Rallying For UHC (IV): Aligning UHC with Civil Society Priorities

Rallying For UHC (IV): Aligning UHC with Civil Society Priorities

 {Photo credit: Paula Champagne/MSH}Jeffrey Sachs speaking at "A Healthy Future for All: Making UHC a Post-2015 Priority".Photo credit: Paula Champagne/MSH

After last Monday’s event launching a report on equity in universal health coverage (UHC), I observed that the global UHC movement can gain broader support by refining its messages to connect with the core values of civil society and provide reassurance that UHC is feasible for low-income countries. It was clear after last Tuesday’s event in New York—hosted by MSH, the Rockefeller Foundation and the Thai UN mission—that to gain support among disease-specific advocates in post-2015 discussions, the UHC movement must also clarify how a UHC goal would relate to disease-specific priorities in the new development framework.

Put another way: what exactly would UHC cover as a post-2015 goal?

UHC has been understood as the broadly inclusive goal that everyone receives the health services they need, without financial hardship. In well-off countries, there are more than enough resources for UHC to incorporate the most important services for HIV, family planning, non-communicable diseases (NCDs)—all issues with strong advocacy communities. But in developing countries, UHC proponents acknowledge that expectations must start low: to many, the first priority is boosting coverage of basic primary care interventions, addressing preventable deaths from pneumonia, diarrhea, malaria and maternal complications.

These relatively modest expectations leave certain “vertical” (disease-specific) health constituencies wondering where they stand. Whether these groups would support UHC as a post-2015 development goal was a key question of UNGA week. Tuesday’s event addressed this question head-on: it convened vertical stakeholders, both on the panel and in the audience, confronting civil society skepticism around UHC.

Economist Jeffrey Sachs’ keynote framed the potential of UHC for uniting global health advocates: he envisions it bringing everyone together under one “big tent.” He unpacked the concept as bringing together six dimensions of “universal”:

  1. People everywhere, but especially those in poor countries.
  2. All people, regardless of class, race, ethnicity, gender, and geography.
  3. All ages, from prenatal and newborn conditions to diseases of the elderly.
  4. All diseases.
  5. All stages of health: promotive, preventive, curative, rehabilitative and palliative.
  6. All sectors, recognizing the health impact associated with environmental pollutants, climate change, the food industry, and others.

I heard afterwards from some UHC skeptics that they’d gladly sign on to Sachs’ version. Sachs’ inclusive vision is what human rights lawyer Gorik Ooms calls “real UHC”: one that meets UHC’s aspiration to provide all needed services. It would encompass key priorities for vertical advocates, not just the non-negotiable health services (like access to antiretrovirals and contraceptives) but even a wider range of important actions (legal reforms to reduce discrimination, tobacco regulation, etc.).

Still, advocates may wonder how this vision can map onto the post-2015 framework. UHC has been proposed as an overarching “umbrella” health goal, by World Health Organization (WHO) and others. Advisory bodies like the Sustainable Development Solutions Network, chaired by Sachs, have instead proposed UHC as a second-level target below an overarching goal relating to “healthy lives at all ages.” (In either scenario, vertical, MDG-like indicators for maternal and child mortality, communicable disease, reproductive health and NCDs would play an important role.)

Pushing UHC to the second level—alongside, rather than above vertical targets—helps reassure vertical constituencies that their issues will still receive attention, regardless of whether developing countries can fit priority health services into their national UHC benefits packages. International HIV/AIDS Alliance has moved to a position like this. (More on the “umbrella” concept and post-2015 architecture in an upcoming blog post.)

For the most part, “attention” really means funding. Sachs contended in The Lancet that $60 per capita gets you a basic primary care package in developing countries, not including ARVs. Ooms suggests that $50 can get you both. Either way, even with countries increasing their domestic contributions to health, international assistance will have to make up a funding gap to reach the $50-60 level in poor countries. (SDSN calls for high-income countries to provide 0.1% of gross national income in international aid, earmarked for health; this less-visible feature of the plan may represent the pivotal cross-subsidy without which the whole thing fails, like the Affordable Care Act’s individual mandate.)

Similar questions exist for financing other interventions. Jonathan Quick and I have argued that post-2015 UHC goal is important because it rallies financing and increases efficiency—a tide that could raise all boats. But certain guarantees appear necessary for constituencies with non-negotiable healthcare asks—both the HIV and family planning communities have got strong claims that access to their core interventions are human rights, even beyond the universal right to health.

Fleshing out details is important for grassroots advocacy, too: in Tuesday’s event, Heartfile’s Sania Nishtar noted that in Pakistan (where she was the health minister), people go to the streets for other public sector reforms, but not for UHC. To rally at the grassroots level, UHC advocates must be able to explain what a UHC plan can actually promise.

For constituencies with major asks beyond the healthcare sector (especially NCDs), there’s got to be assurance that health services won’t be the only post-2015 response to health. Not an unreasonable stance: we already know the burden of disease worldwide has shifted heavily towards lifestyle- and environment-related conditions, and that governance and health are closely entwined.  

My takeaways from Tuesday’s event: contrary to fears, global health advocates really can rally around UHC. (And many already have.) Everyone sees the problems of healthcare access and affordability. Everyone’s inspired by a vision like Sachs’, transforming opportunities for a healthy life worldwide, and especially in developing countries. UHC skeptics are on board with the aspiration; their doubt is whether, in practice, essential priorities might be left out. The best accounts of UHC have described a lofty ceiling—now there’s got to be more attention to the floor.

Related links:

Amanda Glassman and colleagues, Center for Global Development: