(this blog is the write-up of an interview by Action for Global Health with Rob on UHC)
When it comes to health, divided we fall, united we stand. Universal Health Coverage (UHC) day has mobilised over 400 organisations from over 80 countries. Indeed, you have the likes of the World Bank, Oxfam and Action for Global Health working together to rally behind the belief that everyone everywhere should have the right to health. This is a testament to its importance. UHC and health financing have been at the centre of fractious debates over the years, yet the emphasis on financial protection has remained extremely strong; political commitment and public financing are the keys to UHC. UHC is not a one-size-fits-all concept, and countries need to adapt it to fit the needs of their population. There are many factors which affect health, especially education. More money should go into girl’s education which is a huge determinant of health. Public transport, clean water, and more equitable income distribution are all issues that also need to be addressed. Equality equals happiness. The more equitable a country is, the healthier its people are.
UHC means covering the entire population – including HIV services, the elderly and mental health- with no out of pocket payments. Yet, the big debate is on what should be included in the benefit package. As countries become wealthier, they can increase services. Thailand provided universal entitlement to the entire population with a modest benefit package but as it became richer it added services like haemophilia treatment. This works better than fragmenting the population. An over-zealous budget package can result in the wealthier sector of society having access while the poor get left behind. Undoubtedly the bill will be large, but ultimately everyone should be ensuring that lifesaving commodities are on the table, especially for women and children. Typically for middle-income countries that make the big step it’s about 1% of GDP. India looks set to go ahead with universal access to medicines and diagnostics. So far, 324 generic medicines are to be provided free of charge to the population.
There should also be a list of bare minimums but countries should have latitudes to design their own benefit package, which invariably needs to involve civil society. Certain elements are blindingly obvious- like childhood immunization – but there isn’t much of a need for a malaria fund in Norway, so it should be determined by the needs of its population. In addition, access to contraception is not free in most countries. It’s crucial that countries develop UHC packages that include family planning services. The tremendous interest by donors and development agencies in this area means that family planning services are left out of national benefit packages.
Monitoring and financing UHC
Publically financing healthcare is the only solution. For countries like Indonesia, on the verge of spending billions of its own domestic funding, the potentially long term consequences could be devastating. Likewise, with HIV services, this is a long term developmental issue not a short term aid issue. It is vital to get these services domestically financed. In Indonesia, donor financing is drying up and services reliant on donor financing will see their share of health expenditure decrease exponentially. UHC in the overall goal would put pressure on governments to finance health systems properly. Many of the reasons there are push backs from governments is that there is no pressure for them to deliver.
To ensure the implementation of UHC, it must be monitored accordingly. First of all, it must have specific coverage targets. Secondly, people with diseases must be treated on time- we can do that through facility-based data or surveys. Thirdly, we must measure exactly how much people pay on health services. Likewise, UHC should not focus solely on curative health services as preventative measures are also critical.
There is a tendency by politicians to overinvest in urban tertiary hospitals as a way of demonstrating that they are bringing health to the community. But who do these actually benefit? Typically, only the rich, powerful and urban elite. People in rural communities will never set foot in these places. The Queen Mamahato Hospital in Lesotho is exemplary of this where more than half the country’s entire health budget (51%) is monopolised by just one facility, resulting in a reduction in HIV services to rural areas. Monitoring this is essential.
Most investment in health comes down to politics, and UHC is undoubtedly political. Wherever there are elections, we in the health world should be politicizing health. We are missing a trick in recognising how politically powerful this is- health is a hot issue worldwide. The idea of the UHC Policy Forum at Chatham House is to explicitly engage in politics to have a very open debate – not just about involving governments in power but being prepared to share these thoughts and experiences with opposition politicians. We must recognise that we need to help change laws by mobilising communities and improving procurement systems, but all need increased financing. The best way to finance UHC within the health sector is to rally around public financing. What we need is to empower under-served communities to demand the health care they need, and for Civil Society Organisations to take these messages to politicians.
Civil society interventions key to UHC
Civil society plays an incredibly important role in implementing UHC through social mobilisation, service provision and accountability. Civil society puts political pressure on politicians to deliver, as was seen in Rajasthan with the free medicines initiative, and Ethiopia has recruited 30,000 health workers by mobilizing the community to provide services.
One lesson we have learned is that it’s not appropriate to expect civil society to directly finance health services or pay out of pocket. Likewise community based health insurance doesn’t work. Community health workers who disseminate information, and provide service delivery should be paid for it.
Civil society establishes accountability mechanisms. Civil Society Organisations hold sway with the population and articulate to their politicians through demonstrations. This is the importance of having UHC in the goal, to help people understand what it means.
It is vital for Civil Society organisations to expose bad practice of UHC and human rights abuses, and the WHO to set norms and standards. This all fits under umbrella of UHC- the universal right to health services that you need. Ultimately, UHC is very simple. You know when you have it and when you don’t. Everyone on the planet should get the health services they require, that is the ultimate goal of UHC, isn’t it?