The main focus of this year’s World Health Day is universal health coverage (UHC). But is it really achievable? And which model is the best?
Half of the world’s population still don’t have access to essential health services. 100 million people are being driven to extreme poverty because they have to pay for their health care. Over 800 million people globally spend at least 10% of their income on health care.
Though there has been great progress to advance health outcomes in the past century, global health services still don’t provide for all.
If we are to continue to improve health outcomes for rich, middle income, and low-income countries, universal access to healthcare services is going to play a big part. This is why this year’s World Health Day converges around this issue.
In some circles, there are doubts about the cost-effectiveness of universal health coverage. In order to improve health outcomes and reduce extreme poverty, however, both the World Health Organization (WHO) and the World Bank argue that we need to achieve universal health coverage.
Which countries have universal health coverage?
Most wealthy, developed nations have universal health coverage in some shape or form. The obvious exception is, of course, the United States. Of the top 50 countries with very high human development, according to the Human Development Index, the US is the only nation without a universal healthcare system in place.
Despite the innovative approach of the Affordable Care Act (ACA) in 2010, UHC still hasn’t been fully achieved. The US has some of the best quality health services, but most of these cannot be accessed by the wider population.
Post-ACA, the number of people not covered by health insurance has reduced significantly. However, the latest 2017 figures indicated that this promising trend is reversing.
The US is, of course, a concerning anomaly in the western world. But it’s possible to argue that the most pressing issue is not amongst the developed nations.
In Africa, only 11 out of the 54 recognised states have universal health coverage. In Asia, 13 out of 48 nations have access to universal health. In the Americas, meanwhile, only much-lauded anomalies like Costa Rica, Argentina, Cuba and Colombia provide their citizens with universal health coverage.
The drive towards universal health coverage amongst the western media focuses almost exclusively on the ongoing US debate. But the most urgent improvements that need to be made are through system reform in developing and advancing economies.
What are the best universal healthcare systems?
It’s worth noting that universal health coverage does not mean that healthcare is always free at the point of service. Even the NHS, which provides ‘free at the point of use’ healthcare, is paid for through taxation. As the old adage says, you don’t get anything in life for free.
Inevitably, there is considerable debate about which healthcare system works best. However, given that different nations have different economic, social and environmental contexts, it’s difficult to say for certain.
In the UK, we like to think that the NHS is the best model. Indeed, many nations look to the NHS as a shining example. But in the most exhaustive rankings of health systems, compiled by Bloomberg in 2018, the UK doesn’t even feature in the top 10. Hong Kong, Singapore and Spain made up the top three, and all three use different approaches.
There is no one-size-fits-all model that countries should follow to achieve optimal universal healthcare. There are, however, some considerations that can make healthcare systems successful.
Equality of service
A successful healthcare service should, in theory, offer the same level of care to both rich and poor. Dual systems, which offer state-backed health for the poor and private-backed health for those with greater financial resources, often lead to overall reduced quality and increased inequality.
Learning from success
Though countries can’t follow exact models, especially as different nations present different challenges, there are some learnings to be gleaned.
A commitment to quality, affordable healthcare for all should be the driving force in the creation of universal health coverage. But when it comes to funding, both public-private partnerships and tax-funded public projects can be successful if implemented with clear, focused goals.
Tax-funded health can lead to better outcomes
In most developed nations, health services are private in some shape or form. But many are regulated and government-backed, the UK’s NHS being one of the few to buck the trend.
However, experts within the field suggest that progressive tax-funded healthcare can help to ensure universal access. Agnes Soucat, Director of Health Financing and Governance at the World Health Organisation, stated recently in the Guardian that:
“What we have learned over time is that an equitable system always relies on cross-subsidy, from rich to poor and from healthy to sick. Progressive taxation and public subsidy to ensure access to services is the essence if we want to reach universality of access to health services.”
Not focusing on arbitrary targets
In a world where targets are attached to almost every aspect of society, it can be easy to get caught up in the numbers. For example, the Abuja declaration expects African governments to spend 15% of GDP on healthcare. Singapore, one of the most successful health systems in the world, only spends 4.9% of GDP on healthcare.
There is no set amount that will produce a universal health care system that is effective for a nation. It all depends on the context. A country can spend billions on healthcare but without a strategic approach, it can often lead to funds being spent in the wrong areas. Global universal health coverage won’t be possible through blind investment to meet targets.
Of course, increased investment is necessary in many cases. But there needs to be an understanding of local context. A developing African or South American nation will likely have a very different focus than the US, for example, and will subsequently require very different approaches.
Prevention is often better than the cure
When discussing universal health coverage, it can be easy to get distracted by hospitals, nurses and medication. Of course, universal health coverage should help to cure and treat illness. But preventative measures can be equally effective, especially in developing nations.
Social factors like housing, sanitation, welfare and education can have just as much impact. If a population is taken care of, population health can improve. Educating and promoting a healthy diet can help to prevent chronic illnesses such as heart disease and diabetes. In a similar vein, a recent piece by former Australian Prime Minister Julia Gillard in Huffpost referenced a study conducted in Botswana revealed that suggested every additional year of schooling reduces the risk of HIV infection by 8%.
Closer to home, the prevention of ill health is also now one of the NHS’s five priorities as part of the new 10-year plan. Health systems across the globe are starting to realise the value of preventative health.
Political will is vital
There is a global consensus that we need to work towards universal health coverage, but without political will, it may not be possible.
A paper authored by BS Aregbashola builds on this: “evidence from countries such as Ghana, Chile, Mexico, Thailand, Turkey, Rwanda, Vietnam and Indonesia, which have introduced at least some form of universal health coverage scheme, shows that political will and commitment are key to the adoption of new laws and regulations for reforming coverage.”
To achieve global universal health coverage, there needs to be the will to make sure that it happens. Take the US, for example. Great steps have been taken in recent years through the Affordable Care Act to reach universal health coverage. But as we’re seeing, without the will to drive this progress, a previously positive trend is now being reversed.