When João Costa sent his blog to IHP’s editorial team, his accompanying mail finely mentioned that “his text might steer polemics, but they will be indeed healthy ones”. As a privileged pre-publication reader/reviewer, I couldn’t agree more – and hope that the few comments I offer below may positively contribute to the healthy exchange we all aspire to.
In his final paragraph, João Costa makes a case worth considering: why not adopting a more precise target than the rather vague UHC (remember, “definitions of what it entails are not made”), namely “a resolution stating free PHC for all”?
I would add a double question mark: are we talking about the same PHC and UHC?
When defining PHC back in 1978, the Alma-Ata attendees made clear that “health cannot be attained by the health sector alone” and that, therefore, PHC “means much more than the extension of basic services”. They also expressed a couple of caveats. “Resistance (…) is only to be expected (…) from political and professional pressure groups” and, making it more concrete: health “systems frequently restrict themselves to medical care, although industrialisation and deliberate alteration of the environment are creating health problems whose proper control lies far beyond the scope of medical care”. Which is exactly what happened. We reduced PHC to a medical implementation model: primary care became PHC. We had difficulties to accept that a model, built for a context that was still largely rural and with much less massive commodification, was hard to apply in a rapidly changing world. We felt reassured when we found out that primary care performed better than other service models, but turned a blind eye to the limitations of an essentially medical model. It is high time to realize that PHC-as-usual is not enough for health (also not when “free”), and to co-construct a society-wide implementation model for PHC, “in the light (…) of the social changes that are bound to take place in time” as the Alma-Ata signatories summoned us already back then.
As for UHC, João Costa observes that “a system may define itself as providing universal coverage, but still be inequitable”. While all too often true, there should be no confusion between how a system defines itself and what UHC actually entails. Among the three clearly stated objectives of UHC, equity is ranked first: “UHC embeds the goals of equity in service use, quality, and financial protection at the level of the entire health system and population”. With UHC explicitly included as a target of the SDGs, envisaging a “world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured”, it is hard to agree that the word equity “seems to be silently leaving the world stage”. Though I have to admit that in the technical translation from SDG targets to indicators, equity was partly pushed “off the table”.
So much for PHC and UHC. I’ll zoom in now on the core of João Costa’s argumentation: UHC’s affordability, starting with a quote that reformulates UHC as “to ensure everyone in the world has affordable access to health a decade from now”. But this is a somewhat unlucky reformulation by one author of one NGO. The political declaration as adopted by the UN General Assembly mentions ‘affordable’ 9 times, but (wisely so) never as sole condition for access.
I would go a step further and argue that lifting affordability from the individual level (where it should be out of the question because of the financial protection offered by UHC) to the national level (the primary locus for UHC policies) is inappropriate, even objectionable, and probably unneeded. From a conceptional viewpoint, affordability is no less normative than equity or universality: it perfectly reflects the values of outdated mainstream economics. Within a human rights perspective, it is obviously objectionable. And it might be unneeded altogether: when Costa Rica, Thailand and Ghana started their UHC journey, none of them could afford so. Costa Rica came out of a civil war, Thailand was the worst hit in the South-East Asian financial crisis, and Ghana just didn’t have the money. All three made remarkable progress towards UHC nevertheless. And, while a direct causal relation cannot be claimed, all three saw their GDP increasing in parallel with the progress in UHC coverage.
Enough said. Thanks, João, for starting the discussion. Let the readers take it further.