#13 post-2015
Gorik Ooms

Do we Need Universal Health Care?

Only one development goal will focus on health in the Post-2015 Agenda. The health community debates which is the best one.

There is tension in the global health community on how to best position health in the Sustainable Development Goals (SDGs). Health was at the heart of the Millennium Development Goals (MDGs). Three out of eight goals addressed health issues: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria, and other diseases. In the SDGs, health will have only one goal. The health community currently disagrees on how to best position many objectives under a single goal so as not to lose ground in the Post-2015 Agenda. Although for many universal health care (UHC) – a health systems approach aiming at ensuring that everybody obtains the health services he or she needs without suffering financial hardship – seems to be the best candidate for uniting a number of health objectives, so far, it does not look like it will make become the overarching health goal. In this contribution, I explore some of the reasons why the global health community is not united behind UHC.

Anticipating the expiration of the MDGs in 2015 and for the first draft of the Sustainable Development Goals, the World Health Organization (WHO) has predicted that only one goal will address health. The WHO presented UHC as the “single overarching health goal” since it was considered the best candidate for consolidating and further advancing achievements under the MDGs, while integrating ‘new’ challenges such as non-communicable diseases (NCDs) and health systems strengthening (HSS).

In July of this year, the Open Working Group (OWG) for the SDGs finalised its proposal, which was discussed at the United Nations General Assembly meetings in September. The WHO was right in one sense: The OWG proposal contains 17 goals, and only one of them focuses on health. But UHC was not proposed as the umbrella goal. Instead the proposed umbrella goal is to “ensure healthy lives and promote well-being for all at all ages”. Under this umbrella, the OWG proposal contains no fewer than 13 health targets – nine of them (3.1 – 3.9) focused on ‘outcomes’ and four (3.A – 3.D) focused on ‘means of implementation’. UHC is mentioned as target 3.8: “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”.

“Why should there be distinct targets for AIDS, tuberculosis and malaria, for maternal health and child health, for NCDs and others issues, if they can be achieved through UHC?”

This is puzzling, but not really surprising. It is puzzling because if UHC – as mentioned in the proposal – were to be achieved, several other targets would be achieved as well. For example, unless one believes that “sexual and reproductive health care services” (proposed target 3.7) are not truly “essential health care services”, achieving UHC would imply achieving universal access to sexual and reproductive health care services. Why should there be distinct targets for AIDS, tuberculosis and malaria, for maternal health and child health, for NCDs, and other issues, if they can be achieved through UHC? Does this list of issue-specific targets not increase the risk of further fragmenting efforts and health systems?

But though I was puzzled, I was not really surprised. As a member of the Go4Health consortium that has been working on the post-2015 health goals since 2013, I have been invited to many meetings and conferences on this issue, organised by civil society, academic institutions or both. I have found that UHC is not the unifying concept that some would like it to be, but rather a concept that divides the global health community. Why?

There are two lines of argument used by those who are reluctant to promote UHC as the overarching post-2015 health goal. The line of argument that is most often used during the debates is that UHC is too abstract, does not speak to people’s imagination, and cannot be measured easily. The line of argument one hears in the lobby is that there won’t be enough financial (and other) resources for comprehensive UHC, that the implementation of some of its elements will have to be delayed, and that the proponents of disease-specific targets are simply trying to make sure that their issue is among the post-2015 priorities.

In my opinion, the first argument is not really convincing. If the MDGs have made a difference, it was because they came to dominate the agenda of international development cooperation, and involved people who work for national and international governmental agencies and non-governmental organisations, all people who are smart enough to understand what UHC means. I do not believe that the average tax payer in Germany or elsewhere was suddenly more willing to contribute to official development assistance (ODA) because she or he understood reducing maternal mortality better than primary health care or UHC.

But the second line of argument is one I understand quite well. UHC contains the echo of primary health care (PHC), and soon after it became the battle cry of the WHO, primary health care became selective primary health care. Based on the principle of efficiency first, PHC became an argument for excluding life-saving medical interventions, like emergency obstetric care – too expensive, skilled birth attendance first – and antiretroviral AIDS treatment – too expensive, prevention first. Under the present MDGs, maternal health activists can refer to target 5.B: “Achieve, by 2015, universal access to reproductive health”. AIDS activists can refer to target 6.B: “Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it”. Under UHC, they fear, arguments will be formulated (again) for freezing the scaling-up of AIDS treatment and emergency obstetric care to give priority to the allegedly more efficient interventions.

“The underlying tension is about where to place responsibility for health: at the national level, or at a combined national level and international level?”

Are these fears justified? I’m afraid they are. I think the underlying tension is not about efficiency, since – most global health advocates would agree with the principle that all human lives have the same value, and that if choices have to be made between different options, the options that save the most lives (or years of life) should be prioritised. The underlying tension is about where to place responsibility for health: at the national level, or at a combined national level and international level? In the Millennium Declaration, heads of state and government agreed that “in addition to our separate responsibilities to our individual societies, we have a collective responsibility to uphold the principles of human dignity, equality and equity at the global level”. If this were applied to UHC, no AIDS, maternal health, or NCD activist would have to fear that UHC would exclude their priorities. But in the absence of a clear statement that UHC is the practical expression of the right to health and therefore a national and an international responsibility, UHC will remain a dividing rather than unifying concept.

Has UHC become a lost cause? I don’t think so. The negotiations are not over yet. Even if the OWG proposal were to be the final blueprint for the post-2015 goals, it would be easy to mention UHC as one of the ‘means of implementation’ targets – rather than an ‘outcome’ target – to signal that UHC is the way forward in realizing outcome targets. But that doesn’t solve the underlying tension.

To me, one of the most promising events related to the OWG process is (in words taken from an article in The Broker) that “this time around, the global South also had a front-row place at the negotiation table”. In the process, the ‘Group of 77’ or ‘G77’, a group established in 1964 by seventy-seven developing countries that gradually enlarged to today include 133 'developing countries, and China came with more ambitious financial demands than the ones that are usually discussed. The G77 and China demanded a specific time horizon for ‘developed’ countries to achieve their present ODA commitments – 0.7% of the gross national income (GNI) of ‘developed’ countries’ – and a new target for 2030: 1% of GNI instead of 0.7% of GNI. With regards to foreign debt, the G77 wants “debt sustainability” for all ‘developing’ countries, and “debt cancellation” for highly indebted poor countries.

“More and more reliable ODA combined with debt cancellation and increasing domestic resources would make comprehensive UHC feasible.”

More ODA and debt cancellation alone will not provide enough resources for comprehensive UHC everywhere. But more and more reliable ODA combined with debt cancellation and increasing domestic resources would make comprehensive UHC feasible. And even if the present OWG proposal does not include the G77 demands, the negotiations are not over yet – and they are no longer about poverty reduction only, they also include sustainable development. If ‘developed’ countries want ‘developing’ countries to accept carbon dioxide emission ceilings that are lower than the present emission levels of the ‘developed’ countries, the price will be higher than 1% of GNI.

Photo: Copyright GIZ

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