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Affordable Universal Health Coverage – a conceptual challenge

By Joao Costa
on November 19, 2019

In the aftermath of September celebrations of the United Nations General Assembly’s resolution adopting the objective of affordable Universal Health Coverage (UHC) for 2030, skeptical feelings crept in.


It was reported then:


“United Nations members today adopted a high-level political declaration raising the stakes in the global push to ensure everyone in the world has affordable access to health a decade from now.”


A critical reflection on what affordability and UHC entails finds inconsistencies. Affordability refers to what can be paid for; it identifies thresholds, above which, nothing is obtained, and below which, everything can be provided. However, limits may vary in time, locations, population segments, etc., and remain undefined.


Bringing the two concepts together, we could ask: will an affordability threshold be the line defining what is in the UHC packages? What will then be sacrificed in the name of affordability: selected health services or the universality principle itself?


Surely, affordability requires narrowing down the services that people and/or insurers and governments on their behalf can afford to pay. UHC is a broad concept; it does not set limits of services to be guaranteed in relation to existing health needs. There should not be doubts that UHC cannot be based on comprehensive packages of services such as available in developed countries.


On the other hand, ironically, if we think that one cannot have what is not affordable, and that ‘universal’ cannot mean the same types or level of services for everyone, we may arrive to the conclusion that we already have universal and affordable healthcare everywhere. What is missing in this consideration though is equity. This word, equity, seems to be silently leaving the world stage. Having said that, the following considerations seem relevant:


  1. Universal Coverage is a programmatic definition of intended benefit/entitlements. Equity is a normative criterion and principle to judge actual distribution of benefits/entitlements. Affordability is a criterion to observe occurrence (or not) of financial constraints for reaching intended benefits/entitlements.
  2. Universal coverage sounds like the programmatic answer to the equity normative principle. Health services are planned to reach all. However, a system may define itself as providing universal coverage, but still be inequitable because coverage does not assure same benefits’ availability at every location. The British NHS is programmatically defined as universal; however many studies have shown inequitable geographic distribution of access to services;
  3. Healthcare provision may not be equitable because, for instance, lack of human resources or infrastructure to cover everyone. But, where cost-benefit analysis argues against building a hospital, one concludes that economic rationale should prevail over affordability-guided decisions. Trade-offs exist; if something is made affordable, something else may become unaffordable. An economically unjustifiable investment does not require considerations of whether it is affordable or not. Affordability does not override economic efficiency criteria; it is not a sufficient condition to justify expenditures; it is not a normative principle.
  4. Concerns with affordability point at what has not been provided. But, whoever engages in the task of measuring the volume of unaffordable services, will face infinity. The universe of services not provided because they can’t be afforded is continuously expanding, as medicine gets more sophisticated, complex and more expensive;
  5. However, affordability is a suitable concept for communications in political forums. Its vagueness allows communications to circulate without necessarily reaching final commitments. Precision is dangerous; polarizes discussions. Instead, the affordability flag expresses comfortable “uncommitted commitments”. Likewise, UHC is good, as long as definitions of what it entails are not made explicit. One can easily get away without specifying what is to be affordable and who will pay for what;
  6. Besides that, affordability is not an issue that can be addressed and solved within health systems. The health system is too busy taking care of patients. The public health sub-systems do not have in their “terms of reference” the decision powers to solve affordability problems;
  7. The political system focuses on themes according to time availability; then it moves on to the next issue. Political attention is always in short supply. The decision-making windows of opportunity do not include the verification of results. The use of vague words facilitates hurried “uncommitted commitments”. When affordability and UHC occupy center stage, only communications of intentions and promises need to be made. It cannot be different; many themes are projected on the affordability screen;
  8. Affordability comprehends everything a family needs to pay for, not only health. How to choose from when deciding about affording: education, food, energy, water, sanitation, transportation, housing, communication, leisure, health, etc.? The public health systems do not need to (and in fact can’t) deal with solutions of affordability across the varied needs of the citizenry.


To be sure, there are serious affordability problems, and coverage of basic healthcare is far from universal. These themes have particular relevance in the context of health as a human right. No doubt the adoption of those concepts bears the hallmarks of good will.


However, users have been facing affordability problems since user fees exist. Abolition of user fees at Primary Health Care (PHC) level could therefore be a clearer target instead. It would require courage to adopt something precisely defined in such terms. Nevertheless, a resolution stating ‘free PHC for all’ would prevent skepticism.