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Universal health coverage: lessons in The Lancet

The Lancet has just launched a special series on universal health coverage (UHC). As we have seen at events this year – and as we have highlighted in previous blogs – UHC is gaining traction as a major global health priority.

The right to health

UHC refers to all people having access to quality, essential healthcare without financial hardship.

Rooted in the right to health, The Lancet re-states this priority and contributes to the growing evidence for investing in health and identifying key lessons on how to do so.

Acknowledge past mistakes

A major part of achieving UHC is health financing policy and making it more equitable and efficient so that adequate resources are raised progressively. This means increasing pre-payment through mechanisms such as fair taxation, which are pooled across the whole population so that risks and resources can be distributed according to peoples’ needs and not their ability to pay.

This is not news. It’s something we have long advocated for. But it’s finally something all stakeholders recognise and can no longer deny.

Acknowledging the removal of user fees comes at an important time. This year marks the 25th anniversary of the Bamako Initiative, which was adopted in 1987 in Mali by African health ministers and supported by the WHO and UNICEF.

Responding to the challenge of inadequate resource for primary healthcare, one of the key components on the Bamako Initiative was to encourage the introduction of user fees in developing countries.

Time to scrap user fees

This had a disastrous effect on health outcomes and household poverty. As we now know well, direct payments at the point of use, including user fees, are regressive and place disproportionate burden on the poor and sick, discouraging people from accessing essential services and causing catastrophic expenditures, exacerbating poverty and ill health.

Quoting Jeffrey Sachs, “even nominal co-payments can lead to massive exclusion of the poor from life-saving health services.”

This undermines the concept of health as a human right and a public good. As The Lancet’s series clearly states, user fees “should be scrapped”.

Now, 25 years on, is the moment to acknowledge the grave mistakes of the Bamako Initiative. Similarly, next year marks the 20th anniversary of the 1993 World Development Report, which also promoted user fee introduction.

The World Bank has the opportunity to revoke this advice and demonstrate its commitment to equity and UHC by actively supporting countries with the removal of user fees.

Strengthen public systems and invest in health workers

Equitable health financing is a pre-requisite of UHC, but it is insufficient alone. Other social determinants that cause inequities in access must be addressed.

In parallel, service delivery must be strengthened, and this includes having a sufficient, appropriately trained, supported, incentivised, equipped and equitably distributed health workforce.

As Sachs eloquently states, public systems – with public financing and service provision – are more efficient, effective and equitable.

The importance of aid

Further, no low-income country can be expected to achieve even rudimentary UHC without reliable and increased external assistance.

Greater investment – both domestic and donor – must be made to seize this opportunity to achieve UHC.

Garner political commitment

A resolution will be tabled at the UN General Assembly this year, calling on countries to invest more and better in health and social protection.

This is an important opportunity to raise the profile of the issue and engage government more holistically – achieving UHC will require a multi-sectoral commitment. As the Lancet editorial asserts, no government should question public support for investing in health given the pride vested in the NHS, as displayed during the London Olympic opening ceremony.

Achieving UHC will require both political commitment and resource investment, but governments must not underestimate the economic development and political capital it will generate.

As a driver of sustainable development, UHC is a promising concept that should be included in the post-MDG development paradigm.


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