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A new consensus on universal health coverage, the threat posed by health insurance schemes and some bizarre conference dancing

October 14, 2013
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Oxfam health policy adviser Ceri Averill ponders the new consensus on Universal Health Coverage and the potential threat posed byceri averill health insurance schemes

It has got to be one of the more memorable and surreal ends to a conference I’ve ever seen. After four days of serious policy discussions about health financing and universal health coverage (aka ‘UHC’), the 2012 Prince Mahidol Awards Conference in Bangkok closed with the great and the good of the global health community on the dance floor, suited and booted and boogeying away to the tune of YMCA, adapted to fit the words “We believe in U H C” (try it – it does actually work!). Health ministers, government officials, World Bank staff, academics, and civil society activists were all there.

As I watched the scene unfold I found myself wondering what this meant. Was it really possible for people who have disagreed for years on so many issues to unite under the umbrella of UHC? (as it happens there really was a dance troop on stage twirling UHC umbrellas). And if we really do all “believe in UHC” are we understanding it to mean the same thing?

Universal health coverage has risen quickly to the top of the global health agenda. The Director-General of the World Health Organization (WHO) Margaret Chan has described it as ‘the most powerful concept that public health has to offer’, and in December last year the United Nations General Assembly adopted a landmark resolution on UHC. It is a simple but inspiring concept – the idea that all people should have access to health care without fear of being pushed into poverty. As the momentum builds, a diverse range of actors – including governments, multilateral agencies, donors, private foundations, academics, and civil society organizations – are uniting beneath the UHC banner.

On one hand I’m excited and encouraged by the growing enthusiasm. UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. Making health care available to all is in the spirit of Article 25 of the Universal Declaration of Human Rights and it is the continuation of a long struggle for “health for all”, popularized since the Alma Ata Declaration in 1978. It is also the founding principle on which an institution I have known and loved my whole life – the UK’s National Health Service – was built.

health insurance picOn the other hand, I see two major risks. The first is that UHC is reduced to a catchy sound bite and so comes to mean anything and everything, but ultimately nothing. Jim Kim, President of the World Bank Group said recently, ‘All of us together must prevent “universal coverage” from ending up as a toothless slogan’ –  I couldn’t agree more.

The second more serious risk is that the UHC agenda becomes hijacked and business as usual prevails. Already many different things are being done in its name,  not all of which live up to the core principles and objectives set out in the landmark WHO 2010 World Health Report on UHC.

Last week Oxfam published a new report warning that health insurance schemes, touted by some governments and donors as ‘the way’ to achieve UHC in low- and middle- income countries, are excluding the majority of people and leaving the poor behind. In many cases insurance schemes are actually driving up inequality by prioritizing already advantaged groups who work in the formal sector. The report argues that rather than focus efforts on collecting insurance premiums from people who are too poor to pay them, governments should look to learn the lessons from successful UHC countries and prioritize spending on health from general taxation – either on its own or pooled with formal sector payroll taxes and international aid.

Although UHC is not a ‘one size fits all’ journey and governments will need to develop approaches that fit the social, economic, and political contexts of their countries, the lack of a UHC blueprint does not mean that ‘anything goes’. Getting UHC (with clear equity targets and indicators that disaggregate data) into whatever succeeds the MDGs is going to be vital in order to ensure that it doesn’t end up either as a ‘toothless slogan’ or hijacked by an agenda that undermines the core UHC principles of universality, equity and social solidarity.village-people

The risks are real, but they are not insurmountable. Ultimately the momentum for UHC presents an opportunity for the global health community to finally deliver on the right to health for all. Politicians now have to show that they are willing to take action, civil society must unite to demand change, and development partners need to step up to support them. At the same time we all have a responsibility to halt unproven and risky policies that threaten to derail progress.

Needless to say, on that afternoon in Bangkok it wasn’t long before I too made my way to the dance floor, where I found myself flailing my arms in the air and singing along to the catchy tune. I never did quite work out how to do the H though.

See here for more on the health insurance report from Ceri’s co author, Anna Marriott

1 comment

  1. Thanks Ceri and your report is a great contribution. Over the last week alone, I have had UHC dismissed as “pie-in-the-sky everyone agrees with it so it means nothing”, “focusing on services for the middle classes when we should target the poor” and “promoting poor quality services that will get worse when spread thinner”. These are not necessarily genuine misunderstandings, but we have a problem if UHC is able to be characterised so easily in these destructive ways. There is still not an inescapable definition of UHC. Personally I think it is time to develop something like Five Principles of UHC which counteract the accusations of vagueness. Plus I think we should start talking about UHC as principles to be applied to health services now rather than a far-off destination in which “all people” get “all services”. Finally, I suggest that a star jump is the best approximation of an H.

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