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First Comments on ‘Affordable Universal Health Coverage’

By Werner Soors
on November 20, 2019

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.

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Joao Costa says:

Dear Werner

Thank you for your comments. I would like to clarify a few points. First, I think your remarks about the term affordability are valid; the term in the references to the UNGA resolution present interpretations rather than the literal meanings. The way affordability are referred to without using the word is in references to avoidance of health related catastrophic expenses and financial hardship. You find these terms in the documents. But this does not seem to help much. Between facing catastrophic expenses or catastrophic health consequences some people may prefer one or the other. Some may end up with both. However the affordability problem appears when the individual has no real choice and catastrophic expense is not a feasible option. So, preventing catastrophic expense and financial hardship is less than half of the story; one may clinically say that only those who can afford have catastrophic expenses. Nevertheless, irony aside, the more serious problem is prevalent among those who have only the catastrophic health consequences alternative and no other option at all; here is where the problems of equity, fairness and affordability appears.

Second, however difficult it might be to define the components of PHC that are suitable to any country context, there should not be much to struggle with when we think about low income countries and the basic service that needs to be provided for maternal and child health and endemic disease that are easily preventable. The needs are clear and hit the eye. This is the case for many countries in Africa, Asia and Latin America. Of course the more developed the country, the more can be added to the package of healthcare services of PHC, and we do not need to mention the “one size does not fit all” jargon, because we all know we are talking about the possibility of big variation of packages. Nevertheless, if there might be difficulties in listing what should be in a PHC service package, never mind defining what should be under the UHC. As opposed to PHC, defining HC of UHC is a task many would not even try. PHC is a reasonably stable notion; that is not the case of UHC. The message of my blog was basically that any policy-maker may like to use the word Universal without paying much attention that the more it is added to the HC (health coverage) side of the concept, the less Universal it becomes, and therefore, less equitable; an ambitious and generous UHC package will leave many needs unanswered. That is the inherent inconsistency of the concept.

Third, when I say that “equity” seems to be leaving the stage, I agree that I should say more clearly “the headlines”. Equity is a concept that because of its comparatively strong normative character, assigning positive marks to what is equitable and negative otherwise, may cause discomfort. Politicians do not want to have the “equity finger” pointing at their failures, and inequities are always there, in a way or another, if one looks closely enough. So, much better than equity, UHC, whatever it means, is far less risky. Equity then is only included in the list of definitions of what UHC entails; it is one among many other characteristics. Equity is the argument of the oppositions, not of the governments, wherever they might be. Inequitable distribution of benefits is unfair, is unjustifiable, is against human rights, shows lack of attention to segments of the population or even deliberate discrimination, etc. These are some of the arguments opposition leaders may use. So, the term is conveniently left at secondary level, away from headlines, in between paragraphs that may not call much attention.

My fourth and last point is in relation to your comments about considering equity, UHC and affordability, all three, as equally normative. I would rather keep the distinctions I have made instead. Affordability is not normative at all; there is no attached value to either what is affordable or what isn’t, or the capacity and decision to afford or not. If a country cannot afford to provide radiation therapy, we can be sorry for it but we cannot conclude that something improper, incorrect or unjust has been done by the simple fact that radiation therapy cannot be afforded. What has normative force carries the possibility of the assignment of positive or negative value to one or the other of the alternatives – that is perfectly the case in relation to equity. No one could confer a positive judgment to the distribution of a benefit that is inequitable. That is clear cut conceptual distinction. Inequity can be the consequence of a policy decision, which can be judged. Affordability is in itself, so to speak, a circumstance independent of the decisions – it can be as simple as “there is money, yes, we can afford, there isn’t, well we can’t”; there are no decisions to be judged. What one does with affordability is another story. The use of the money can then be judged in terms of equity, efficiency, suitability, etc., criteria with normative dimensions. UHC however, is in between the distinction of what can be assigned positive or negative values or neither. One may say that the HC that is not Universally provided has a negative connotation. This very much resembles equity concept, as the equity assessment technique can exactly be the one to be used to attest or not universality. But, given the huge scope of what can configure and be part of HC in UHC, no one can expect that every single need of every single one in that particular “Universe” will meet its respective service – that is a fundamental impossibility. So, while an assessment of equity of a particular service, considering those in need of them, can be precisely defined and done, in the Universal business the scope is just too broad to allow a firm valuation in strict positive or negative terms. The result of the evaluation will be always mixed: positive here, negative there, and so on. That is also the message of the blog. The appeal of the “Universality” for policy makers rests exactly in its weak normative force, meaning, the fragility of any judgment valuation that may conclude that the system is not providing universal access as it is supposed to do by its own definition; the picture will always be mixed. This is why I said that UHC is a programatic definition of intentions, not a normative for judging its success or not. To be sure, advances in equity, like in Costa Rica, Brazil and many other countries could be observed, once their health systems have adopted the self-definition as providing Universal Coverage. Despite the fact that inequities are still there, having set the universality as a orientation of the system, certainly produced positive dynamics. I am not denying the value of the UHC flag in that sense. I only think that the same aim could be achieved without using such inconsistent concept; there are ways of being more precise, adopting similar orientation. Free PHC is one of them. PHC Can be universally provided almost anywhere (the concept is not so hard to unpack); that is certainly not the case for ambitious and generous HC in UHC.