MMI discussion paper: Universal Health Coverage (UHC) · And the MMI Network Strategy 201115 2 entitled - “We will make the MMI Network a real community of change for strengthening

27 May 2013 – Discussion paper for MMI Network members MMI Assembly in Barcelona 8 June 2013, agenda item 11

MMI discussion paper: Universal Health Coverage (UHC)

Content 1. Background and relevance ....................................................................................................... 2 1.1. Health systems strengthening – current strategic focus of the MMI Network ........................ 2 1.2. UHC: From shared enthusiasm to some worries ...................................................................... 2 1.3. Why a MMI discussion paper? .................................................................................................. 3 2. Starting points: What is in Universal Health Coverage? .......................................................... 4 2.1. WHO definition: the “UHC cube” .............................................................................................. 4 2.2. Health systems financing: the path to UHC .............................................................................. 4 2.3. UHC as an overarching health goal ........................................................................................... 5 3. Discussion 1: UHC in the context of national health financing

and social protection systems .................................................................................................. 6 3.1. Extending financial coverage .................................................................................................... 6 3.2. Extending the range of services ................................................................................................ 8 3.3. Avoid fragmentation, take care of the system(s) ..................................................................... 9 3.4. The journey is the destination (isn’t it?) ................................................................................... 9 4. Discussion 2 : “Globally Universal Health Coverage”

- a transnational issue and an international responsibility.....................................................10 4.1. Globalizing the principle of solidarity .....................................................................................10 4.2. Towards global governance for health ...................................................................................11 5. Discussion 3: UHC and health equity ......................................................................................12 5.1. UHC – the road to health equity and Health for All? ..............................................................12 5.2. UHC – key to fulfilling the right to health? .............................................................................13 5.3. Health equity as our core ........................................................................................................13 6. Conclusions .............................................................................................................................14

1. Background and relevance

1.1. Health systems strengthening – current strategic focus of the MMI Network The MMI Network Policy adopted in 2009 states: “The members of the Medicus Mundi International Network

share the vision of access to health and health care as a fundamental human right (‘Health for All’). While

recognizing that poverty, inequality, violence and injustice are at the root of ill-health and death in many low

income countries, MMI Network members are convinced that accessible, equitable and affordable health care is

essential to the improvement of global health, fighting diseases and reducing poverty; a major challenge is to

keep basic health care sustainable and affordable; and a key strategy is to strengthen the health system as a

whole.”1

And the MMI Network Strategy 2011-152 entitled “We will make the MMI Network a real community of

change for strengthening health systems” defines the strategic focus of the Network for the current years as

follows: “Contributing to health system strengthening will be the common denominator of joint enterprises and

political statements of our Network.”

Implementing this strategy, and having initially focused the Network’s attention related to health systems

strengthening on the role and integration of NGOs and private not for profit health care providers in national

health systems3, MMI was, like many other actors in global health, overwhelmed by the attention given to the

concept of Universal Health Coverage in the last two years, mainly by the World Health Organization. The

“UHC hype” brought health systems strengthening back to the top of the global health agenda. With her speech

at the World Health Assembly in May, WHO Director General Margaret Chan took herself the lead in a

something which became kind of a “UHC movement”:

"In my view, universal coverage is the single most powerful concept that public health has to offer. It is our

ticket to greater efficiency and better quality. Universal coverage is the umbrella concept that demands solutions

to the biggest problems facing health systems. (…) Universal coverage is the hallmark of a government’s

commitment, its duty, to take care of its citizens, all of its citizens. Universal coverage is the ultimate expression

of fairness." (WHO DG Margaret Chan at the World Health Assembly, May 20124)

1.2. UHC: From shared enthusiasm to some worries In spring 2012, MMI joined a “Civil society call for action on Universal Health Coverage”, calling for states to

deliver universal access to health systems according to their legal commitments to the Right to Health.5

However, in autumn 2012, when the debate on health in the post-MDG development agenda started to heat up

and Universal Health Coverage was promoted by WHO as the new overarching and universal health goal, MMI

hesitated to follow the pace of the “UHC enthusiasts”. In our MMI thematic guide on UHC6, we stated:

1 MMI Network Policy: www.medicusmundi.org/en/mmi-network/documents/mmi-network-policy 2 MMI Strategic Plan 2011-15: www.medicusmundi.org/en/mmi-network/documents/mmi-strategic-plan-2011-2015.pdf.

See also MMI thematic guide: www.medicusmundi.org/en/topics/health-systems-strengthening-starting-points. 3 See, as an example, the workshop at the People's Health Assembly, July 2012, organized by a group of NGOS including

the MMI Network: “In the public interest? The role of NGOs in national health systems and global health policy”, www.bit.ly/pha3-ngo-workshop. MMI thematic guide: The role of NGOs in national health systems, www.bit.ly/mmi-ngoguide

4 http://www.who.int/dg/speeches/2012/wha_20120523/en/index.html 5 Civil society call to action on universal health coverage, http://www.actionforglobalhealth.eu/index.php?id=303 6 www.bit.ly/mmi-uhc

“If Universal Health Coverage seems to be the way our vision and strategy are promoted these days by the

WHO, the UN General Assembly7 and the World Bank8 we have nevertheless good reasons not to become too

enthusiastic about it. Coverage alone cannot be sufficient, good governance of the health system (including

strong accountability mechanisms and continuous participation of a representative civil society in the policy

making) and good quality of health care services are equally important. And we have not even yet talked about

‘globally Universal Health Coverage’: the international solidarity mechanisms towards countries unable to

realize a decent level of coverage needed for UHC being truly comprehensive instead of a selective package.

And we have not talked about the political, economic and social determinants of health and the underlying power

relations not addressed by UHC: The conditions in which people are born, grow, live, work and age, including

the equity of these conditions, have a greater impact on population health than health care services.”

So let us do this now.

1.3. Why a MMI discussion paper? The current paper drafted by an ad hoc team9 led by the MMI executive secretary presents the key elements of

our analysis of the concept of Universal Health Coverage, linking this concept with our own ambition of Health

for All such as stated in the Network Policy.

As the debate on UHC goes on at an incredible pace – every week a new paper, every month a new international

conference – we consider this document not as an integrated, final or comprehensive position of the MMI

Network, but first as an instrument for fostering a dialogue among Network members before and during the

upcoming Jubilee Assembly of the MMI Network on 8 June 2013 in Barcelona:

Let us find out how far can we go together in our analysis of UHC, and let us also see if there are elements of our

analysis Network members strongly disagree with. If we find a common MMI position (and language) on

Universal Health Coverage, the Assembly might, in a second step, ask the drafting team to develop a position

paper.

7 Social Protection and Universal Health Coverage. UNGA resolution, December 2012,

www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36 8 World Bank topic: Universal Health Coverage. Including 22 country studies "analyzing the nuts and bolts of programs

that have expanded health coverage from the bottom up." http://web.worldbank.org 9 Members of the ad hoc drafting team: Bart Criel, Sarah Edwards, Thomas Gebauer, Martin Leschhorn, Carlos Mediano,

Mariska Meurs, Zbigniew Pawlowski, Itai Rusike, Remco van de Pas. Lead author: Thomas Schwarz.

2. Starting points: What is in Universal Health Coverage?

“Advancing universal health coverage as a WHO leadership priority for the years 2014-19 means:

enabling countries to sustain or expand access to essential health services and financial protection and

promoting universal health coverage as a unifying concept in global health.”10

Universal Health Coverage still means different things to different people, and there is much confusion how far

the concept shall be extended. On the other hand, the definition of UHC and of processes and paths chosen to

move towards Universal Health Coverage matter because these have important implications for the equity

impact of interventions.”11. In this section we outline the main current concepts of UHC which we will

afterwards discuss in detail in the sections 3 to 5.

2.1. WHO definition: the “UHC cube” According to WHO, the goal of achieving

UHC has two inter-related components –

coverage with needed health services

(prevention, promotion, treatment and

rehabilitation) and coverage with financial

risk protection. If you add “for everyone” to

these two statements on what needs to be

covered, you come to the famous “UHC

cube”

The other core element of WHO’s concept

of UHC is its progressive realization: WHO

states that “Universal Health Coverage is a

dynamic process. It is not about a fixed minimum package, it is about making progress on several fronts: the

range of services that are available to people; the proportion of the costs of those services that are covered; and

the proportion of the population that are covered.”12

2.2. Health systems financing: the path to UHC With this approach, WHO has already moved further than in its World Health Report 2010 on “Health systems

financing: the path to universal coverage”. The title of that report clearly puts health financing as core of UHC.

The “UHC forward” website still supports this approach:

“We define UHC according to the following core principles adapted from the 2010 World Health Report.

Different countries may make different policy choices, but those that are pursuing UHC consider these three

principles:

Reduced Out-of-Pocket Spending: Globally, over three billion people, many of them in the poorest half of the

world’s population, pay out of pocket for health services, often forgoing necessary care due to their inability to

10 Twelfth WHO Global Program of Work, adopted by the 66th World Health Assembly, May 2013,

http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_6-en.pdf 11 Mariska Meurs, UHC blog (not yet published) 12 Source: Positioning Health in the Post-2015 Development Agenda, WHO discussion paper, October 2012,

www.worldwewant2015.org/file/279357/download/302852. More WHO reference documents with the World Health Report 2010 “Health systems financing: the path to universal coverage” are listed in the MMI thematic guide on www.bit.ly/mmi-uhc.

pay. UHC reforms aim to reduce direct payments (or out-of-pocket spending), the monetary exchange that

happens between a provider and an individual seeking medical care.

Prepayment: To facilitate a reduction in out-of-pocket spending, UHC reforms aim to facilitate prepayment for

care by those who can afford to contribute. This means that people don’t have to pay for health care at the point

of service. Health care services are prepaid by a mix of general taxes, payroll taxes, member contributions or

premiums, and donor support. There is considerable variation in terms of how prepayment is organized by

countries.

Risk Pooling: To facilitate prepayment, UHC reforms aim to pool together financial risk so that the financial

cost incurred when an individual seeks health care services is spread across the entire pool of people who are

part of the system.

Ultimately, health financing systems that are moving towards UHC seek to raise sufficient funds for health,

provide financial risk protection in order to increase access to services, and use the funds in the most equitable

and efficient way possible. These systems have very different starting points and country contexts. Thus, each

country will need its own road map in order to achieve the core principles of UHC.”13

Referring to these two concepts which both put UHC as core elements of health systems (financing), we will

discuss the following:

• UHC and health equity in the context of national health and social protection systems. See section 3 of this

paper.

• Globally Universal Health Coverage as a transnational issue and international responsibility: below. See

below, section 4.

2.3. UHC as an overarching health goal

In the debate on future development goals that heated up in autumn 2012 and led to an incredible amount of

consultations and papers, Universal Health Coverage has been put forth by WHO as a unifying health goal. The

enthusiasm of WHO DG Margaret Chan in her promotion of UHC (see above) has been, to a certain amount,

also strategic: In order to save health as a key development issue after the “decade of global health” (2000-2010)

WHO considers (or considered) UHC as being the most acceptable goal:

“Using Universal Health Coverage in the post-2015 agenda is a way of accommodating the wide range of health

concerns. There are a number of caveats, and it is noted that Universal Health Coverage is a dynamic process.

Few countries reach the ideal, but all – rich and poor – can make progress. It thus has the potential to be a

universal goal.”14

The flurry of conferences and documents on both topics, health post-201515 and Universal Health Coverage, led

to some great analysis and discussions, but also to even greater confusion. For UHC enthusiasts, Universal

Health Coverage became a quasi-synonym of Health for All, health equity, and fulfilling the right to health. And

this UHC enthusiasm created again some harsh reactions.

If we refer to ambition of promoting UHC as a universal and overarching health goal, we need to discuss the

relation between UHC and health equity and Health for All: See below, section 5.

13 http://uhcforward.org/about/universal-health-coverage 14 Positioning Health in the Post-2015 Development Agenda. WHO discussion paper, October 2012,

www.worldwewant2015.org/file/279357/download/302852 15 See MMI thematic guide: Health in the post-2015 UN development agenda www.bit.ly/mmi-beyond2015guide

3. Discussion 1: UHC in the context of national health financing and social protection systems

“Universal Health Coverage is in, Health Systems Strengthening is out. It’s great to be part of this global

drive towards UHC!”16

Let us start the discussion with the UHC “cube” definition (see above, section 2.1). The “progressive”

achievement of UHC within the national health system has been put by WHO also in the economic context:

“Moving towards Universal Health Coverage is a process that needs progress on several fronts: the range of

services that are available to people (consisting of the medicines, medical products, health workers,

infrastructure and information required to ensure good quality); the proportion of the costs of those services that

are covered; and the proportion of the

population that is covered. These gains

need to be protected during financial or

economic downturns.” (Universal

Health Coverage: WHO secretariat

report to 66th World Health Assembly17)

Health financing and coverage are part

of the “building blocks” of health

systems MMI refers to in its Network

strategy.18

WHO states: “Moving towards universal coverage requires a strong, efficient health system that can deliver

quality services on a broad range of country health priorities. This requires health financing systems that raise

sufficient funds for health, access to essential medicines, good governance and health information, people-

centered services, and a well-trained, motivated workforce, for example.”

This all makes sense. Nevertheless, it makes sense to highlight some “must haves” and “must nots” of UHC19 in

the context of national health and social protection systems as we will do in the following:

3.1. Extending financial coverage The equation of universal coverage with financial coverage focuses on the mere element of affordability or

economic accessibility of health care. This has several implications.

First, in this perspective UHC risks to become to be seen as synonymous of health insurance schemes that would

fund a limited package of services and allow infiltration of the private sector into national health systems,

potentially undermining the public health sector. To avoid this, UHC should aim at increasing the proportion of

health care services that are owned and governed by the public sector and financed by progressive taxation

systems. No country in the world has made substantive progress towards UHC by relying on voluntary

contributions to insurance schemes, so it is not 'just' prepayment that is important, but mandatory prepayment, in

the form of taxes (be it income, payroll, VAT) in some cases combined with mandatory contributions.

16 David Hercot, http://e.itg.be/ihp/archives/uhc-is-in-hss-is-out 17 http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_24-en.pdf 18 MMI thematic guide: Health systems strengthening: Starting points http://www.medicusmundi.org/en/topics/health-

systems-strengthening-starting-points 19 In the next sections, we strongly refer to an inspiring paper which was sent to us by the authors but unfortunately has

not yet been published: Adriano Cattaneo et al.: The seven sins and the seven virtues of Universal Health Coverage

In relation to risk pooling, it is important to mention that the pools need to be large and comprise diverse

populations to allow for cross-subsidization between sick and health and between poor and non-poor. In fact, it

matters how resources are raised: ensuring that the tax system is progressive, that the rich and large businesses

pay their share. This touches upon underlying structures and policies that cause and maintain inequities.

Public funding is essential for UHC, but national public budgets are under stress. The current debates about

financial crises and macro-economic stability strongly influence the UHC debate: UHC and social protection

mechanism will be severely affected in those countries that "choose" for macroeconomic stability, e.g. via tax

funded bailing out its bankrupted banks, privatisation of public services and financial austerity of social and

health services (see Greece, Spain, and Portugal as examples).20

On the other hand WHO, UN and World Bank papers suggest that fiscal reality is cast in stone and that only

within this fiscal reality countries have the political space to move forward to UHC. This approach, in essence,

tells us something about the sad situation we have come to live in. But what are the mechanisms that cause and

maintain resource scarcity in low income settings? And what is needed to counter those mechanisms for the sake

of a more just distribution of resources and wellbeing?

It is a fact that untaxed private wealth hinders many countries to finance strong public systems to reach or

maintain Universal Health Coverage. In many emerging economies, such as South-Africa, Indonesia; but also in

European countries with traditional generous social security systems, there is strong political pressure to remain

attractive for international (financial) investors.

In parallel there is similar pressure to reduce public spending on health care and create space for health insurance

companies in the market of (mandatory) social insurance packages. Authors have coined this process of tax

competition “a race to the bottom in slow motion”, with specific policies becoming less generous without

disappearing, or creating a public debt that will eventually force their termination.

The question is whether all the countries that are now supporting the cause of UHC are willing to make progress

on the reform of their fiscal policies in order to extend the current budget limitations.21

Finally it is well known that globalization has widened health inequalities. However, more emphasis should be

given to the fact that the transforming of health services into commodities, the linkage of access to health care to

individual purchasing power, the dismantling of public health systems, has only been possible in the context of

the neo-liberal ideology, a concept that has replaced social values and institutions such as solidarity and common

goods by self- responsibility and individual entrepreneurship and widely affected those who are suffering its

negative consequences, the global poor.22

At the core of ‘There is no such a thing as society’, Margret Thatcher said in the early 1980s – paving the way

for the cynical credo of neoliberal politics: if everyone takes care of him/herself, then ‘all’ are taken care of.

Millions of people have been excluded from health and social care as a consequence of neglect of the social

principles that nurture the cohesion of societies.

20 See: Financial crisis, austerity, and health in Europe. Marina Karanikolos et al. in: Lancet, Vol 381, April 13, 2013 21 This section is taken from: Remco van de Pas, The political context of Universal Health Coverage, in: Get involved in

global health! http://getinvolvedinglobalhealth.blogspot.ch/2013_02_01_archive.html 22 Thomas Gebauer, Institutionalizing Solidarity for Health, http://www.medico.de/media/thomas-gebauer-

institutionalizing-solidarity-for-h.pdf

3.2. Extending the range of services

There is little said about feasible and sustainable ways to extend the range of services within a national health

system. But in this regard there is a great risk that if the road towards UHC is not based on clear values,

including a commitment to, through the extension of services, reduce inequity and promoting human rights, the

cube risks becoming a black box in which any health intervention can be labelled as contributing to UHC.

The focus on the goal (more services covered) and the neglect of the means to achieve it has already been one of

the problems of the MDG. The UN resolution on UHC23 promoting national ownership in the implementation of

UHC suggests that every country is free to choose the best way towards UHC.

So it seems not to matter if we have a system in a poor country that has a lot of vertical programmes because this

is the easiest way can reach many people, scaling up services and, if there is international funding, reducing the

financial burden for the individual.

Looking at all the vertical global health initiatives addressing particular health conditions and illnesses, a rush to

UHC in a sense of rapidly scaling up the range of health services covered might support quick fix health care

solutions for the poor (see “One Million Community Health Workers until 2015”24)

In a globalized health aid market, such scaling up initiatives are often driven by the push for new pharmaceutical

or technological solutions to real or presumed health needs, in what is known as disease mongering25, and not

integrated in an overall health policy.

UHC – although today presented as a comprehensive concept – risks to be reduced to a selective one in the

course of its implementation.

In our understanding, UHC is more than about extending coverage of curative health services. It should include

all public health interventions such as educating school children in nutrition (instead of leaving that to food

companies), health officers regularly checking working conditions (in order to avoid disasters such as the one

that just happened in Bangladesh) – and much more. It is fine that the WHO Director General perceives

universal coverage as the “single most powerful concept that public health has to offer”, but we have to make

sure that this concept includes strengthening of public health.

On the other hand, UHC will positively affect health services only if due attention is paid to their quality.

Quality care is the delivery of safe and effective interventions in ways that, by taking into account the needs and

the background of users and their communities, ensure the best possible outcomes to all. Unacceptable quality

jeopardizes the ultimate aim of health services. Delivering care which is not technically sound implies increasing

the costs for the system and households without achieving health. Improving quality, however, implies no less

difficulty than increasing access.

And last, but not least, as in other global or national health systems programs, UHC organized top-down risks to

oversee the people it is intended to serve. There is not enough emphasis on community participation and

ownership in the framing and implementation of UHC. A very old and awkward questions needs to be asked

again: Who shall define the health needs and priorities? What about the local acceptability of globally or

nationally promoted solutions? The experience of MMI Network members and partners shows that the success of

23 Social Protection and Universal Health Coverage. UNGA resolution, December 2012,

www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36 24 One Million Community Health Workers until 2015 (this is NOT a satire). Thomas Schwarz in: MMI Network News, April

2013 http://www.medicus mundi.org/en/mmi-network/documents/newsletter/201304

25 Moynihan R, Doran E, Henry D. Disease mongering is now part of the global health debate. PLoS Med 2008;5:e106.

every program depends not only on money and on comprehensive global and national plans, but on the

ownership by the people, those actors on behalf of their own health who are able to tackle the problems from the

bottom.

“To put in a blunt way, there should be more health workers and practitioners involved in the debate on UHC,

and perhaps a bit less economists and financial experts…”26

3.3. Avoid fragmentation, take care of the system(s) The concept of “building blocks” of health systems strengthening might mislead to the idea that if all these

blocks are properly managed, the system works well. This might be valid until a certain degree, but handle the

system with care – and as a system, not a sum of elements!

Health is a complex adaptive system27, within wider cultural, social and economic complex adaptive systems.

Changes in access to health brought about by UHC are likely to affect other building blocks within the health

system and in other sectors. Systems thinking28 is therefore key for policy and decision makers dealing with

UHC, as well as planners and researchers.

This would be easier if UHC was integrated into a wider social protection framework.29

3.4. The journey is the destination (isn’t it?) Last but not least, the strong statement by the WHO that Universal Health Coverage is a dynamic process and

not merely a fixed minimum package, but actually contributing to the reduction of health inequalities within and

between countries, does not allow misusing the attention currently given to UHC for easy promotional messages

in the field of health financing. “We achieved UHC”, such as we recently heard from Mexico30, is absolutely

misleading and demotivating. It destroys the dynamic of further investing in public health and the national health

system.

On the other hand, “progressive realization” (of UHC, of the Right to Health) should not allow just waiting and

seeing. Countries are responsible to undertake all necessary steps to realize universal coverage, and to propose

indicators for monitoring this progress, so that they can be hold accountable.

26 Communication by Bart Criel 27 See MMI colloquium „Health-y answers to comple#ity: Are we able to move beyond the control panel?” in Brussels,

November 2013, www.bit.ly/mmi2013-brussels 28 de Savigny D, Adam T. Systems thinking for health systems strengthening. WHO, Geneva, 2009, and other key

documents: see MMI thematic guide, http://www.medicusmundi.org/en/topics/health-systems-strengthening-starting-points

29 Universal Health Coverage - reflections from a development perspective. Viktoria Rabovskaja, GIZ discussion on Social Protection

30 Mexico achieves universal health coverage, enrolls 52.6 million people in less than a decade. http://www.hsph.harvard.edu/news/features/mexico-universal-health/

4. Discussion 2: “Globally Universal Health Coverage” - a transnational issue and an international responsibility

“The General Assembly acknowledges that when managing the transition of the health system to universal

coverage, each option will need to be developed within the particular epidemiological, economic,

sociocultural, political and structural context of each country in accordance with the principle of national

ownership.”31

“All humans should be able to claim the right to health from their own governments, but we emphasize that,

under certain circumstances, the right to health also gives rise to obligations of international assistance.”32

There is no question that, ideally, investments in health care and health determinants be financed with domestic

resources. No question also that national ownership and stewardship is key.

But there is also no question, though, that many low-income countries do not have the resources to offer a

meaningful package of essential services to their entire population. The report by the WHO Secretariat on

Universal Health Coverage clearly indicates that “despite increased health spending, funds are still insufficient to

ensure universal coverage with even a minimum set of health services (that is, to support prevention, promotion,

treatment, rehabilitation and palliative care) in many countries.”33 For these countries, UHC risks becoming a

meaningless concept for those countries. How to get out of this trap?

Universality is a global issue, and transnational issues and international responsibilities are so far underserved in

the discussion on UHC. In doing so, the question of how countries impact on UHC across their borders is often

overlooked. Or it is acknowledged but then left aside, because it is complicated to deal with. It is high time we

do start dealing with it.

4.1. Globalizing the principle of solidarity The UNGA resolution urges for political national commitment toward UHC as part of the sustainable

development agenda. A lot of attention is placed on what poor countries need to do to realize UHC within their

capacities.34 Mechanisms to overcome national limitations are still based on development assistance. However,

we need to move beyond aid and the underlying charity concept to a new global solidarity based on the human

right to health and the resulting obligations.

We already talked about global mechanisms behind the national fiscal realities. We add here that UHC cannot be

left up to individual poor countries, but that it is high time to extend national obligations to international or even

global obligations and entitlements. In the following we propose to extend the concept of financial coverage of

health services to a shared global responsibility. It would then be “Globally Universal Health Coverage”.

Without international financing or redistribution mechanisms, UHC risks becoming a hollow promise. Such

mechanisms must at its core have a redistributive mechanism, one that is based on a legally binding global

agreement between states. Fair domestic and international progressive taxation policies (e.g. on carbon

emissions) are properly suited to provide the necessary funds for such a global redistributive agreement. Indeed,

in an interdependent, globalized world, we ultimately might come to a global solidarity fund to retain peace and

stability. 31 Social Protection and Universal Health Coverage. UNGA resolution, December 2012,

www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36 32 The post-2015 international health agenda: universal health coverage and healthy environment, both anchored in the

right to health. Go4Health position paper, 2012, www.worldwewant2015.org/ru/node/299637 33 Report of WHO secretariat to 66th WHA, see note 16 34 See above, section “Financial coverage and national fiscal reality: Limitations cast in stone?”

Health care systems based on the principle of solidarity (still) exist in European countries, where they form part

of the foundations of societies. Most likely these systems can only be defended by extending them to the

international level. To bridge the gaps, an international financing mechanism is required that obliges rich

countries to contribute also to the health budgets of poorer ones.35

In the words of the UN Special Rapporteur on the right to health, Anand Grover: “In order to shift the global

paradigm of international assistance for health from a donor-based charity regime towards an obligatory system

based on the principle of solidarity, global pooling mechanisms should be founded upon international or regional

treaties under which States incur legal obligations to contribute to the pool according to their ability to pay and

through which funds are allocated based upon need. Such a shift is necessary in order to ensure the availability

of sustainable international funding as required by the right 36to health. In order to promote ownership and

accountability within the regime, each State would contribute to the fund regardless of its income level and all

funding and programmatic processes must be transparent and include the active and informed participation of

civil society and affected communities. In order to realize the right to health globally, States should therefore

take all necessary steps towards the development of treaty based global pooling mechanisms, comprising

compulsory progressive contributions allocated based upon need and driven by transparent, participatory

processes.”

4.2. Towards global governance for health Following this path, UHC becomes a matter of “global domestic health policy” and global governance for health.

The overarching principles and recommendations for global governance for health can be summarized in three

points (the three R’s): Systemic resource redistribution between countries and within regions and countries to

enable poorer countries to meet human needs; effective supranational regulation to ensure that there is a social

purpose in the global economy; enforceable social rights that enable citizens and residents to seek legal redress.37

35 This section quoted from: Thomas Gebauer, Institutionalizing Solidarity for Health,

http://www.medico.de/media/thomas-gebauer-institutionalizing-solidarity-for-h.pdf. See also: Global Social Protection Scheme. Moving from Charity to Solidarity. Medico international, 2013, http://www.medico.de/en/themes/health/documents/global-social-protection-scheme/1243/

36 Report to the UN General Assembly, 13 August 2012, UN document A/67/302 37 Labonte & Schrecker, Globalisation Knowledge Network: Towards Health - Equitable Globalisation. Rights, Regulation

and Redistribution. Final report to the commission on social determinants of health, 2007, p116-130, quoted from Comment by Medicus Mundi International Network on: “Health in the Post-2015 Development Agenda. Report of the Global Thematic Consultation on Health. http://getinvolvedinglobalhealth.blogspot.ch/2013_02_01_archive.html

5. Discussion 3: UHC and health equity

"The vision of Universal Health Coverage is rapidly becoming a reality, with access to health care no longer

the privilege of a few, but the birthright of many. In years to come, those whose actions helped bring about

the rise of UHC can rightly be proud of this legacy; while those who persist in their opposition will find

themselves increasingly trying to defend an argument that, as today's issue shows, makes no ethical, political,

economic, or health sense."38

This discussion takes up some elements of both sections before. Here we focus on the question: Is UHC fit for

playing the role of an overall, universal health goal? Can UHC be considered as (good) “old wine in a new

bottle” 39, as today’s expression of our vision of health for all and health equity?

We define equity as a core legal concept intimately linked to the notion of justice. It deals with the willingness to

give to each that which they deserve, or “to each according to her needs”. The objective of health equity thus is

to be seen in the context of a wider search for social justice. Achieving health equity requires social policies of

empowerment and a redistribution of social wealth. “Equality results from having equity just as inequality results

from having inequity.”40

5.1. UHC – the road to health equity and Health for All? To many people, UHC may sound like Health for All. However, what is currently proposed as “Universal Health

Coverage” differs substantially from “Primary Health Care” (PHC) as proposed in 1978 in the Declaration of

Alma Ata. PHC intended to transform health systems, as opposed to health care systems, within a broader social

transformation. “The signatories of the Alma Ata Declaration were aware of the importance of the social

determinants of health well before the report of the WHO Commission on Social Determinants of Health”41

Primary health care included education, nutrition, water and sanitation, in addition to essential health care.

Unless UHC is implemented within a framework of social and economic transformation, it will not transform

health as profoundly as hoped. “Paradoxically, an excessive focus on UHC could divert attention and resources

from other sectors with a bearing on health.”42 So we might re-read the Declaration of Alma Ata. Or eventually

some of the strong statements in the report of the WHO Commission43 just as the following ones:

• “Social injustice is killing on a grand scale.”

• “A toxic combination … of poor social policies and programmes, unfair economic arrangements, and bad

politics … is responsible for the fact that a majority of people in the world do not enjoy the good health that

is biologically possible.”

...and then act accordingly;

...and then not necessarily call this then “Universal Health Coverage”, but eventually “UHC plus”.

38 Lancet editorial, September 2012, www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61485-8 39 Universal health coverage: Old wine in a new bottle? If so, is that so bad? Adam Wagstaff

http://blogs.worldbank.org/developmenttalk/universal-health-coverage-old-wine-in-a-new-bottle-if-so-is-that-so-bad 40 Quotation and overall reference: Claudio Schuftan, Equity and equality are not equivalent they cannot either be

reduced to simple risk factors as is often done in human rights talk. In: Social Medicine. http://www.socialmedicine.org/2013/02/08/human-rights/equity-and-equality-are-not-equivalent-they-cannot-either-be-reduced-to-simple-risk-factors-as-is-often-done-in-human-rights-talk-part-1-of-2/

41 The seven sins and the seven virtues of Universal Health Coverage, see note 17 42 As above. 43 Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the

social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008.

5.2. UHC – key to fulfilling the right to health? The International Covenant on Economic, Social and Cultural Rights44 states that “the right to health is not to be

understood as a right to be healthy”, that it is “an inclusive right extending not only to timely and appropriate

health care but also to the underlying determinants of health”, and that “a further important aspect is the

participation of the population in all health-related decision-making at the community, national and international

levels.” It states also that “The right to health [care] in all its forms and at all levels contains the following

interrelated and essential elements”: (a) availability, (b) accessibility in its four overlapping dimensions: non-

discrimination and physical, economic (affordability) and information accessibility, (c) acceptability, and (d)

quality of services.

Unless the international community pushes the right to health up in its scale of values and stops considering

health as a dependent variable of the global economy, and unless it makes the respect of human rights mandatory

and those who violate them legally accountable, UHC is unlikely to yield the expected results.

5.3. Health equity as our core Past experiences have shown that “some reforms, often implemented in the name of expanding coverage, may

actually compromise equity”45. For Universal Health Coverage to contribute to – or at least not to harm – health

equity, it is crucial to take lessons from past experience into account, and to monitor progress using indicators

that address both equitable and effective access to health services and financial risk protection.

Reducing inequity in health is a core element of Universal Health Coverage. However, in the famous cube (see

above), it is only implicitly there and the commitment to equity is not as broadly shared as many of us might like

it to be.

Programmes aimed at universal coverage at country level can have inequitable effects and that it is crucially

important to reach a broad understanding of and commitment to the underlying values of the health system

reform through an inclusive and democratic process, to continuously monitor the equity impact of interventions

and to have the will to adjust the design of an intervention if the impact turns out to be inequitable. 46

To avoid this, Davidson Gwatkin47 promotes “progressive universalism” opposed to a "trickle down pattern" of

coverage that is often used and has increased inequity. Gwatkin calls for “a determination to ensure that people

who are poor gain at least as much as those who are better off at every step of the way toward universal

coverage, rather than having to wait and catch up as that goal is eventually approached. Of course, to show that

progressive universalism is feasible is not to argue that implementation will be easy. But consider the alternative:

in the absence of a determination to include people who are poor from the beginning, drives for universal

coverage are very likely, perhaps almost certain, to leave them behind.”

44 United Nations Economic and Social Council. The right to the highest attainable standard of health (E/C.12/2000/4).

United Nations, New York, 2000. 45 Joseph Kutzin, Anything goes on the path to universal health coverage? No. In: Bulletin of the World Health

Organization 2012; 90:867-868, http://www.who.int/bulletin/volumes/90/11/12-113654/en/index.html 46 This paragraph quoted from Mariska Meurs, UHC blog, not yet published 47 Davidson Gwatkin: Universal Health Coverage: friend or foe of health equity? The Lancet, Vol 377 June 25, 2011

6. Conclusions

Universal Health Coverage is in essence linked to political demands, choices and inherent power relations, both

at the national and global level. If the MMI Network agrees to promote Universal Health Coverage in view of

improving health equity, then we should be willing to be truly involved in the political and ideological battle that

will enfold over the coming period.

The discussion of Universal Health Coverage also helps us to better position the strategic focus of the Medicus

Mundi International Network – and to make its limitations better visible – in view of the next strategic period

beyond 2015. “Strengthening the health system as a whole” is a must for improving access to health, but “Health

for All” is more than this – both an international responsibility and an intersectoral project. NGOs are and their

Networks such as Medicus Mundi International are invited to reflect about their role and contributions to

progress at all levels.