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Progress at the UHC Forum but 5% of GDP would be real progress

Here in Tokyo, the Universal Health Coverage (UHC) 2017 Forum saw speeches from the great men. Only men. Even the line-up of leaders of international agencies had only one woman and she is an interim who will soon hand over the permanent appointment who is, you guessed it, a man. Is this truly Health for All?

Despite this glaring problem, there were some important developments. The new Director General of WHO, Dr Tedros Adhanom Ghebreyesus, was elected by member states with UHC as his top priority and is continuing to talk about it at every opportunity. Jim Yong Kim, President of the World Bank, pointed out that many countries seem happy to spend on health when they have aid funding and concessional loans but, when they become middle-income, are suddenly much more reluctant to spend their own money. Bill Gates sent a video message and said clearly, for the first time, that his Foundation strongly supports UHC and sees primary health care as the platform. Japanese Prime Minister Shinzo Abe pledged $2.9 billion to UHC.

Civil society organisations here decided on two priorities for this Forum. We are pushing for an approach to UHC which leaves no-one behind and does not cause poverty or discrimination. We have also driven a strong focus on national resources and called for 5% of GDP to be a minimum for public health spending in all countries.

This target is not universally accepted, especially by the many low and lower-middle countries that are far from it. We already know that the process of replacing voluntary private expenditure (out-of-pocket spending) with public financing has not started. Despite the commitments made to health under the MDGs and the SDGs, public funding for health from domestic sources in low and middle-income countries stagnated between 2000 and 2014. A new report from WHO launched at this Forum shows that in low-income countries, domestic government sources for health have declined from 30% to 22% as aid increased from 20% to 30% – we need to change this model if aid is deterring governments from increasing their own resources.

But we know that where public financing is lower than 5%, too many service users end up paying cash or not getting any care. McIntyre, Meheus and Røttingen analysed what level of government spending is needed to reduce impoverishment, the costs of sufficient numbers of health workers and the cost of achieving 90% coverage of essential health services to conclude that “a target of government expenditure of at least 5% of GDP is an appropriate one.” All governments could and should be raising and spending 5%, through progressive taxation, efficiency gains and increased harmonisation with other resource flows. While taxing people is certainly more difficult in countries with large informal economies, many countries can improve tax collection, stop illicit financial flows and tax avoidance, increase fair taxes including as land and sin taxes and mandatory social health insurance.

Of course, for very poor countries, even 5% of GDP would not be enough and donors should particularly assist countries that are doing their best but whose economies are too small to deliver essential health services. No-one imagines that simply allocating money to health is the end of the story or will magically lead to UHC. Bangladesh is spending a lot less but doing well. The US is spending a lot more without achieving UHC. Yet, 5% is a worthy benchmark alongside ensuring that health budgets are well-spent, inefficiencies and corruption are reduced, essential services at primary and community level are prioritised and that quality of healthcare is constantly improving.

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