Universal Health Systems: a better pathway to achieving universal and equitable access to comprehensive healthcare.

June 2024
 

Task Force 1 – Fighting inequalities, poverty, and hunger.
Topic 1.4 – Promoting universal health coverage, digital health, and open innovation to fight health inequalities
 

Authors

 
Leonardo Mattos, Researcher, Fundação Oswaldo Cruz, Brasil
Ligia Giovanella, Researcher, Fundação Oswaldo Cruz, Brasil
T. Sundararaman, Retired Professor, JIPMER International School of Public Health, India
Lauren Paremoer, Senior Lecturer, University of Cape Town, South Africa
José Manuel Freire, Professor Emeritus, Instituto de Salud Carlos III, España
Alicia Stolkiner, Professor, Universidad Nacional de Lanús, Argentina
Indranil Mukhopadhyay, Professor, OP Jindal Global University, India
Carolina Tetelboin Henrion, Professor, Universidad, Autónoma Metropolitana, Mexico
Matheus Zuliane Falcão, Researcher, Universidade de São Paulo, Brasil
Leonardo Castro, Researcher, Fundação Oswaldo Cruz, Brasil
José Carvalho de Noronha, Researcher, Fundação Oswaldo Cruz, Brasil
 

Abstract

 
The current Universal Health Coverage (UHC) strategy aims to improve health services coverage, financing, and financial protection with equity, especially in the LMICs. Despite being the main framework for health policies and reforms results have been poor. Coverage stagnated and financial protection retreated. Insurance-based models and restricted basic services packages boosted the healthcare market but couldn’t improve access and worsened inequalities. Primary care was constrained by fragmentation and segmentation. Private provision preference led to exclusion, unaffordable prices, and poor-quality care in secondary and tertiary care. The Covid-19 pandemic exposed unaddressed systemic barriers such as the inequitable access to health technologies, the international disparity of power and resources, the unbalanced corporate power, and the need to strengthen the public sector. In this context, the international community should revisit concepts, principles, guidelines, and strategies for achieving UHC as the current framework is no longer fit for purpose. This Policy Brief provides a critical evaluation of the UHC developments and present the Universal Health Systems (UHS) as a better alternative to achieving universal and equitable access to comprehensive healthcare. Based on the evidence and lessons learned, both approaches are compared considering dimensions such as the role of the state, financing, access, and equity. An updated universalization strategy should conceive healthcare as a common good and require reclaiming the role of the state in social protection and provision, based on principles of solidarity, cooperation, social justice, and participation.
 

Keywords

 
Health Systems, Health Policy, Universal Health Coverage, Universal Health Care
 

Diagnosis

 
The Universal Health Coverage (UHC) strategy promised building accessible and equitable health systems through the improvement of health coverage, financing, and financial risk protection (WHO, 2010). Introduced by the World Health Organization (WHO) in 2005 and included into Sustainable Development Goals (SDG) in 2015, UHC achieved widespread support of governments, multilateral institutions, forums such the G20, financial and philanthropic agents, being disseminated as the main framework to guide health policies and reforms (Cueto, Brown, and Fee 2019; McBride, Hawkes, and Buse 2019).
 
The key proposals were first to increase financing through compulsory prepayment of financial contributions and taxes, especially relying on publicly financed private or mixed insurance models. These funds should be pooled and allocated for different financing/provision schemes and social groups, aiming to reduce financial barriers to access and expand health coverage through the purchase of essential services. New governance mechanisms should also enhance health systems’ efficiency and equity (WHO 2010).
 
However, results are poor. Global spending on health more than doubled in the last two decades, but rich countries still account for 80% of it. The government spending share increased in higher income countries and emerging economies but stagnated or declined in lower-middle/low-income countries where nearly half of Primary Health Care (PHC) and non-PHC spending was private (WHO 2021). The world is far off track of the SDG 3.8 targets as health coverage has stagnated since 2015 in all regions and 4.5 billion people are not fully covered. Financial protection retreated and the catastrophic out-of-pocket expenditures reached more than one billion people, while financial hardships affected more than two (WHO and World Bank 2023).
 
Poor outcomes have also been observed in terms of equity. Implementing multiple coverage schemes for different social groups resulted in segmentation and fragmentation, produced inequalities in financial allocation, access, coverage, and quality of health services, and hindered the ability of health authorities to implement integrated national policies (Averill and Marriot 2013, Giovanella et al. 2018). Comprehensive PHC approaches have been limited to basic commodified services (Sanders et al. 2019) and privatisation has proven to be an unreliable solution due to exclusion, unaffordable prices, and poor-quality care (Goodair and Reaves 2024).
 
This scenario, together with growing demand related to social, demographic, and epidemiological changes, opened new opportunities for transnational capital. While UHC stimulated private insurances and providers as strategic partners, market-oriented reforms expanded accumulation spaces and attracted financial investors. Healthcare provision has been transformed into a high-return financial asset class and health systems experienced a growing cycle of financialization (Eren Vural 2017, Benjamin and Hunter 2019).
 
The life losses and the disruption of health systems during the Covid-19 pandemic exposed systemic barriers. Fragmentation and insufficient capacities in the public sector undermined effective answers. Social determinants of health were forgotten. In the Global South, the debt burden limited broader responses and post-pandemic recovery was constrained by austerity measures and defunding of social sectors. The established global health governance failed to build solidarity and counterbalance the international disparity of power and resources. The proposed solutions couldn’t touch the political, financial, and commercial barriers leading to the inequitable access to health products and technologies, such as the Covid-19 vaccine (Paremoer et al 2021, Freeman et al 2023).
 
The dominant interpretation in post-pandemic international discourses reaffirms the same UHC strategy, considering the alarming situation as an opportunity to correct implementation gaps (UN 2023). Alternative views indicate the need to revise the relation between health and economy, restoring social justice and Health for All as top priorities (Labonté 2022, WHO 2023). This sums to other voices in science, civil society and Global South countries advocating that the promotion of public Universal Health Systems (UHS) should be the core of a universalization strategy that conceives healthcare as a common good and a social right, redefining the role of the state in social protection financing and provision, based on solidarity, cooperation, participation and social justice (Noronha 2013, Giovanella et al. 2018, Sanders et al. 2019, PHM 2023).
 
This Policy Brief provides a critical assessment of the UHC strategy and compares it to the UHS approach in different dimensions, providing evidence and policy recommendations for the G20 member states and the international community. We argue that UHS are a better alternative for expanding coverage, ensuring the right to health, and building equitable health systems.
 

Recommendations

 
Promote a broad international revision of the UHC strategy
 
The current UHC strategy has failed in several dimensions (WHO and WB 2023). Insisting on it means giving up on transformative pathways for health systems and the right to health. The G20 should call the international community for a critical revision of this strategy, embracing new concepts, goals, principles, strategies, guidelines, and indicators to make Health for All a priority and reality. Scientific research about UHS as an alternative strategy should be promoted to address the recommendations below.
 

UHS as the core of the universalization strategy
 
The UHS approach (Giovanella et al 2018) is defined as the technical, political, and strategic choice to promote public and government-ruled health systems aiming to achieve universal and equitable access to comprehensive healthcare for all, based on the understanding of health as a common good and a social right. Such care should be free-of-charge, inclusive of all health needs, of sufficient quality, and provide preventive, curative, rehabilitative and palliative care throughout the life cycle, regardless of socioeconomic status.
 
UHS should be built on relationships of respect, cooperation and solidarity between governments, institutions, health professionals, patients, and society, pursuing collectively defined health goals and ensuring that clinical choices, public health and health policy decisions are democratic, participatory, and not driven by market forces.
 
A UHS-based strategy must be integrated into a broader set of social reforms that reduce economic, social, racial, gender and class inequalities and oppressions, strengthen public social protection systems, and address the social determination of health. This also requires a cooperative and solidaristic global governance and a just political and economic international order, restoring the vital link between universal healthcare and social justice.
 
UHS is a better alternative to promote universal and equitable access to comprehensive healthcare.
The UHC preference towards insurance-based solutions and demand-side interventions should be reconsidered, as this option is more regressive, leads to higher costs, poorer health outcomes, fragmentation of pools and services, and negative labour market effects (Wagstaff 2009, Giovanella et al 2018, Gabani et al. 2023). This tends to benefit the formal sector and the rich, reinforcing socio-economic inequalities, undermining the redistributive role of health policy and naturalizing discrimination in terms of access, coverage, scope, and quality of care between different coverage schemes.
 
Health systems are superior in outcomes, quality, efficiency, and equity when they are tax-based, government ruled, publicly provided, grounded on universal access and comprehensive care (Wagstaff 2009, Giovanella et al 2018, Gabani et al. 2023).
 
The UHC approach reduces the understanding of universality and equity in health systems to coverage and financial protection, very limited policy objectives and indicators. The shift towards UHS can provide better policy-making guidance and metrics aligned with broader health goals and principles. UHS can also offer better financing, provisioning, and governance alternatives.
 
Redefine the role of the state in healthcare financing
 
Implementing the UHS strategy requires redefining and strengthening the role of government and the public sector in all dimensions of health systems, going beyond regulation and correction of market failures.
 
Increasing public health spending through tax-based systems should be the priority for financing UHS. This requires abandoning austerity measures, relieving of the Global South countries debts, promoting tax justice, reimagining macroeconomic policies to support long-term UHS investments and goals, and developing higher quality and stable financing mechanisms (Labonté 2022, PHM 2023, WHO 2023)
 
Health funds should be unified and managed by the state, gradually eliminating private intermediaries, and establishing single-payer systems. This will create better allocation options for equitable and universal access, supply-side interventions and allow for more efficient organization of integrated health service networks.
Strategies to reduce private spending should be developed, focusing not only on out-of-pocket expenditures, but also on voluntary and compulsory insurance, user fees, co-payments, or any other forms.
 
Redefine the role of state in healthcare provision and governance
 
Reviewing insurance solutions and the basic services package promotion is key to address health systems fragmentation, inefficiency, high administrative costs and prices, poor quality care, and weak capacity to tackle health inequalities.
 
The UHS should organize healthcare based on health needs and through the development of a broad, integrated, regionalised, and territorialised network of comprehensive public health services oriented by PHC under the strong leadership of national and local health authorities and social participation.
To achieve that, it’s necessary to redesign healthcare governance, institutions, and mechanisms to deliver and manage public health services as common goods, focusing on use value rather than exchange value.
 
Private health services and insurance should be shaped (rather than regulated) by UHS according to collective needs and kept under strict public control, decoupled from profit metrics, and insulated from financial markets. Removing financial barriers, ensuring quality of care and integration with the UHS goals are crucial.
 
National strategies are key to incorporate into healthcare the main technological advancements of Digital Health, such as AI, ensuring continuity across different levels of care and optimal, just, and accountable use of health data for innovation, supporting the public interest and protecting the beneficiaries’ rights.
 

PHC as a key strategy to achieve UHS and ensure the right to health
 
PHC can be understood as a political and technical strategy to organize public UHS, achieve universal and equitable access to comprehensive healthcare with a community-based approach, and tackle broader socioeconomic health determinants with coordinated intersectoral action to promote health. PHC should be the entry point of UHS, counting with appropriate and effective technologies and strong social participation (Giovanella et al. 2018, Sanders et al. 2019).
 
Within the current UHC strategy, PHC is reduced to a limited range of essential health services and targeted interventions, subsidizing demand for selective and commodified packages. This limited role undermines PHC’s ability to reduce inequalities, improve health outcomes and address social determinants of health (Giovanella et al. 2018, Sanders et al. 2019).
 

UHS is more effective in health emergencies prevention, preparedness and response
 
The Covid-19 pandemic showed that the unjust and inequitable global distribution of technologies and medical products (diagnostics, equipment, therapeutics, and vaccines) resulted from the dominant profit-based model of innovation, production, and distribution.
 
To avoid new medical apartheids, the G20 leaders must advocate for a new governance architecture that supports the development of health manufacturing and innovation infrastructure in the Global South, ensures technology transfer and capacity building, revises intellectual property rights to increase equitable access, enshrines the principle of common but differentiated responsibilities in pandemic governance and imposes conditionalities on publicly funded products to ensure they meet public needs.
 
The UHC model failed to mitigate long-standing barriers that exacerbated inequalities during the pandemic. Fragmentation, privatization, and insufficient technical and institutional capacities in the public sector hindered coordinated national answers. Insurance-based UHC schemes left under-served geographic areas, allowed exclusion due to huge financial barriers to hospital care and couldn’t create trusting, long-term, and holistic relationships between providers and patients. This complicated surveillance, containment of outbreaks, vaccination efforts, and treatment access.
 
UHS and PHC can better address the need of improving the public health institutions, staff, and infrastructures (including surveillance and diagnostics), ensuring interoperability of medical information systems, promoting rational distribution of human and medical resources, standardizing treatment protocols, and tackling social determinants of health. This enables broad, unified, and coordinated responses during health crises when limited resources must be used efficiently and equitably.
 

Scenarios of Outcomes

 
Based on the policy analysis we draw four different prospective scenarios of outcomes. The first, worst and more realistic is the conservative scenario, where UHC is kept as the main health system strategy, with no major changes in the articulation between health and economy, in the global health governance and the international order. The world keeps far from reaching universal health coverage, markets prevail over health goals, health inequalities increase, and health systems struggle to provide comprehensive care with equity, leaving many unassisted. Weak public sector and unreformed international governance allows repeated failures in health emergencies while global inequities and access barriers are reiterated.
 
In the second scenario, UHC remains but progressive economic strategies are implemented to achieve Health for All as the international community reforms multilateral institutions and global health governance to promote a more just, solidaristic and cooperative international order. Public financing and coverage might increase slowly, while institutional innovations open opportunities to reshape health systems and markets. However, the approach limited to health coverage, financial protection and insurance-based schemes undermine those efforts and better health systems outcomes as fragmentation and privatization advances and the public sector struggles to organize integrated policies.
 
In the third scenario, the international community revises the UHC approach in favour of the UHS strategy, but there are no broad changes in the international economic and political landscape. Health systems start to change and make better use of available resources, making progress towards universal and equitable access to comprehensive care. However, unaddressed systemic barriers, weak international institutions, reiterated neoliberal economic agendas, and poor solidarity and cooperation keep hindering social justice and Health for All.
 
In the last and most optimistic scenario, the UHS strategy is widely adopted together with progressive social, economic, and institutional reforms seeking social justice. The state’s role is strengthened and redefined, public financing increased, and private expenditures reduced, while public provision is redesigned and understood as a common good. The inclusion of a large contingent of excluded groups occurs, especially in the Global South. Reshaping global health governance supports this transformation towards Health for All, creating conditions for fast changes in healthcare organization, international cooperation, and the reduction of long-standing inequalities.
 
 

References

 
Avrill, C. and Marriot, A. 2013. “Universal Health Coverage: Why Health Insurance Schemes are Leaving the Poor Behind”. Oxfam Briefing Paper 176. Oxford: Oxfam International. http://hdl.handle.net/10546/302973
Cueto, M., T. M. Brown, and E. Fee. 2019. The World Health Organization: a history. Cambridge: Cambridge University Press.
Eren Vural, I. 2017. “Financialisation in Health Care: An Analysis of Private Equity Fund Investments in Turkey.” Social Science & Medicine 187 (August): 276–86. https://doi.org/10.1016/j.socscimed.2017.06.008.
Freeman, T., Baum, F., Musolino, C., et al. 2023. “Illustrating the Impact of Commercial Determinants of Health on the Global COVID-19 Pandemic: Thematic Analysis of 16 Country Case Studies.” Health Policy 134 (August): 104860. https://doi.org/10.1016/j.healthpol.2023.104860
Gabani, J., S. Mazumdar, and M. Suhrcke. 2022. “The Effect of Health Financing Systems on Health System Outcomes: A Cross?country Panel Analysis.” Health Economics 32 (3): 574–619. https://doi.org/10.1002/hec.4635.
Giovanella, L., A. Mendoza-Ruiz, A. Pilar et al. 2018. “Universal health system and universal health coverage: assumptions and strategies” Ciência & Saúde Coletiva 23 (6): 1763–76. https://doi.org/10.1590/1413-81232018236.05562018.
Goodair, B., and A. Reeves. 2024. “The Effect of Health-Care Privatisation on the Quality of Care.” The Lancet Public Health 9 (3): e199–206. https://doi.org/10.1016/s2468-2667(24)00003-3.
Hunter, B. M., and S. F. Murray. 2019. “Deconstructing the Financialization of Healthcare”. Development and Change 50(5), 1263-1287. https://doi.org/10.1111/dech.12517
Labonté, R. 2022. “Ensuring Global Health Equity in a Post-pandemic Economy”. 2022. Int J Health Policy Manag 11(8) 1246–1250. https://doi.org/10.34172/ijhpm.2022.7212
McBride, B., S. Hawkes, and K. Buse. 2019. “Soft Power and Global Health: The Sustainable Development Goals (SDGs) Era Health Agendas of the G7, G20 and BRICS.” BMC Public Health 19 (1). https://doi.org/10.1186/s12889-019-7114-5.
Noronha, J. 2013. “Universal health coverage: how to mix concepts, confuse objectives, and abandon principles” Cad. Saúde Pública 29 (5): 847–49. https://doi.org/10.1590/s0102-311×2013000500003.
Paremoer, L., S. Nandi, H. Serag, and F. Baum. 2021. “Covid-19 Pandemic and the Social Determinants of Health.” BMJ 372 (29).https://doi.org/10.1136/bmj.n129.
People’s Health Movement. 2023. PHM Comment – UN High-Level Meeting on UHC. https://docs.google.com/document/d/1YnOQoQvuc_RFcmrEIn33-Raz9fmnfsCo9ybPff2Y8qE/edit?usp=sharing
Sanders, D., S. Nandi, R. Labonté, et al. 2019. “From Primary Health Care to Universal Health Coverage” The Lancet 394 (10199): 619–21. https://doi.org/10.1016/s0140-6736(19)31831-8.
United Nations General Assembly. 2023. Resolution 78/4 – Political Declaration of the High-level Meeting on UHC. New York: UN.
Wagstaff A. 2009. Social health insurance vs. tax financed health systems-evidence from the OECD. Washington: Development Research Group, World Bank.
World Health Organization. ?2010?. The world health report: health systems financing: the path to universal coverage. Geneva: WHO.
World Health Organization. 2021. Global expenditure on health: public spending on the rise? Geneva: WHO.
World Health Organization. 2023. Health for All – transforming economies to deliver what matters: final report of the WHO Council on the Economics of Health for All. Geneva: WHO.
World Health Organization and World Bank. 2023 Tracking universal health coverage: 2023 global monitoring report. Geneva: WHO/World Bank.