Universal Health Coverage (UHC) is a human right deeply rooted in the social-justice approach to health. Unfortunately, in several Low and Middle Income Countries (LMICs) it is still a mirage at a time when its achievement is not obvious in the High Income Countries (HICs) either. As such, UHC rests on everyday fight with uncertain results
By Pietro Dionisio
EU health project manager at Medea SRL, Florence, Italy
Degree in Political Science, International Relations Cesare Alfieri School, University of Florence, Italy
The Uncertain Status of UHC and the Latent Balance of the Social-Justice Approach to Health
Since the Alma-Ata Declaration, in 1978, the health and human right movement entered the international stage and rooted in the early 1990s in response to the HIV/AIDS epidemic.
According to the movement, the link between health and human rights means that everyone should have the right to the highest attainable standard of physical and mental health. As such, the definition of a healthcare system should be driven by standards including adequate infrastructure availability, high quality services provision, transparent health information, as well as the active participation by individuals and communities in decisions affecting health, non-discrimination, and other relevant mainstays.
The human right to health is protected in several declarations and covenants. Among these, the “Universal Declaration of Human Rights” and the “International Covenant on Economic, Social and Cultural Rights” maintain that healthcare system must be accessible to everyone (child, mothers and disadvantaged people first), while being equipped to prevent catastrophic health conditions.
A social-justice approach to health could actually safeguard the right to access health services and goods.
This approach requires a full understanding of the socio-economic, cultural and political contexts and their implications for healthcare services and resource allocation according to the collective needs. It also requires a commitment to share and learn from the communities and local experts. As such, the role of the central governments in putting aside the industry interests for the benefit of the collectivity should be emphasized.
In the face of this equity-based ideal approach, a grim reality shows how Universal Health Coverage (UHC) and a social-justice approach to health still lag behind as hardly achievable conquests for million people worldwide.
Concerning this, few examples from Asia, Africa and North America are enlightening.
In India the cost of rolling out UHC would actually be only 0.28% of Country’s GDP (the current GDP is estimated at $ 2,26 trillion), and well within the Country’s health expenditure. However, a mix of misplaced priorities, adding to a lack of evidence-based decision-making, are thwarting the achievement of a UHC system. For instance, while more new health insurance packages came-up in the last year, their utility is frustrated by distant health facilities and no trained healthcare workers providing services. The situation is so critic that despite India has become the global pharmacy for myriad inexpensive drugs, 63 million of its people sink into poverty each year because of unaffordable healthcare costs.
Among other issues, resources misallocation is an usual practice in African countries. As such, a huge number of African people look at UHC as a mirage, though for some critical health services and interventions an impressive progress in coverage has been registered. The most rapid improvement has been the change in supply of insecticide treated bed nets for children, which increased on average by about 15% per year between 2006 and 2014. All of the maternal health indicators have also improved over the last 20 years. Antenatal care visits and skilled birth attendance have also both increased from about 40% in 1990, to around 60% in 2014. In spite of this, wide disparities remain within countries including relevant to skilled birth attendants, treatment regimens for severe illnesses, and to access to more complex interventions. Even for schedulable routine services such as immunizations, very few countries are achieving universal coverage since the Regional immunization coverage, irrespective of its rise from 57% in 2000 to 76% in 2015, has remained below the expected target.
Furthermore, the UHC achievement in several African countries is undermined by the poor quality of care meaning, among other things, significant deficits in essential drugs and medical equipment availability, as well as in the knowledge and practices of frontline health workers.
However, if India and African countries cases are emblematic for LMIC, the most striking case is the U.S one. The former President, Barack Obama, implemented the Affordable Care Act, nicknamed Obamacare, as the first concrete American step towards the launching of a UHC system in the Country.
The Trump’s administration is endangering the Act and the President has begun a personal fight against the Law. In 2017, He and Republicans failed in their effort to cut Medicaid but they are going to try again in 2018. In fact, the strategy is to dismantle it on his own by scrapping subsidies to health insurance companies that help pay Out-of-Pocket Payments (OOPs) of low-income people, thus letting insurance premiums soar and fleeing insurance companies from the health law’s online marketplaces.
This inexplicable attitude towards the Act is grounded on conviction that healthcare entitlements are the big drivers of the U.S. debt. However, this approach is baffled by the propensity of many States, such as Maine and Virginia, for vowing to expand Medicaid.
UHC cannot be considered an once and for all achievement. The contexts mentioned above are just few and superficially analyzed examples on how the UHC issue is both relevant and critical as an often forgotten people right. As such, no wonder that even in those countries professing democratic attitude and having the needed cultural and economic resources UHC is a hardly achievable goal.
Accomplishing UHC requires properly equipped policies in place. In this regard, a focus on providing good coverage for a well-defined basket of benefits would be preferable to shallow coverage for any service with high patient cost sharing.
Financial sustainability needs to be built into the system from the start, including by exploring options to broaden revenue sources and prioritize the appropriate use of resources. Reforms in delivery systems should prioritize investment in non-hospital services, high-quality primary and community care services, and in public health programs. Nonetheless, these requirements often crash against the political will of decision makers thus making impossible stemming the tide of health inequities.
Tough progress results on a world scale are clear, the blatant examples here show how much has yet to be done and how, even in HICs, results not followed by a strong political will risk to be aleatory in the long run.