David Heymann
Head and Senior Fellow, Centre on Global Health Security
International agencies have a great opportunity to capitalize on the inherently political nature of universal health coverage, writes David Heymann with Robert Yates, Senior Health Economist, World Health Organization.
Worker of the Ngoma health center issues a health insurance card for a new patient on 5 February 2014 in Ngoma, Rwanda. Photo by Thomas Imo/Photothek via Getty Images.Worker of the Ngoma health center issues a health insurance card for a new patient on 5 February 2014 in Ngoma, Rwanda. Photo by Thomas Imo/Photothek via Getty Images.

Universal health coverage (UHC) – the idea that all people should receive the health services they need without suffering financial hardship when paying for them − is intrinsically political. It is built on principles of fairness and equity that require governments to allocate healthcare benefits according to need, and financial contributions according to ability to pay. It therefore requires the healthy and wealthy to subsidise the sick and the poor. By its very nature, this creates a large role for the state in ensuring a fair health financing system that the market alone cannot provide. As a recent Chatham House report shows, this means that UHC must be built on a foundation of public financing, and achieving it depends on getting the politics right.

The transition towards UHC is primarily a political negotiation between interest groups concerned with the following questions: Who should be covered? What services should be covered? Who should pay? These questions form the axis of the oft-cited ‘UHC box’ in the 2010 World Health Report, which illustrates the policy choices facing governments as they plan their strategies. They also represent the different priorities of the major stakeholder groups: with the population and politicians focusing on who is covered, health sector workers mostly interested in issues concerning the supply of health services, and ministries of finance concentrating on financing and economic issues.

The different priorities of these groups can lead to dysfunctional processes, with health ministries often presenting highly technical supply-side strategies, which fail to convince sceptical ministries of finance of the economic benefits of increasing health budgets. The international community has tried to address this problem by presenting the economic case for increasing public health spending, notably through initiatives such as the 2001 Commission on Macroeconomics and Health and more recently the 2013 Lancet Commission: Investing in Health. However, low and sometimes falling budget shares in many low- and middle-income countries suggest that many ministries of finance remain to be convinced about the need to raise public health financing.

To date though, the international community, particularly agencies providing development assistance, have been reluctant to address the political arguments inherent in the promotion of UHC. In which case, now could be the time to adopt an alternative strategy and focus on engaging political actors in trying to implement it. 

UHC: A proven vote-winner

Politicians increasingly recognize that UHC reforms can win votes and therefore bring them political benefits. Many major UHC initiatives have come from political leaders in the run-up to elections and immediately following a transition of power. In a recent publication called  ‘Arguing for UHC’, the World Health Organization lists a number of countries where politicians have apparently launched UHC reforms as a means to win or retain power. Examples include Bismarck’s social health insurance reforms in Germany, prime minister Thaksin Shinawatra’s Universal Coverage Scheme in Thailand and US President Barack Obama’s ongoing attempt to close coverage gaps in the United States. Furthermore, there have been many examples of this phenomenon in Latin America following the transition of power from military dictatorships to democratic governments. Indeed, it is striking how many governments, elected after a period of political turmoil, have chosen rapid UHC reforms as a quick-win social policy to build confidence in the state. Recent examples include Nepal, Liberia, Sierra Leone, Burundi and Rwanda.

Advocates of UHC in the international community should bear this in mind and adopt new and bolder approaches in their advocacy. Encouraging heads of state to champion UHC increases the probability that the reforms will secure buy-in across government and that ministries of finance will feel compelled to increase public health funding. Furthermore, there is growing evidence that a typical politician’s preference to prioritize the percentage of the population covered over expanding the benefit package for a more limited population may be a more effective, efficient and equitable way to reach UHC. Research papers from Latin America, Thailand, Sri Lanka and Nepal show that this strategy is improving health outcomes and financial protection faster than when countries try to expand population coverage gradually.

However, the international community has not been very successful in promoting UHC reforms to political leaders. While many multi-lateral and bi-lateral agencies and academic institutions support ministries of health in planning and implementing supply-side reforms, and some try to influence ministries of finance, it is rare for international agencies to engage directly with political leaders on domestic issues such as UHC reforms. Given the sensitivities, it is also difficult for such agencies to interact with opposition parties’ political leaders, who may be more inclined to champion UHC than the incumbent government. Recently this has been the case in Indonesia and Myanmar. Civil society organizations might be less constrained, but often struggle to secure the necessary access to top-level political leaders.     

If UHC is to be part of an overall health goal in the post-2015 world, it will be imperative to scale up development support in this area and help country-level stakeholders recognize and exploit political opportunities to extend health coverage. In particular, greater attention must be paid to helping ministries of health market the political benefits of UHC reforms to their national leaders. Experience shows that this could be the most effective way to unlock the necessary funds from treasuries and bring true universal coverage to all who need it. 

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