host on 24 – 26 August. To pave the way, G7 health ministers, assembled in Paris on 16 – 17 May, “reaffirm[ed] that primary health care is a cornerstone of a sustainable health system for Universal Health Coverage (UHC) and health-related Sustainable Development Goals, to reduce inequalities and contribute to the improvement of well-being and socio-economic development, as well as social stability and security in all countries”.
At the regional level, other summits have supported and often led the call. The African Union has put health at the centre of its summit agenda and the Caribbean Community has pioneered the global effort to produce the critical component of preventing non-communicable diseases.
The ascent of universal health coverage to the very peak of global summit governance will continue at the United Nations in New York on 23 September 2019, at the UN High Level Meeting on UHC. Its theme is Universal Health Coverage: Moving Together to Build a Healthier World. It will culminate in a UN political resolution to stimulate and shape the path to the achievement of the 2030 goal.
The benefits of universal health coverage
In making universal health coverage so central to the SDGs and global governance as a whole, these global leaders recognise that the benefits brought by universal health coverage are very big and broad. They begin with reduced child and maternal mortality, increased cognitive capacity and learning for children and longer years of life expectancy at birth.
They continue with a more productive workforce with more and better jobs, a more innovative economy and enhanced economic growth, development and prosperity.
They include individual and family income security, stability and freedom from catastrophic health expenditures that can plunge people into poverty or even death. They extend to poverty reduction, equality for women and girls, social cohesion and inclusiveness, and happier, better functioning, more stable and secure societies overall.
They offer some protection against and mitigation of the compounding climate crisis and ecological devastation, and they help bring the values of dignity, social justice, fairness and equality to life.
As these enormous benefits of universal health coverage pull world leaders to act, they are also pushed by the proven success universal health coverage has brought when introduced by countries around the world. Such proven successes in securing universal health coverage provide all a firm foundation, several models and an inspiration on which to build.
Among the advanced economies, Germany looks back on 150 years of developing a universal health system based on social insurance, and remains a global leader to this day. In 1948 an economically exhausted United Kingdom introduced the National Health Service that fuelled its ensuing economic growth and innovation and became a fundamental feature of its social, political and cultural life. In the 1950s a recently devastated Japan started its successful campaign that eradicated tuberculosis and helped put in place the high-quality universal health coverage that its long-lived people enjoy today.
Among the emerging economies, in 2003 Turkey adopted its Health Transformation Programme that achieved universal health coverage a decade later. Uruguay is the first country to become 100% free of indoor tobacco smoke in the Americas, thereby reducing the burdens on its emerging universal health coverage system. Thailand has also been a pioneer.
Among developing countries, China expanded its national health insurance from 317 million people in 2005 to more than 1.3 billion a decade later, to cover 95% of its citizens. India eliminated polio in 2014 through an immunisation programme that formed the basis of a healthcare system now reducing other diseases and fostering high-quality universal health coverage to address them all. Niger is now pointing a path to the future, by pioneering digital solutions for universal technology coverage that could bring universal health coverage to more people.
Investing in universal health coverage
Amidst these compelling pulls and pushes, global leaders, their citizens and stakeholders remain concerned about the money, asking how much will universal health coverage cost, where will the money come from and is it the wisest place to invest the limited funds at hand.
As answers to these important questions, the evidence shows that investing in universal health coverage is one of the smartest economic and political choices a country and the global community can make. It is reliably estimated that one dollar invested in immunisation – a critical component of universal health coverage – will bring $16 back in immediate savings in healthcare expenses and reduced productivity and an ultimate return of $44 when the broader rewards of longer, better lives are factored in.
To finance this smart choice for universal health coverage, the money can come from many sources. In general, economic growth, budget reprioritisation and efficiency-improving measures are the main drivers of fiscal space for mobilising a country’s own domestic resources. This includes the taxes raised by a fair and effective national tax system, in some cases also taxation of unhealthy goods and products such as tobacco.
Public financing is essential for countries to make sustainable progress towards universal health coverage. Well-designed mandatory systems of social solidarity with a redistributive component can take different shapes as existing examples from all around the world show. Many systems still include co-payments and user fees that can deter people from accessing services.
External funding (in the form of aid) represents less than 1% of global health expenditure and is a small and declining proportion of health spending in middle-income countries; but it is increasing in low-income countries unable to invest fully in universal health coverage on their own.
Here new aid donors can be mobilised, and all official donors can increase their aid and the share of it devoted to universal health coverage. Such traditional concessional international public resource transfers can be supplemented by several international sources, such as contributions in cash or kind from non-governmental organisations and even a possible surtax on the world’s billionaires.
To outline directly and in more detail why universal health coverage is a political choice – and a choice that must be made at the highest level for global governance as a whole – the contributions to this publication unfold as follows.
The opening contributions, in Section 1 on ‘The global SDGs’ commitment’, begin with the whole of global governance at the highest level. It comes with the call to action from María Fernandez Espinosa Garcés, president of the UN General Assembly, which will host the high-level meeting in September 2019, amidst the surrounding UN summits on the SDGs taking place there.
Her call is reinforced by Amina J. Mohammed, UN deputy secretary-general. They are joined by Dr Tedros, WHO director-general, at the core of the UN’s galaxy of dedicated health organisations bringing universal health coverage to life. Achim Steiner, who as head of UN Development is responsible for integrating the entire UN’s work on the SDGs, highlights how investing in universal health coverage will help realise them all.
Section 2, ‘Editors’ introductions’, highlights a powerful but often overlooked solution to the challenge of securing universal health coverage: mobilising equally the talents, voice and influence of half of the human community – women – who are all too often left out. Ilona Kickbusch notes that turning the gender gap into a gender dividend will help bring universal health coverage to solve many of the problems that leaders face, from finance, development resources and employment to migration and security, both at home and abroad. The solution lies in the ‘3+5 formula’ – forging a full leadership alliance between SDG 3 on health and SDG 5 and gender.
Section 3, ‘Country leaders speak out on universal health coverage’, contains contributions from the leaders of key countries from around the world. They start with Prime Minister Shinzo Abe of Japan, who will host the G20’s Osaka Summit in June, and President Emmanuel Macron of France, as host of the G7’s Biarritz Summit in August. They continue with Chancellor Angela Merkel of Germany, President Tabaré Vázquez of Uruguay, President Uhuru Kenyatta of Kenya and former prime minister of New Zealand, Helen Clark.
Section 4, ‘Top economists speak out for universal health coverage’, answers immediately the critical questions of where the money will come from and what impact will it have. Its contributions come from leading economists from the academic, NGO and international organisation communities and those who have contributed directly to the work of the UN, G7 and G20.
Section 5, ‘What to expect from the UN High Level Meeting on UHC’, presents the perspectives and priorities of several key stakeholders. They include the HLM’s pioneers and those representing youth, the health workforce of the future, patients, women, mothers and the newborn.
Section 6, ‘Why we should be optimistic’, outlines why great expectations could be realised, based on the traditional and innovative progress already underway and achieved in many countries around the world since the devastation of the Second World War. The contributions highlight the accomplishments of Turkey, France, Japan, India, and the Caribbean and other small island developing states, while those of China and other success stories are added in other sections.
Section 7, ‘Supporting the vulnerable’, highlights how and why universal health coverage is needed to help some of the largest but vulnerable groups of people in the world. They include those still suffering from and threatened by HIV/AIDS, poor food and nutrition, stroke, dementia and other diseases of the brain, mental health, and women and girls.
Section 8, ‘Keeping the world safe’, explores the broader context in which the quest for universal health coverage is embedded and the immediate threat its actual delivery faces in many conflict-ridden places now. It focuses on the need for health security, with contributions from those working with dedication and distinction under the most difficult and violent circumstances, to make universal health coverage in its most basic form a reality on the front line.
Section 9, ‘Addressing the inter-sectoral challenge of the SDGs’, shows why and how universal health coverage from SDG 3.8 is essential to meeting the many other SDGs. It contains contributions from the head of the UN functional organisations dedicated to labour, social security, the environment and biodiversity, and to preventing pollution from hazardous waste and poisonous chemicals. It includes the work of those in regional organisations forging the links between health and climate change and building sustainable development as a whole.
It ends with a review of the advances made on universal health coverage by the central global plurilateral summit institutions of the G7 and G20 and recommendations about what they might add at their sequence of summits in this summer through to the UN High Level Meeting on UHC, in September 2019.