Financing universal healthcare coverage [excerpt]

Over the past few decades, public-private partnerships (PPPs) have become a primary resource in addressing global health. These partnerships, which are made up of private organizations that work closely with governments, aim to combat global health crises more effectively than other systems.

Governing Global Health: Who Runs the World and Why? analyzes the effectiveness of global health organizations in their efforts against communicable diseases. In the excerpt below, authors Chelsea Clinton and Devi Sridhar discuss the implementation of healthcare among countries with universal health coverage.

On 12 December 2012, [universal health coverage] received an unequivocal endorsement from the UN General Assembly (including the United States) with the approval of a resolution on UHC that confirmed the “intrinsic role of health in achieving international sustainable development goals.” The 2005 World Health Assembly’s definition of UHC makes clear what its achievement would look like: “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access,” rather than how it would be achieved. In 2012, a WHO discussion paper on the post-2015 health agenda (what would emerge as the Sustainable Development Goals or SDGs) identified UHC as a “way of bringing all programmatic interests under an inclusive umbrella.” Yet despite UHC’s growing prominence in the post-2015 agenda, there is not yet any single agreed-upon plan on how institutionally it should be carried forward and financed. This is not particularly surprising.

“For the most part, key donors believe that domestic resources are growing fast enough in most developing countries to enable governments to strengthen their health systems and provide universal health coverage, if that is what they choose as an area of investment.”

Across countries with UHC, no two versions are alike in their financing, in what they cover, or in how they are structured. Some countries with UHC rely on a public system of coverage while others mandate insurance coverage, requiring individuals to buy health coverage in a regulated private insurance market or from the government, while still others have a mix of the two approaches. Additionally, a further challenge is that the conversations and debates surrounding UHC are rarely tied to those relating to health systems strengthening, community health-worker models, or other health-care delivery priorities. We find this persistent decoupling illogical.

Thus far, neither donors nor developing countries have turned to vertical funds directly to strengthen health systems or to assure health care for all members of society (for example, through UHC tied to health systems strengthening). One possible exception to this are the health systems strengthening funds that the Global Fund and Gavi at times have made available; however, these have always remained the significant minority of funds each has disbursed as mentioned in earlier chapters. In addition, to qualify, applicants have had to be clear about how such funds will strengthen health systems with a direct relationship to achieving their respective infectious disease mandates. Not surprisingly then, such funds have not supported broader capacity building, despite health-worker shortages across the developing world. In the horizontal-versus-vertical-funding terminology debate we engaged with earlier, this approach is referred to as “diagonal.”

For the most part, key donors believe that domestic resources are growing fast enough in most developing countries to enable governments to strengthen their health systems and provide universal health coverage, if that is what they choose as an area of investment. They also worry that governments in developing countries would use any new funds as an excuse to reduce their existing health investments—viewing such aid as a substitute for domestic spending on health, not as an addition to it. Research from the IHME supports these concerns. It also points to this effect only when development assistance flows directly to developing country governments, rather than when it flows to NGOs working within the same country. Arguably, then, this is a valid concern in the context of UHC, as most UHC-targeted development assistance would be expected to flow, at least in significant part, to governments.

“Many donors are also wary of further fragmenting global health governance, cognizant that the aid harmonization efforts of the past decade stretching from Paris to Busan and beyond have largely failed.”

Additionally, donors believe that national programs must be country-led (even if donor influenced) and country-designed because of differences among health systems (such as the presence or absence of a domestic private-care delivery system or preexisting domestic private insurance markets). For some, it is also crucial that such investments be tied to government approaches to fighting disease risk factors (such as tobacco for NCDs). Many donors are also wary of further fragmenting global health governance, cognizant that the aid harmonization efforts of the past decade stretching from Paris to Busan and beyond have largely failed.

Still, Japan plans to make UHC a major priority during its presidency of the 2016 G7. Is UHC a rousing enough topic to get the attention and funding from heads of states and the requisite legitimization from their publics, as happened at the 2000 G7 with what would become the Global Fund? At least at the moment, UHC currently has far from universal donor support. The Gates Foundation has expressed its discomfort with UHC as a unifying post-2015 theme. One strategic idea for raising the profile of UHC is to tie it to health systems strengthening (in a broader context than ever articulated by the Global Fund or Gavi) and to make it a pillar of achieving meaningful global health security. Yet, this strategy is not without possible complications; “global health security” remains a debated term. Since World War II, this concept has become increasingly narrowed to one in which health threats are perceived to be largely related to outbreaks with the potential to affect wealthier and more powerful countries’ citizens and interests. Health security became part of national security, instead of its original definition as the health part of human security. In part, this was intentional as seen in UN Resolution 1308, which classified HIV/AIDS as a security threat. At the time, the hope was that such a linkage would increase urgency around the burgeoning epidemic, and that such urgency would be followed with increased political cooperation and funding. On that front, as seen in the advent of the Global Fund and later the US PEPFAR program, it was undeniably successful. Its legacy, however, is one in which it is easy to classify Ebola as a security risk and more challenging to imagine the rising burden of NCDs or persistent lack of UHC as the same in a traditional, or even global health, context.

Featured image credit: “Blank world map with blue oceans” by Petr Dlouhý. CC BY-SA 3.0 via Wikimedia Commons.

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