Universal Health Coverage

Twenty-five hundred years ago, the young Gautama Buddha left his princely home, in the foothills of the Himalayas, in a state of agitation and agony. What was he so distressed about? We learn from his biography that he was moved in particular by seeing the penalties of ill health – by the sight of mortality (a dead body being taken to cremation), morbidity (a person severely afflicted by illness), and disability (a person reduced and ravaged by unaided old age). Health has been a primary concern of human beings throughout history. It should, therefore, come as no surprise that healthcare for all – “universal healthcare” (UHC) – has been a highly appealing social objective in most countries in the world, even in those that have not got very far in actually providing it.

The usual reason given for not attempting to provide universal healthcare in a country is poverty. The United States, which can certainly afford to provide healthcare at quite a high level for all Americans, is exceptional in terms of the popularity of the view that any kind of public establishment of universal healthcare must somehow involve unacceptable intrusions into private life. There is considerable political complexity in the resistance to UHC in the US, often led by medical business and fed by ideologues who want “the government to be out of our lives”, and also in the systematic cultivation of a deep suspicion of any kind of national health service, as is standard in Europe (“socialised medicine” is now a term of horror in the US).

One of the oddities in the contemporary world is our astonishing failure to make adequate use of policy lessons that can be drawn from the diversity of experiences that the heterogeneous world already provides. There is much evidence of the big contributions that UHC can make in advancing the lives of people, and also (and this is very important) in enhancing economic and social opportunities – including facilitating the possibility of sustained economic growth (as has been firmly demonstrated in the experience of south-east Asian countries, such as Japan, South Korea, Taiwan, Singapore and, more recently, China).

Further, a number of poor countries have shown, through their pioneering public policies, that basic healthcare for all can be provided at a remarkably good level at very low cost if the society, including the political and intellectual leadership, can get its act together. There are many examples of such success across the world. None of these individual examples are flawless and each country can learn from the experiences of others. Nevertheless, the lessons that can be derived from these pioneering departures provide a solid basis for the presumption that, in general, the provision of universal healthcare is an achievable goal even in the poorer countries. An Uncertain Glory: India and its Contradictions, my book written jointly with Jean Drèze, discusses how the country’s predominantly messy healthcare system can be vastly improved by learning lessons from high-performing nations abroad, and also from the contrasting performances of different states within India that have pursued different health policies.

Over the last three decades various studies have investigated the experiences of countries where effective healthcare is provided at low cost to the bulk of the population. The places that first received detailed attention included China, Sri Lanka, Costa Rica, Cuba and the Indian state of Kerala. Since then examples of successful UHC – or something close to that – have expanded, and have been critically scrutinised by health experts and empirical economists. Good results of universal care without bankrupting the economy – in fact quite the opposite – can be seen in the experience of many other countries. This includes the remarkable achievements of Thailand, which has had for the last decade and a half a powerful political commitment to providing inexpensive, reliable healthcare for all.
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Universal health coverage post-2015: putting people first
www.thelancet.com Vol 384 December 13, 2014 
Dec 12, 2014 marks the world’s first Universal Health Coverage (UHC) Day. Defined in the World Health Report 2010, UHC means that all people who need quality, essential health services (prevention, promotion, treatment, rehabilitation, and palliation) receive them without enduring financial hardship. UHC also means different things to different people.
Vivian Lin, health systems director (WHO regional office for the Western Pacific), told The Lancet, “some define UHC as a journey or an aspiration but it is actually a strategy to get to equitable and sustainable outcomes”. UHC is indeed considered one of the key components of the Sustainable Development Goals (SDGs) to be finalised in September, 2015.
The SDG Open Working Group proposal target 3 is to ensure healthy lives and promote wellbeing for all people at all ages. Arguably, healthy populations are the basic engine to reach sustainable development, and health contributes to all 17 SDG targets. Evidence to measure specific health effects is, however, ill-defined— eg, the relationship between health and marine resources or urbanisation. A Lancet Commission on planetary health will report on these themes in 2015.  Read more

Profile  David Evans: putting universal health coverage on the agenda
www.thelancet.com Vol 384 December 13, 2014
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Universal Health Coverage for 2.1 Billion Populations:  Lessons Learned from ASEAN Plus Three Countries
Shila Kaur, Health Consultant, Third World Network (TWN)
67^th World Health Assembly 19 – 24 May 2014, ASEAN plus Three Countries side meeting Tuesday 20 May 2014 Palais des Nations Geneva
Background
ASEAN Plus Three Countries, Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand, Viet Nam, China, Japan and South Korea are diverse  with regard to  population size, social and economic conditions as well as health systems.  The countries span two regions of WHO ie South East Asia Region (SEAR) and West Pacific Region (WPR) and cover 2.1 billion populations, with vast Universal Health Care (UHC) experiences and different stages of UHC development.
At this side event, the listed panelists shared country experiences on UHC.
Dr Toomas Palu (World Bank) congratulated WHO for its strong leadership of UHC, adding that it had been a privilege to work with Asian countries who had shown a strong commitment to UHC.  He indicated that there was clear momentum for international commitment on UHC.
Amongst the lessons learnt in the process were:

• Governments must take responsibility for the poor and near poor for UHC.
• UHC is not just about raising money for health.  Expenditure is also important.  Services that are provided must prove value for money, as was efficiency.
• Supply side readiness of delivery also mattered. Service delivery was the emerging bottleneck and it was important that this was addressed as it relates to NCD.
• Affordability was a consideration; the Thai and Philippine experiences had demonstrated that it is possible to get UHC and good quality health care at low cost.

In her summing up, WHO’s Dr Marie-Paul Kieny reiterated that availability, affordability and good quality were the basis for UHC.  She indicated that even the richer countries struggle to meet changing health needs and demands.  For example Japan is taking action to provide more community based health care in view of its rapidly aging population.
She asserted that UHC is not a vague concept; it was clearly defined.  ASEAN countries had shown that UHC was feasible and that all countries can make measurable progress.
The full report is available here

Timor Leste
East Timor striving for universal access to health care
When asked about his vision for East Timor’s health system, Health Minister Sergio Lobo says it is about access. He compares East Timor with its richer neighbours, Malaysia, Singapore, and Australia. In those countries, he says, not everyone can always access their world-class health services. “In Malaysia, Singapore, Australia, any problem, they will fix it. The services are there, but not for everybody”, Lobo told The Lancet.
More than a decade on from gaining independence, East Timor has made gains in health but still faces an uphill battle to achieve universal health coverage and access.
Chris McCall reports in the Lancet
www.thelancet.com Vol 384 October 25, 2014

Medicines in Health Systems Report 2014, edited by Maryam Bigdeli, David Peters and Anita Wagner, focusses on advancing access, affordability and appropriate use. The Report validates a health systems approach, covers evolving systems and concepts and explains why an explicit focus on medicines is needed to achieve Universal health Coverage.  Download the whole report here