Principle Meets Pragmatism on Universal Health Coverage

Principle Meets Pragmatism on Universal Health Coverage

 {Photo credit: Brooke Huskey/MSH.}Photo credit: Brooke Huskey/MSH.

This post is part of our Global Health Impact series on the 67th World Health Assembly (" href="http://www.msh.org/blog-tags/wha67">WHA67), held in Geneva, May 18-24, 2014. This year, MSH co-hosted three side events focusing on the role of universal health coverage (May 20), chronic diseases (May 20), and governance for health (May 21) in the post-2015 framework. Six MSH representatives attended WHA as part of the 60-plus-person Global Health Council (GHC) delegation.

Jonathan Jay coordinates Health for All Post-2015, a worldwide campaign of over 30 civil society organizations advocating for universal health coverage  (UHC) as an essential component of the post-2015 health agenda. The campaign has been active at recent discussions of United Nations permanent missions in New York, as well as at WHA67 in Geneva. More information on the campaign is available at www.healthforallcampaign.org/call-to-action.

Global health movements rely on big ideas about what’s fair. Social justice motivates international efforts to combat disease and improve wellbeing: it’s unfair that where you live, or who you are, should determine whether you’ve got access to lifesaving care and the other services you need. Fairness, or equity, might be the single most important principle for the civil society organizations that advise, assist, and critique government efforts on health.

In this spirit, many were surprised last week when the World Health Organization (WHO) proposed a global goal of achieving universal health coverage (UHC) by 2030—specified by, among others, a target of at least 80 percent coverage with key health services.

Here’s the problem: WHO itself defines UHC as everyone receiving the good-quality services they need without financial hardship. How could just 80 percent suffice? With the clock ticking and deliberations ongoing on the post-2015 development framework—a refresh of “the world’s report card” launched in 2000 as the Millennium Development Goals—this question will force civil society stakeholders to confront their own philosophies, roles, and tactics in improving health.

The politics of ‘possible’

WHO’s Assistant Director-General, Marie-Paul Kieny, explained to a World Health Assembly audience that the 80 percent target was chosen because it’s ambitious yet realistic. One of the indicators of service delivery, for example, is diabetes detection and treatment. It’s currently estimated to reach fewer than 40 percent of people who need it in Chile, a fairly strong middle-income health system. In Tanzania, a low-income country, it reaches fewer than 10 percent. The 80 percent standard is even tougher to meet because it measures effective coverage: not just the number of people who enter treatment, but whose treatment works. 

The rationale for a target under 100% is not just technical but political. WHO and the World Bank, its close collaborator on UHC monitoring, are mindful of historical precedent. In 1978, WHO adopted the Declaration at Alma-Ata calling for primary health care for all by 2000. Criticized as unattainable and lacking clear targets, the movement lost traction. As UHC has reemerged as a WHO priority in recent years, the lesson was clear: convince critics that it’s achievable and measurable.

From this standpoint, calling for 100 percent coverage seems like no target at all. One hundred percent effective coverage of services is an aspirational ideal that no country could achieve in the foreseeable future, let alone every country. 

Principle

At the same time, accepting less than 100 percent coverage is a bitter pill for UHC advocates in civil society. A central appeal of UHC is that its universality affirms everyone’s right to health. Moreover, when coverage is missing, it’s predictable who’ll suffer. At the World Health Assembly last week, where WHO and World Bank announced their latest proposals, activists were quick to point out that the 20 percent lacking coverage will be those already most marginalized and least served. People with disabilities, for example, already experience shocking disparities in healthcare access worldwide. The proposed framework, citing lack of available data in most countries, would not require all countries to break down their coverage numbers according to disability (nor age, ethnicity, or sexual orientation—only income, gender, and urban/rural geography). Accepting an 80 percent target sounds like an endorsement of the inequitable status quo, with predictable pockets of poor coverage among subpopulations whose access isn’t monitored.

The challenge

Civil society organizations face a complex decision. On one hand, activists have to push governments into uncomfortable territory, countering the inertia and political forces that commonly slow bureaucratic response. Early in the global AIDS movement, groups such as ACT UP and Treatment Action Campaign took principled stands for equal access to medicines and other services, helping to drive progress that would have seemed unrealistic to many at the time. Moreover, there are services that the development world has deemed realistic and necessary for all governments to provide, such as universal primary education.

On the other hand, there is ample precedent for civil society agreement around targets that fall short of ideal. The noncommunicable disease advocacy community has rallied around the UN-endorsed target of a 25 percent, not 100 percent, reduction in mortality from chronic diseases by 2025. Many civil society groups have signed onto global AIDS targets that, every few years, increase by several million the number of people to receive antiretroviral therapy.

Campaigns to end preventable maternal, newborn, and child (MNC) mortality are an interesting case. While “ending preventable mortality” has the sound of a zero target—calling for no more deaths that could have been prevented—the levels of mortality identified as “preventable” are not zero. They’re based on factors including the levels currently achieved in rich countries, which perform comparatively well but not perfectly. Activists would acknowledge that in the future, we will likely raise our standard of how much mortality is preventable. So while ending preventable mortality is quite ambitious, it’s not the extreme hard line on every woman and child’s right to survival.

Focus on gap-closing?

One approach to framing the 80 percent global target would be as closing the gap across countries and across populations within countries. At least for certain key indicators, 80 percent represents the rate of coverage among the richest quintile in the richest countries (see Fig. 2, “Coverage of prevention and treatment services, by region”). In all other populations, in all countries, coverage falls short. While everyone, rich or not, should receive the services he or she needs, a principled first step would be to eliminate these inequalities en route to universal health coverage.

To accept this approach, civil society would need better information on the benchmark levels across all proposed indicators, as well as projections for achievable improvements by 2030. (Save the Children has called for both.) Moreover, this gap-closing approach to UHC would have to be presented in the context of a long-term goal of 100% coverage among all groups—preferably with a specified time horizon.

Next steps

Politics versus principle is an ongoing question for campaigns such as Health for All Post-2015, which represents over 30 civil society organizations worldwide supporting UHC in the post-2015 framework—but only as long as it embodies principles like equity. The next few months will reveal how effectively this process incorporates another core principle: participation. The WHO/World Bank proposal already reflects public consultation on an earlier draft. The services coverage target has moved partway in response to comments, though several civil society concerns remain unanswered.

But government-civil society collaboration must be a two-way street. As civil society organizations consider our response to this latest proposal—which includes other potential shortcomings, including protections for marginalized groups and sexual and reproductive rights—standing firm behind principle can’t be a knee-jerk reaction. We must prepare for thoughtful discussions on where principle and politics can work best for those who need health services the most. 

 

Comments

Jonathan Jay
WHO's Ties Boerma has recently pointed out to me that the language of the service delivery target "in all populations" must not be lost. In the first draft monitoring framework, the service delivery target was at least 80% coverage among the lowest 40% of income. Based partly upon civil society feedback, the new target addresses "all populations" regardless of income, gender, or geography: data will be broken down according to two additional dimensions of equity beyond just socioeconomic status. Groups had proposed additional equity stratifiers, including age, disability status (which has received support from member states in the UN post-2015 process), ethnicity/indigenous group affiliation, sexual orientation, and others. Gender and geography were chosen partly because they are considered more realistic for developing countries where data collection is very weak. The core consideration discussed in this piece--pragmatism vs. principle--may apply to this "which populations" question as well.
Jon Rohde
the concern about 80% coverage not being "universal" is valid BUT, we learned in the 1990s after the first ever Global Summit - the World Summit for Children - that over ambitious goals lead nowhere - eg "reduce LBW to less than 10%" was seen as preposterous in India and Bangladesh where LBW was (and still is) over 30% of births. the Millenium Goals wisely called on each country to half, or reduce by 2/3rds etc. Perhaps even more salient is to reduce DISPARITY within a country - to bring the lowest 40% (by wealth) up to 80% of the highest 40% by wealth etc. These are ambitious but different in each country yet achievable and worthwhile. setting goals to 100% is to accept failure universally!

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