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Financing universal healthcare coverage [excerpt]

Over the past few decades, public-private partnerships (PPPs) have become a primary resource in addressing global health. These partnerships, which are made up of private organizations that work closely with governments, aim to combat global health crises more effectively than other systems.

Governing Global Health: Who Runs the World and Why? analyzes the effectiveness of global health organizations in their efforts against communicable diseases. In the excerpt below, authors Chelsea Clinton and Devi Sridhar discuss the implementation of healthcare among countries with universal health coverage.

On 12 December 2012, [universal health coverage] received an unequivocal endorsement from the UN General Assembly (including the United States) with the approval of a resolution on UHC that confirmed the “intrinsic role of health in achieving international sustainable development goals.” The 2005 World Health Assembly’s definition of UHC makes clear what its achievement would look like: “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access,” rather than how it would be achieved. In 2012, a WHO discussion paper on the post-2015 health agenda (what would emerge as the Sustainable Development Goals or SDGs) identified UHC as a “way of bringing all programmatic interests under an inclusive umbrella.” Yet despite UHC’s growing prominence in the post-2015 agenda, there is not yet any single agreed-upon plan on how institutionally it should be carried forward and financed. This is not particularly surprising.

“For the most part, key donors believe that domestic resources are growing fast enough in most developing countries to enable governments to strengthen their health systems and provide universal health coverage, if that is what they choose as an area of investment.”

Across countries with UHC, no two versions are alike in their financing, in what they cover, or in how they are structured. Some countries with UHC rely on a public system of coverage while others mandate insurance coverage, requiring individuals to buy health coverage in a regulated private insurance market or from the government, while still others have a mix of the two approaches. Additionally, a further challenge is that the conversations and debates surrounding UHC are rarely tied to those relating to health systems strengthening, community health-worker models, or other health-care delivery priorities. We find this persistent decoupling illogical.

Thus far, neither donors nor developing countries have turned to vertical funds directly to strengthen health systems or to assure health care for all members of society (for example, through UHC tied to health systems strengthening). One possible exception to this are the health systems strengthening funds that the Global Fund and Gavi at times have made available; however, these have always remained the significant minority of funds each has disbursed as mentioned in earlier chapters. In addition, to qualify, applicants have had to be clear about how such funds will strengthen health systems with a direct relationship to achieving their respective infectious disease mandates. Not surprisingly then, such funds have not supported broader capacity building, despite health-worker shortages across the developing world. In the horizontal-versus-vertical-funding terminology debate we engaged with earlier, this approach is referred to as “diagonal.”

For the most part, key donors believe that domestic resources are growing fast enough in most developing countries to enable governments to strengthen their health systems and provide universal health coverage, if that is what they choose as an area of investment. They also worry that governments in developing countries would use any new funds as an excuse to reduce their existing health investments—viewing such aid as a substitute for domestic spending on health, not as an addition to it. Research from the IHME supports these concerns. It also points to this effect only when development assistance flows directly to developing country governments, rather than when it flows to NGOs working within the same country. Arguably, then, this is a valid concern in the context of UHC, as most UHC-targeted development assistance would be expected to flow, at least in significant part, to governments.

“Many donors are also wary of further fragmenting global health governance, cognizant that the aid harmonization efforts of the past decade stretching from Paris to Busan and beyond have largely failed.”

Additionally, donors believe that national programs must be country-led (even if donor influenced) and country-designed because of differences among health systems (such as the presence or absence of a domestic private-care delivery system or preexisting domestic private insurance markets). For some, it is also crucial that such investments be tied to government approaches to fighting disease risk factors (such as tobacco for NCDs). Many donors are also wary of further fragmenting global health governance, cognizant that the aid harmonization efforts of the past decade stretching from Paris to Busan and beyond have largely failed.

Still, Japan plans to make UHC a major priority during its presidency of the 2016 G7. Is UHC a rousing enough topic to get the attention and funding from heads of states and the requisite legitimization from their publics, as happened at the 2000 G7 with what would become the Global Fund? At least at the moment, UHC currently has far from universal donor support. The Gates Foundation has expressed its discomfort with UHC as a unifying post-2015 theme. One strategic idea for raising the profile of UHC is to tie it to health systems strengthening (in a broader context than ever articulated by the Global Fund or Gavi) and to make it a pillar of achieving meaningful global health security. Yet, this strategy is not without possible complications; “global health security” remains a debated term. Since World War II, this concept has become increasingly narrowed to one in which health threats are perceived to be largely related to outbreaks with the potential to affect wealthier and more powerful countries’ citizens and interests. Health security became part of national security, instead of its original definition as the health part of human security. In part, this was intentional as seen in UN Resolution 1308, which classified HIV/AIDS as a security threat. At the time, the hope was that such a linkage would increase urgency around the burgeoning epidemic, and that such urgency would be followed with increased political cooperation and funding. On that front, as seen in the advent of the Global Fund and later the US PEPFAR program, it was undeniably successful. Its legacy, however, is one in which it is easy to classify Ebola as a security risk and more challenging to imagine the rising burden of NCDs or persistent lack of UHC as the same in a traditional, or even global health, context.

Featured image credit: “Blank world map with blue oceans” by Petr Dlouhý. CC BY-SA 3.0 via Wikimedia Commons.

Recent Comments

  1. April

    Any Clinton writing about Universal Healthcare is a total joke. The Clintons have fought tooth and nail against single-player, DESPITE it being what the PUBLIC wants. Therefore, this book is a total slap in the face to Americans.

  2. Jim

    I wonder to what extent they exposed lawyers’ roles in escalating malpractice premiums; how heavily they mandate care and therapies. Socialized Medicine will not make health care better in the US, and as we’ve seen with Obamacare there is NOTHING the government regulates and makes better.

  3. Sitaraman Sitharaman

    The universal haeathcare system b extended to all humanbeings barring their origins and b elegible for healthcare of government whereverthey r stayi ng

  4. Joy Harmon

    Thank you both for your thorough investigation of these essential topics oF Global well-being. People can only solve problems that they KNOW EXIST…and your book has brought detailed clarity to the problems of World Health that already exist…….and the tadks/conditions needed to atrack the problems SUCCESSFULLY!! Thank you both…this is a HUGE STEP in the right direction!!!

  5. Jeni

    Please read the book before commenting, at the very least read the excerpt and if that’s too much read the title. This isn’t a focus on the US healthcare system, its global health in which the Clinton’s have significant experience. Look beyond national bias and headlines and actually learn about what global health means, which organisations are responsible for saving countless lives, who is at the table fighting for lower pharmaceutical pricing and access to medecins (which by the way trickles into the US healthcare system, so, you’re welcome).

  6. Mary Jane Carroll

    Canada has had universal healthcare for approx 60 years thanks to Mr Tommy Douglas the then leader of our NDP, a federal social party . Our healthcare is not without issues and problems but overall it provides very good healthcare to our entire population. Obviously if you live in a small town or city travel is required to access specialised care like neurosciences , heart institutes, difficult cancer treatments , children’s hospitals. We have very little private health care but it is available in large cities in a minimal way. Our healthcare is provided through corporate and individual tax dollars. As a Canadian I am very proud to say we can all access healthcare.

  7. Elizabeth Smith

    Correction to someone else’s comment. The Clintons favored a single-payer system early on. It’s Congress that refused to consider that so a different approach had to be put forth way back in the 1990s. This report should be excellent.

  8. Samson Terie

    Well done to both authors!
    The little girl I remember coming to the Whitehouse not that long ago, using her time wisely in educational growth- and instead of being bitter with all the negative that surrounded her, stayed undeterred in making a difference by contributing knowledge regarding a novel cause like Healthcare in a Global Healthcare System.
    Am very proud as a healthcare provider and most of all as a parent of two young boys!

  9. Derek Chang

    While most industrialized countries provide universal health care to their citizens, there is no reason why the United States can’t. (Actually, as we all know, there must be a lot of reasons behind it.). When this far-fetched dream would become reality!?

  10. Alex

    Really nice article. you know why there is a difference between GDP (Gross rankings and HDI (Human Development Index) rankings. Because countries focus on increasing their incomes failing to provide good basic facilities like healthcare etc.

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