Universal health coverage
The goal of moving towards universal health coverage is gaining support, sometimes very enthusiastic support, often very high-level support.
Since publication of the 2010 World health report on health system financing, more than 70 developing countries have requested WHO technical support for their plans to move towards universal coverage. The online edition of that report has been downloaded, either in summary or full-text version, more than 640,000 times.
Countries that have already reached the goal are sharing their experiences. They are singing some praises. But they are also making it clear: This is a struggle. It takes time. It takes unwavering political commitment at the highest level of government.
Last September, I participated in the launch of a Lancet series on universal health coverage. Papers in that series show the positive impact of universal coverage on health outcomes.
They explore the transition to universal coverage in its political and economic dimensions, and offer lessons about how health financing reforms have been enacted in a number of lower income countries. Commentaries in the series offer a big-picture view of the historical significance of what is now perceived to be a movement.
It is extremely helpful to have a respected economist, like Jeffrey Sachs, argue strongly against what he calls ‘lazy thinking’. This thinking assumes that user fees will reduce overconsumption of health services or increase their value in the user’s eyes. Not true. User fees punish the poor.
Here is another warning. Health financing reforms are just one part of the picture. Health insurance raises public expectations. People expect ready access to medicines and services, and they want quality. They want care from people who care about them.
A commitment to universal coverage means meeting these expectations as well. Don’t punish the poor, but don’t disappoint them either.
Also last year, the United Nations General Assembly adopted a resolution that endorsed the goal of universal health care and gave it a high place on the global health agenda.
The resolution was sponsored by more than 90 countries, from every corner of the globe, and adopted by consensus. In a move described by some as ‘momentous’, the resolution urges member states to develop health systems that avoid significant direct payments at the point of care.
It further urges them to establish mechanisms for pooling risks to avoid catastrophic health expenditures that drive households into poverty. The resolution also affirms the strong links between universal coverage and the UN’s Political Declaration on the prevention and control of non-communicable diseases.
And there are other links, of course. In fact, a health system designed to deliver universal care provides a solid platform for tackling all health problems, for reaching all health goals, in a fair, integrated, and efficient way.
I have expressed my personal commitment to universal coverage on several occasions. I regard universal coverage as the single most powerful concept that public health has to offer.
It is the best way to cement the health gains made during the previous decade. It operationalises the highest ethical principles of public health. It is a powerful social equaliser and the ultimate expression of fairness.
The recent enthusiasm for universal coverage occurs in a world in which social inequalities, in income levels, in opportunities, and in access to health care, are at the greatest levels seen in at least half a century.
At a time when policies in so many sectors are actually increasing social inequalities, I would be delighted to see health lead the world towards greater fairness in ways that matter to each and every person on this planet.
Ladies and gentlemen, there is no universal formula for reaching universal coverage. Each country must carve its own way forward.
Any move towards universal coverage is an inherently country-owned initiative. It must be home-grown, strongly rooted in the country’s culture, its domestic political institutions, the legacy of the existing health system, and the expectations of its people.
This is a key purpose of this meeting: to give countries a platform for exchanging experiences in specific areas. The meeting places particular emphasis on health financing reforms, including the management of fiscal and macro-economic policy concerns, and the use of financial incentives to promote efficiency, high-quality care, and results.
To be most effective, mechanisms for pooled financing should go hand-in-hand with a primary health care approach. This is the most cost-effective way. Use of health services will increase. Health spending will increase. We know this.
But these increases can be counterbalanced through cost-effective prevention, early detection, and management of many conditions in the community or in homes. Such an approach becomes all the more important as the world braces for the coming onslaught of non-communicable diseases.
A commitment to efficient and fair health services asks health officials to make some key policy decisions, and enforces their authority to do so.
Officials can fix prices and fees, adjust provider incentives, introduce policies that promote generic medicines, and rationalise the use of expensive technologies. In some cases, policy-makers will also need to find ways to protect against the overuse of health services.
We also need to think about the over utilisation of health technologies. Unlike many other areas of technological innovation, like mobile phones, where devices get cheaper and easier to use, advances in medical interventions are usually additive, not replacement technologies.
As I conclude, let me refer to a commentary published in the Lancet series. It describes the movement to achieve universal health coverage as a ‘great transition’ that is ‘sweeping the globe, changing how health care is financed and how health systems are organised.’
Let us think about that perspective as this meeting gets under way.
Opening remarks at a WHO/World Bank ministerial-level meeting on universal health coverage – Geneva, Switzerland, 18 February 2013