A (by now, rather famous) quote from Margaret Chan supports the global branding of Universal Health Coverage (UHC). In the quote, the WHO Director-General states: “I regard universal health coverage as the single most powerful concept that public health has to offer.”
I argue in this short piece that this quote does not capture the very nature of UHC, is somewhat misleading and can lead to (possibly, massive) implementation failure. The quote is a key component in the packaging of UHC, though, globally and nationally. It occupies a prominent place in all key communication tools of WHO related to UHC. You find it for instance on the WHO UHC website. Above, I highlighted some of the terms in the quote I find especially troublesome.
Let’s focus first on UHC as a ‘single concept’.
Dr Margaret, engages herself deeply in this quote (see ‘I regard…’). She gives the quote in this way all the symbolic value attached to her function as the Director-General of WHO, but also commits herself as an individual human being to UHC. This personal engagement is powerful and important. So far so good.
Admittedly, the phrase ‘the single … concept that …’ may be stressing more the overall powerfulness of the UHC idea, in the quote, rather than UHC being a ‘single concept’.
Still, the very term ‘the single concept that …’ is a bit misleading. It gives the overall impression that UHC is a unique, clearly circumscribed concept that can be reached fully by Public Health (and once achieved, can be taken pretty much for granted). True, that is not WHO’s view. Elsewhere for instance WHO acknowledges: “Universal Health Coverage is a dynamic process. It is not about a fixed minimum package, it is about making progress on several fronts”. WHO also considers UHC as an “umbrella target” in the SDG health agenda, with the target 3.8.
If you have Joe Kutzin’s razor sharp intellectual abilities, then UHC is in fact a clearly defined concept – in a recent WHO Bulletin piece, he sets UHC (successfully) apart from Health Systems Strengthening (HSS), resilience of a health system & health security. In a previous one, he already convincingly argued that not anything goes under the umbrella of UHC.
Yet, for most people on the globe, not the least citizens, UHC will always be a bit fuzzier, and not that easily isolated from other objectives (or even means). And that is just fine! Indeed, the ongoing quest to set UHC “apart” (while at the same time seeing UHC as an umbrella target), while understandable, entails some risks as well. No doubt, the isolation attempt also has to do with other (good) reasons such as the need to have well-defined and measurable indicators, but there’s always a risk of branding UHC as yet another vertical program (which could then further jeopardize national health systems). This is one of the reasons why I find the quote a bit problematic.
The definition (as in target 3.8) – “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” – already tells a different story on the nature of UHC. As Joe, Adam Wagstaff & many others (including Chan) rightly argue, UHC in its very nature is composite. There are several key sub-dimensions such as equity and quality, it’s about more than (just) access and coverage (or the UHC ‘cube’). Those concepts of equity and quality are themselves hard to define, grasp, measure and achieve, and require very complex interventions that still need more clarification from the global community of researchers.
Lately, UHC is also increasingly being linked to global health security & resilient health systems, for obvious reasons – in the words of Marie-Paule Kieny for example, the “Post-Ebola realisation of the crucial importance of HSS, and the intimate connection between HSS, UHC and health security”. Those ways of looking at UHC are great, and deserve a more prominent place in the global branding effort.
I have a hunch that the original quote from Chan was inspired by the initial focus on the (still very relevant) “UHC cube”. Yet, by now, UHC has become a “benign” beast with many more heads and subdimensions – quality, equity, global and national health security concerns, … are all becoming more important in the new SDG UHC era. So rather than UHC as a ‘single’ concept, I’d argue it’s ‘married, and even polygamous & unfaithful’ ! (Which might, at least in the UHC case, not necessarily be a bad thing 🙂 ).
Let’s go then to the second criticism: the quote states that UHC is a concept “that …Public Health has to offer”.
In my opinion, public health in several low and middle-income countries has a rather limited clout and leverage in terms of boosting and providing of UHC. In several African countries, for example, public health is integrated in the ministry of health or the ministry of public health. Medical doctors usually lead this governmental body. While they do very important work, I strongly believe that UHC requires a double social transformation: the first one involves going from an individualistic perception of life to a society with more social cohesion and a new social contract; a second transformation is also required to reach a global and national “mutualization” of efforts and resources in order to achieve better social inclusion and protection. This double social transformation requires in many LMIC settings, among others, a key governance transformation, which would hopefully spark – very importantly – also more trust in (national, regional, …) governance entities. The Ebola outbreak in West Africa just showed – again – the importance of the latter. Something similar is true for UHC – by way of example, why on earth would people in communities trust an (in their view unreliable and/or corrupt) government with collecting national health insurance premiums? Catalyzing and leading these sorts of broad societal & political transformation, taking also into account the unpredictable and complex nature of UHC reform, are far beyond the scope of capacities of a public health body dominated by medical doctors. So in the post-2015 era, among others, “governance” has become a key UHC concern, as parts of WHO themselves emphasize.
The focus on ‘public health’ in Chan’s quote can probably to a large extent be explained by the (initial) capture of the concept by the ministries of health, and the tacit or explicit exclusion of other key social bodies that have a key (and often more crucial) role to play in the process.
So with the current knowledge of the global health community, I feel the quote has to be adjusted. It has to recognize that ‘public health’, dominated as it tends to be by medical doctors, is limited in its capacity to help societies adopt and move faster to UHC. At the very least, the quote would have to use a term like ‘Public Health 2.0’. Also, Chan would do well to recognize that UHC is not particularly ‘single’ either.
For the ones who want to quote me on this: “I strongly believe that UHC is a polygamous, married and slightly unfaithful concept. The achievement of UHC requires the engagement of all the ‘driving forces’ in the country (as well as relevant global ones) under the leadership of – transparent and trusted- public governance.” This is the kind of UHC quote, I’d like Chan (or her successor) to come up with someday. (I admit, it feels a bit odd, having ‘unfaithful’ and ‘trusted’ in the very same quote. But health systems are complex!)
By the way, WHO and many other key global health actors in favour of UHC seem to understand this too, increasingly – see the idea to set up a UHC 2030 Alliance, as discussed at the latest IHP+ Steering Committee meeting in Geneva.
So who knows, maybe one day Chan will utter the magical words?