No one questions the value of universal health coverage, writes SA Medical Journal editor Bridget Farham, but what the concept requires – worldwide, especially in lower-income countries – is political will, at the very least, and some form of global health financing mechanism.
Farham writes:
At the recent United Nations General Assembly in New York, a number of high-level meetings on health topics took place, covering pandemic preparedness, the fight against tuberculosis (TB) and universal health coverage.
These meetings were held in the context of a theme of accelerating action on the 2030 Agenda and its Sustainable Development Goals.
Pandemic preparedness and the fight against TB also fit within a universal health coverage agenda – arguably, neither pandemics nor TB would wreak the harms that they have if full universal health coverage were available to all.
At this same UN meeting, the Political Declaration of the High-level Meeting on Universal Health Coverage was released.
I don’t think there is anyone who would argue against the principle of universal health coverage, except perhaps a handful of libertarians in strange countries like the USA, who see this as an intrusion on people’s right to get sick and die because they can’t afford medical treatment.
But, can any country afford universal health coverage? And I am not talking about our own proposed National Health Insurance (NHI) scheme, which, arguably, is more about centralising control over the supply of medical care than about providing universal health coverage.
Jeffry Sachs and Henry Perry, writing in The Lancet last week, spell out the facts. If you score countries for universal health coverage out of 100, as a 2020 study did, higher-income countries (HICs) score 85, countries in south Asia score 46 and sub-Saharan Africa scores 43.2.
Further massive differences are seen in life expectancy – 81.8 years in HICs, and 63.9 years in low-income countries (LICs); child mortality (under five years) – HICs have a rate of five deaths per 1 000, and LICs have a rate of 60 deaths per 1 000; and maternal mortality – HICs have a rate of 12 deaths per 100 000 live births, versus 409 deaths per 100 000 live births in LICs.
These figures add up to an extra 4.2m deaths in LICs in 2023.
The UN draft declaration is full of the usual buzz words and phrases that come out in any document dealing with universal health coverage – “strengthen national health plans based on a primary health care approach … provision of a comprehensive, evidence-based, nationally determined package of health services, with financial protection, to enable access to the full range of … affordable and essential health services, medicines, vaccines, diagnostics and health technologies needed for health and well-being throughout the life-course”.
The declaration, quite rightly, emphasises primary healthcare and community health workers. It also points to the need for more external financing, calling for governments of HICs to put more into established mechanisms such as the Global Fund to Fight Aids, Tuberculosis and Malaria, and Gavi, the vaccine alliance.
Sachs and Perry argue strongly that LIC governments cannot afford universal health coverage through domestic financing. They point out that a typical LIC has a gross domestic product (GDP) of just $741 per person, and government revenue of around 20% of GDP.
If governments were to use as much as 20% of revenue on healthcare – a big ask for most LICs – the annual public outlay would be just $30 per person, compared with the minimum of $100 to $200 per person required for universal health coverage.
The thrust of their commentary is that what is required is a global health-financing mechanism, based on primary healthcare and community-based health delivery.
They argue that the total health financing gap for countries in need of external finance (LICs plus low- to middle-income countries) is $50-$100bn per year – a total that is around 0.1 – 0.2% of the $61.5trn GDP of the HICs – and less than 5% of the $2.1trn spent in 2022 on armaments.
This is a laudable aim.
But with the current state of the world at the moment, I – and many others I have read and talked to – suspect this is aspirational.
My experience of working with the World Health Organisation (WHO) Regional Office for Africa is that there is a decreasing amount of money available through the traditional health funding agencies, such as the Global Fund and Gavi.
The massive funds still available through large philanthropic organisations such as Rockefeller, Bloomberg and the Helmsley Charitable Trust, are carefully managed, and although all subscribe to the principles of universal health coverage, are pretty realistic about what can be achieved in sub-Saharan Africa without increases in domestic financing.
Indeed, the WHO Regional Office is advocating for greater domestic investment in health from its member states to reduce reliance on external funding.
Investing in health is essential in LICs, particularly given our young populations. And in many countries, like South Africa, the money is there.
It is a question of how it is spent (and not stolen) that is at issue.
While I was in Botswana recently for the WHO Regional Committee for Africa, the country was regularly held up as a model for the rest of the region – probably the closest to universal health coverage of any African nation.
Of particular note, given our own government’s insistence that the private sector in SA must go, is Botswana’s active encouragement of growth within the private health sector.
Botswana, like us, is classified as upper-middle income. In 2013 – and apparently the figures are still similar – total health expenditure was $397 per capita, with government health expenditure (GHE) of $227 per capita. GHE has remained relatively constant since 2005, with health financing boosted by the growth of private health insurance, although the health system remains dominated by the public sector, which is based on a primary healthcare model, and significant support from donor funding (which is falling).
To me the lesson here is that moving closer to universal health coverage requires not more money, but political will, unencumbered by ideology.
Let’s hope that this political will is present in SA.
Needed: a financing breakthrough at the UN High-level Meeting on Universal Health Coverage
See more from MedicalBrief archives:
How COVID gave African countries the opportunity to improve public health
Healthcare in the age of opportunity: Perspectives from the next generation of professionals
World Health Organisation Global Tuberculosis Report 2019