Universal health coverage: a call for health equity

People want dignity. They want rights.

This is not surprising. Every year in Africa, nearly 250,000 children under the age of five die because their parents cannot afford the treatment they need.

According to the World Health Organisation, every year 150 million people bear the disproportionate costs of health care and 100 million are driven into poverty by direct payments. People living in poverty are increasingly protesting that their basic right to the health care they need is being denied.

To remedy this situation, transformative solutions are needed, not just patches. It is time to ensure universal health coverage.

Universal health coverage: a simple and unifying concept

Some people argue that the concept of “universal health coverage” (UHC) has not been clearly defined or is difficult to understand. The truth is that it is quite simple. The CSU is about guaranteeing the right to health.

It means that all people – regardless of whether they are poor or rich – have access to good quality health services, without being in danger of being trapped in poverty. No person should have to live in fear of becoming ill because they cannot afford the assistance they would need to survive.

As President Kim said last week, there is now compelling evidence that user fees for health services have only worsened expected health outcomes. We could not agree more with him.

There is also strong evidence that a larger public budget for health care is a key investment. Twenty years ago, in its World Development Report: Investing in Health, the World Bank made it clear that investing in health was investing in economic prosperity.

The Lancet’s report Global Health 2035, published a few months ago, went a step further and provided evidence of the positive impact of investment in health on economic growth.

That universal health coverage is needed is more than evident. We now need an ambitious plan to achieve it.

A realistic objective requires ambitious goals

When Senegalese President Macky Sall launched a plan in 2013 to ensure the CSU at the national level – which included a target of covering half of Senegal’s population by 2015 – it proved to be ambitious.

When Nigerian President Goodluck Jonathan set a target of 30% of the population by 2015, he also showed great aspirations. Now that we are embarking on the debate on what the post-2015 sustainable development goals should look like, it is time to demonstrate our high ambitions.

In 15 years we can achieve universal health coverage. This is an ambitious goal, but it is also feasible. Ambitious targets can unite the international community to improve people’s access to health care and make the economic barrier disappear, worldwide.

Governments do not systematically collect the data needed to measure health service coverage and protection against financial risks. This makes measuring these indicators difficult.

This could change, precisely because of the international community’s common goal of achieving the CSU. The World Health Organization and the World Bank have worked hard to propose a monitoring framework for the CSU. This framework now exists and has shown that it is possible to measure the CSU.

To measure progress towards the CSU, there are three areas where the international community must show sufficient ambition to meet the demands of all of us, leaving no one behind:

Access to health services and medicines

Focusing on the CSU also provides an opportunity to accelerate progress on other health-related Millennium Development Goals, to address the burden of non-communicable diseases and to improve sexual and reproductive health.

There is no reason why poor people should not have access to hospitals. To ensure this, public policies need to be put in place to achieve equitable health financing. A package of services guaranteed by policies aimed at achieving CSU should, therefore, be comprehensive, ambitious and universal.

Strong and equitable public financing mechanisms

The CSU should be based on the principle of solidarity in the form of cross-subsidy income – from the rich to the poor – and cross-subsidy risk – from the healthy to the sick – so that access to services is determined by need and not by ability to pay.

This implies that services should be provided free of charge at the “point of supply”. User charges are the most inequitable way of covering health costs. They prevent poor people from accessing life-saving treatment and, each year, add millions of people to poverty.

To expand health services and achieve a CSU, a strong public health sector is needed to pay for and provide most services. Governments should therefore ensure that an appropriate share of national budgets is directed towards the provision of public health services.

Measuring equity

Finally, in order to guarantee equity and universality, it is key to set specific objectives to ensure that people living in poverty benefit at least as much as those in an affluent position. Focusing on the poorest 40% of people, as proposed by the World Bank and WHO in their CSU monitoring framework, is a good starting point.

But it is not enough. This monitoring framework must measure progress in different groups according to their income and especially with respect to the poorest and most vulnerable 20% of the population, not just the poorest 40%.

Through this comprehensive approach, the goal of achieving a CSU is also an opportunity to make progress towards achieving decent, affordable and equitable health coverage for all people.

The measurement of the CSU must reflect what all people want: universality and equity. It means making progress towards eliminating user fees, developing strong public services, and reaching the whole population through universal policies. We must not leave anyone behind.