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The Universal Health Coverage Divide

By Remco van de Pas
on September 26, 2019

(crossposted from Medium ‘Health for All’ where it was first published)

There was once a dream. A dream that led to the establishment of the United Nations (UN) in 1946 whereby an idealistic view of international cooperation was regarded as a key mechanism to prevent war and free humanity from widespread misery. Chapter I of the UN charter clarifies that the organization is based on the sovereign equality of all its member states while Chapter IX clarifies that the UN shall promote “higher standards of living, full employment, and conditions of economic and social progress and development”. The latter principles were formalized in the International Covenant on Economic, Social and Cultural Rights in 1966, currently ratified by 170 nation state parties.

These principles resonate well with the ones mentioned in the political declaration of the UN-HLM on UHC, albeit in a modern frame. Health is a human right; UHC is fundamental for achieving the SDGs; national ownership and responsibility of governments at all levels determine the path towards UHC, mainly through domestic resource mobilization. See here; the essentials of global health how it should be. Granted, in the abovementioned UN charter, none of the leaders at the time aimed to ‘invest in human capital’, ‘promote resilience’ or ‘leverage the full potential of the multilateral system as well as other actors’. Also, ‘peace’ is mentioned 47 times in the UN charter but is lacking in the UHC declaration (except for the word ‘peaceful’). A conspicuous omission, you might say, given that an entire SDG (16) focuses on this objective. But then, what’s in a name? Language is a dynamic system and so might be the diplomatic semantics of the UN, no?

The UN mandate was from the beginning constrained by the need to balance security and economic interests of a handful of powerful countries. These countries got a seat in the Security Council including veto power. They organized themselves in security alliances (NATO and Warsaw pact, respectively) and they championed separate economic international orders. The ‘Western’ countries did this mainly via the initiation of the Bretton Woods system of monetary management that aimed to secure an open trade relation between independent states. The IMF was designed to secure financial stability (by providing loans to countries in need). The World Bank was created to invest in reconstruction and economic development by providing low-interest loans to countries that didn’t have access to capital. Official Development Assistance (ODA) found its origin in the management of financial aid from the US to rebuild Europe (The Marshall Plan) and the creation of the OECD. This development aid, including for health, was later expanded to decolonized countries in Latin-America, Africa and Asia. ‘Donors’ realized that there needed to be a form of social assistance to offset the negative externalities from open economies, capitalism and free trade. This led to the norm of 0.7 % of Gross National Income of OECD members to be spent on ODA.

This ‘Westernised’ global governance regime of multilateralism, gunboat diplomacy or outright military interventions, and debt-based economic development fueled by cheap oil and conditional aid shaped social and economic development in a majority of countries. It is not for nothing that the group of G77 countries, via the UN, called for an alternative ‘New International Economic Order’ (NIEO) in the 70’s as to recognize their right to sovereign economic development and fair trade. The Alma Ata declaration on PHC refers to a NIEO as a structural requirement for countries to develop an equitable health system.

High-level politics took another turn, however. After the economic crisis in the 70s, economic globalization deepened, showing its more ugly side in the process. After the US had left the Gold Standard (in the 70’s), neoliberal policies reigned from the 80’s onwards, bringing with them structural adjustment, fiscal austerity and a debt crisis across the ‘developing’ world that basically subsidized western economies. The Soviet Union and its bloc imploded and the European Union (EU) was born. Deregulated capitalism and public -private partnerships became the norm, not to say hegemonic. This story has been documented many times, including eloquently in the book ‘the Divide’ by Jason Hickel (2017). While I do recognize undeniable progress in some domains, this broad picture sketched above, provides, in my opinion, the structure for Global health how it is: selective, neglecting determinants of health inequalities, and fragmented, with philanthropy and humanitarian charity trying to fill the (many) gaps.

So, where are we now, 30 years after the fall of the Berlin wall? The UHC declaration indicates that the (seductive) story of sustainable development and inclusive economic growth remains pervasive. This includes the image of ‘explanatory nationalism’ which holds that national differences in development trajectories are the key factors explaining why severe poverty persists. The focus on domestic resource mobilization largely ignores the reality of deep globalization and what economists refer to as a golden straightjacket. Following this line, I doubt that many low-income countries will have the fiscal space to finance inclusive UHC by 2030, unless more heterodox economic approaches in public investment are considered.

WHO economists estimated that $371 billion per year is needed to reach universal health system targets by 2030 — this would potentially save 97 million lives. A (mere) 1% of GDP increase in domestic resources, as mentioned in the political declaration, will be far from sufficient (the understatement of the SDG health era) to cover this gap. As for the international solidarity enunciated in the political declaration, that seems a hollow shell from the onset. This is why our constituencies have been so critical in the assessment of, and the statement prepared for the UN-HLM.

I always thought that more redistributive, just and transformative forms of health cooperation would be possible so that global health systems could become [1] more equal and inclusive. But now, I am not so confident about that path anymore. The house of cards of western-based economic global governance is coming down. Ecological, financial and social crises have become so prominent that other, more drastic politics and narratives are required. Meanwhile, while the SDGs are still trying to stabilise and justify the ‘old’ multilateral order, a big chunk of economic and political power has already shifted eastwards. The new Belt and Road initiative will shape cooperation between countries in the foreseeable future.

In short, rather than calling for more political commitment for the ‘old’ paradigm (sustainable development and inclusive economic growth), our times force us to reflect upon, think through and then alter the narrative. This new story would move away from the economic growth and development logic. Instead, our common future would build on the realisation that there are essential social needs and at the same time also ecological planetary boundaries (with quite a few already overshot, as you know). Following Raworth’s thinking on Doughnut economics, this new (and hopeful) narrative requires us to aim for environmentally safe and socially just spaces in which humanity can thrive. Evidently, this would require a new global economic order and governance where power and resources will have to be redistributed in a radically different way. Rather than focusing on economic growth, we would have to focus on wellbeing within an overall “limits to growth” thinking, as was already foreseen by the Club of Rome in the late 60s. I hope (and encourage) fellow global health, academic and development actors from across the world to embark together with me on such a transformative path linking the social, economic and ecological domains. It will be a political and inherently ideological trajectory but our times and certainly the next generations deserve nothing less.

[1] I would like to acknowledge my colleagues of the Institute of Tropical Medicine, Antwerp who published in 2011: Global health: what it has been so far, what it should be, and what it could become: