“Ultimately, the greatest threat to global health security is the fact that billions of people lack access to essential health services. Universal health coverage and health security are two sides of the same coin.”
Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization
The case for universal health coverage (UHC) is a powerful one. But it is inherently political. Equitable coverage requires the rich to subsidise the poor, the healthy to support the sick. The power of the state must be used to force people to pay, through taxes, or compulsory insurance contributions. For this reason, those who advocate for UHC on the world stage – such as the World Health Organization – have often tried to link this goal to others, that are less subject to hostile political criticism. In recent years, epidemics such as Ebola and H1N1 have given renewed impetus to the cause of global health security (GHS) – the ability of states to prevent, detect and respond to disease outbreaks and avoid their spread across international borders. This is an objective that a broad coalition of global actors – even those that may be suspicious of UHC – can rally behind. Hence, as Gorik Ooms and his colleagues point out in a recent article, those who seek to make the case for UHC frequently assert the mutual interdependency of the UHC and GHS goals, suggesting that a dollar spent on either will normally serve the interests of both.
And to an extent, this is likely to be true.
UHC is about providing equitable access to the health-related goods and services that people need, and to eliminate the financial hardship that healthcare utilisation can cause. If people are more likely to utilize care, health systems are more likely to detect, and be able to respond to, disease outbreaks. Hence, UHC and GHS are aligned to this extent. A tension arises, however, because UHC is also about insurance. This is scarcely a trivial issue. Globally, more than 800 million people spend over 10% of their annual income on medical bills and nearly 180m spend over 25%. Healthcare costs are a leading cause of bankruptcy and impoverishment in all countries without a comprehensive tax-based or social insurance system.
But the money available for insurance is finite, meaning that governments have to make difficult trade-offs about what to cover, and to what extent. That means we have to pay close attention to our priorities – and they will differ depending on how we define our goals.
If we make financial protection for people the priority, we should allocate money to needed treatments that are costly. Many of these will take place in hospitals. We might even consider reallocating resources away from primary care to these more expensive healthcare sites – since most care delivered in primary care settings will be affordable to all but the poorest in society.
Really existing UHC efforts often do this, at least indirectly. It is what is being done in India, just now. There, policy is focused on the strengthening social insurance programmes which are, in turn, primarily focused on hospitals. At the same time, primary care is hugely underfunded, and a majority of the population pays for the care they need out of pocket from small-scale private providers. This is also, less obviously, the model underpinning calls for a ‘single payer structure’ by advocates of more progressive health financing arrangements in the United States.
When UHC is conceptualised as a model of insurance, it is unlikely to generate the spending on national emergency preparedness plans, systems for medical countermeasures in emergencies, reporting networks/protocols and laboratory capacity that the International Health Regulations – the cornerstone of the GHS ideal –demand.
In their recent work, Ooms and his colleagues ruminated that “tying [UHC and GHS] together may come with pressure on low income states to use the limited public financing resources for efforts in infectious disease control whilst relying on private sources to finance the rest of UHC.” If UHC is taken forward as a goal that helps to organize efforts to strengthen systems, with an expanded primary care system at their heart, this is much less likely.
If we really wish to link these two powerful ideals, coverage and security, we must focus on a much more expansive definition of UHC – and take seriously the kinds of investments we need to make to achieve this. Such an approach is likely to include good community-based clinics, teams of generalist clinicians, effective reporting protocols, modern laboratories etc, that are much more germane to the GHS cause – in other words, the development of excellent primary care systems. It is also likely to provide a powerful impetus behind efforts to address the causes of healthcare demand – for example, under-vaccination for diphtheria, tetanus and pertussis, or treatment for HIV and Tuberculosis, that are also crucial to the global health security agenda.
Only then are the synergies between the two goals as striking as global health advocates sometimes suggest.