Addressing UHC challenges is urgent, and can deliver multiple benefits. Rapid UHC reforms that deliver full population coverage are feasible and affordable. The key to success is to learn from experience in managing the politics of reform.
Drawing on the work of the Commission for Universal Health, we highlight six key messages for political leaders considering launching UHC reforms in contexts of crisis and shock:
1. Action on universal UHC is urgent
- There is a global commitment to achieving UHC whereby everyone receives the quality health services they need without suffering financial hardship. However, global indicators for health coverage and financial protection have been lagging since 2015.
- The COVID-19 pandemic and other recent crises have deepened poverty and inequality, while demonstrating the importance of national health systems as a critical foundation for UHC and health security interventions.
- The cost of ensuring UHC and health security is low compared with the cost of responding to crises.
- Given the multiple threats now facing societies, including from climate change, it is an urgent task to strengthen our health systems and their resilience now.
2. Crises, shocks and other ‘focusing events’ can create a window of opportunity for radical reform
- Our study shows the historical links between crises of various kinds and UHC reforms, but also the need for leaders who are willing to recognize the window of opportunity and drive health reforms forward through these events.
- Crises can support reforms by (i) increasing the salience of problems (for example, by highlighting ways in which current health systems are failing); (ii) creating awareness of new policy options to address them; and (iii) changing the political landscape in ways that enable reforms – through the emergence of new parties with reformist agendas, for instance.
3. There are substantial potential benefits from UHC reforms
- Literature and case studies all illustrate the potential for UHC reforms to significantly increase health coverage, improve the quality of care and financial protection, as well as reducing health and wider inequalities and improving health outcomes.
- UHC can also build resilience and protect against shocks, including climate change. There are also substantial wider economic, social and political benefits from UHC. Economic benefits include improved workforce productivity, increased economic growth and reduced poverty. Social benefits include increased social cohesion. Politically, UHC can deliver electoral gains and expand trust in political systems.
4. We know (broadly) what action is needed
- Case studies demonstrate the benefits of a comprehensive approach to UHC reforms that includes investment in supply-side readiness and addressing barriers to demand, while engaging communities and allowing for iteration to react to challenges that emerge over time.
5. UHC reforms are affordable and deliver benefits quickly
- A small increase in public finance is needed in order to undertake UHC reforms, but in large part the reforms involve a substitution of public for private funding, which generates gains through improved efficiency and equity as a result of better purchasing and allocation of resources.
- Countries studied have typically injected around 1 per cent GDP of additional public financing into their health systems to improve the supply side and improve access during the UHC reforms reviewed.
6. Managing the reform process is key
- UHC is an intensely political process, involving redistribution of resources, which therefore requires a good understanding of the key actors and strategies to manage them, including managing opposition from vested interest groups.
Recommendations
There is no single blueprint for UHC reforms, and one size will not fit all. In developing an effective UHC strategy, each country needs to consider its own context: this means paying close attention to the progress it has made so far towards UHC, and how the health sector is currently functioning, as well as taking careful account of country-specific economic, social and political factors. However, there are important lessons to be learned from the experiences of countries that have implemented successful UHC reforms in the aftermath of crises and shocks, summarized in these five overarching policy recommendations:
Recommendation 1: Prioritize reaching full population coverage quickly, by providing a universal entitlement to a comprehensive (but affordable) package of publicly financed health services. This is preferable to creating fragmented health insurance schemes for different socio-economic groups and expecting people in the informal sector to pay health insurance contributions.
Recommendation 2: Increase public health financing by around 1 per cent of GDP to expand the supply and quality of services and generate additional demand by removing financial barriers to services. This will support efforts to ensure universal entitlement to services becomes a reality rather than remaining an aspiration.
Recommendation 3: Concentrate additional public expenditure on improving cost-effective primary care services and strengthening health systems in areas such as human resources, essential medicines, infrastructure, information systems and governance.
Recommendation 4: Remove or drastically reduce user fees so that health services in the UHC package are provided free at the point of delivery, including ensuring that essential medicines and diagnostics are available free of charge.
Recommendation 5: Promote universal health reforms as a flagship policy of the government, and build on the popularity of UHC measures to facilitate revenue generation policies, for example through raising taxes and cutting inappropriate subsidies (e.g. fossil fuel subsidies). Linking popular UHC reforms to broader fiscal reforms may enable governments to raise more revenue for health services than the additional 1 per cent of GDP needed to kick-start their health reforms.
