Opinion: Keeping the promise — time to move from declarations to deeds on UHC

A clinic provides basic health care in the Philippines. Photo by: ECHO / Pierre Prakash / CC BY-NC-ND

On Dec. 12, the world celebrates Universal Health Coverage Day, which marks the 2012 passage of a United Nations resolution urging countries to accelerate progress toward quality, affordable health care for all. Formally designated by the U.N. just two years ago, UHC Day has been steadily gaining attention as a global day of action. This year’s UHC Day theme is “Keeping the Promise.”

Is there cause for celebration this UHC Day? Is the promise being kept? The news is very mixed.

The good news is that 2019 saw a significant increase in global political attention and commitments toward UHC. At this year’s U.N. General Assembly, leaders adopted a historic political declaration on UHC, which commits all U.N. member states to take action to accelerate progress toward the Sustainable Development Goal targets 3.8.1 and 3.8.2 — ensuring everyone has access to a basic package of essential health services and is protected from experiencing financial hardship to get the care they need. The declaration was, rightly, a moment for celebration among UHC advocates.

Meanwhile, 12 multilateral agencies signed the Global Action Plan for Healthy Lives and Well-being for All, committing to new ways of partnering to strengthen their support for lower-income countries to reach SDG 3. And G-20 finance and health ministers also committed to increase collaboration toward sustainable financing for UHC.

Now for the bad news. The “2019 Global Monitoring Report” from the World Health Organization showed that UHC is far from a reality for more than half of the world’s population — and the outlook is deteriorating. WHO estimates that, as of 2017, the pace of health coverage expansion is slowing, and future increases in coverage are projected to be offset by population growth.

Similarly, the report finds that paying for health care out of pocket is causing financial hardship for more than 930 million people and pushing nearly 90 million into extreme poverty annually, with impoverishment rates getting worse. Lower-income countries account for the largest populations lacking coverage, with poor and conflict-affected countries lagging furthest behind. If current trends continue, WHO projects that up to 5 billion people will be unable to access or afford essential health care by the SDG deadline of 2030.

The news on financing for health is similarly bleak. In its report to the G-20, the World Bank estimated that 54 low- and lower-middle-income countries will need an additional $176 billion by 2030 to finance an essential package of quality health services for all. The bank also stressed that countries at all income levels face challenges that are driving up health care costs and threatening future domestic revenue mobilization, efficiency, and equity. Among these are pandemic threats, forced displacement of populations, climate change, and population aging and the corresponding increases in noncommunicable diseases and demands for long-term care.

Closing these massive gaps to reach UHC by 2030 will be a major uphill climb, and the goal may already be out of reach. Yet with urgent, concerted, and accelerated global action in three areas, there’s still hope for making significant progress.

First, lower-income countries and their partners must invest more, and more smartly, in health. Closing the gap requires a large infusion of both domestic and international investments that target scale-up of health access and affordability to the poorest and most vulnerable communities. This means a strategic shift for governments and donors toward health system strengthening and sustainable financing, with the priority of expanding more cost-effective primary health care. Government health budgets must grow as a percentage of GDP and move from reliance on inequitable out-of-pocket payments toward more efficient, technology-enabled prepaid and pooled financing mechanisms.

Although 2019-2020 will produce record levels of new financing for global health through the combined replenishments of The Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank’s International Development Association, Gavi, and the Global Polio Eradication Initiative, these investments won’t make much of a dent in UHC unless they are deployed to incentivize — not replace — domestic resource mobilization and to fix the underlying bottlenecks to care.

Second, UHC plans must reflect a whole-of-government approach. Whether called “multisector” or “health in all” policies, a whole-of-government approach must be front and center in UHC programming and budgeting. We know, for example, that expanding education and social protection programs plays a critical role in driving better health outcomes, but if increases to the health budget come at the expense of these programs, then everyone loses — especially vulnerable children.

Closing the UHC gap requires raising revenues and an overall reprioritization of public expenditures, such as replacing inefficient and inequitable fuel subsidies with pro-growth investments across the board in building human capital and community infrastructure. The threats to UHC of pandemics, climate change, and forced migration also necessitate a comprehensive response beyond the health sector. These are tough, political choices, so leadership must come from the seat of power: the head of state and finance minister. Lower-income countries like Kenya — where President Uhuru Kenyatta just announced the nationwide rollout of UHC in the coming year — are showing the way.

Third, we must step up advocacy and accountability. Political declarations are an important step. But the day-to-day building of political will and translating commitments into policy, legislation, budget allocations, implementation, and evaluation require a much greater investment in the infrastructure of UHC advocacy than currently exists. It requires sustaining sophisticated civic movements that can crank the gears of policymaking, mobilize public pressure, and hold decision-makers’ feet to the fire to prioritize those left behind during multiple changes in government leadership. The UHC2030 global coalition has made a good start at galvanizing global attention but lacks the political power or national-level armies to drive lasting change. Philanthropy for UHC advocacy in lower-income countries has been tiny relative to specific global health issues like HIV.

So UHC Day 2019 is a day to celebrate, but it’s also a sobering moment. To keep the promise of UHC by 2030, countries must urgently move from declarations to deeds, and international funders must shift their investment strategies to accelerate country action. With smarter funding, a comprehensive view, and sustained policy advocacy, we can launch the UHC countdown decade with hope.

About the author

  • Carolyn reynolds final 1

    Carolyn Reynolds

    Carolyn Reynolds is a Distinguished Fellow with The George Institute for Global Health and a Senior Associate at the Center for Strategic and International Studies. Previously she served as vice president of policy and advocacy at PATH and senior manager of external and corporate relations at the World Bank Group.