I believe that it is the obligation of the state to respect, protect, and fulfill the right to health. It is the role of the community to participate actively in its achievement. And it is the necessity of duty bearers in the international community to work with communities and governments to assure that in a globalized world, the attainment of human rights is truly global.
The central problem is that it represents selective “sets of services.” The danger of “nationally determined sets” is that governments could interpret the phrase to mean a limited range of health services, such as those that are profitable commodities, and leave much of the health needs to the whims of private markets.
A UHC that means a few select services for everyone while the rest are left to the market does not serve to promote equity. It also exaggerates the agency of resource-poor countries to “determine” these sets of services.
Overall, this serves to undermine the meaning of health as a human right.
The 1978 Declaration of Alma-Ata stands in stark contrast to this declaration. It called for the achievement of health for all by the year 2000, and it made clear that “a new international economic order” was required. However, the establishment of a sustainable and equitable economic order was ultimately not advanced by signatories.
Rather, global capitalism was taken over by neoliberalism, resulting in increased national and global inequities, instability and crises, and the promotion of selective primary health care. The idea of health for all was turned into the idea of some health for some.
For me, this is not just a policy debate. Being born and growing up in my rural village in Rwanda right after the Alma-Ata declaration meant renewed hope for my mother and millions of others in low- and middle-income countries. We had been excluded from the fruits of modern medicine for the entirety of our lives to date. And this had been painful. Like my four older siblings, for example, I was very prone to malaria induced fever and seizures. But Alma-Ata meant that my mother would no longer have to wait, or sell valuable livestock or land, to secure the user fees to take me to the nearest health facility.
That hope was short-lived. Within a few years, the issue began to narrow, and selective primary health care meant that the global commitment for my five older siblings and I was only growth monitoring, immunizations, oral rehydration therapy, breastfeeding, and other female health and hygiene lessons, family planning, and food supplementation.
The unbearable costs of seeing a provider, paying for laboratory tests or medication, or referral to advanced care hospitals continued to hinder our access to timely and adequate health services.
Four decades later, we know a selective approach is doomed. Despite selective interventions that ironically included growth monitoring and food supplementation, for example, at least one in every four children under the age of 5 in LMICs is chronically malnourished, affecting their brain development and costing Rwanda alone an estimated $546 million a year, or 11.5% of GDP.
The new declaration barely acknowledges failures like this — and worse. Rather than renewing the goal of true health for all — high quality, equitable health care — this UHC declaration and the currently dominant UHC discourse appear to represent some health for all. They focus on demand-side barriers, namely user fees and health insurance, and less on planning a robust supply-side of care provision — one that has enough staff, supplies, and infrastructure to address the full burden of ill-health.
My concept of truly transformative UHC is an integrated approach encompassing primary, secondary, and tertiary care that meets the health needs of the whole population with high-quality care that includes social support and addresses the social determinants of health. It has to be country-led, and adequately financed to address gaps on both the demand and supply-side of high-quality care.
Yes, that might appear difficult. To turn such ambition and global commitments into reality by the agreed-upon deadline of 2030 will require global solidarity and a rejection of the status quo. It will require that donor nations increase global health funding to close the financing gap of about $50-100 billion annually between what LMICs can mobilize domestically and what is needed for UHC. Clearly, the financing gap is far beyond the low-income governments’ financing capacity.
But looks are deceiving in this case. The high-income donor countries have a combined gross national income of around $54 trillion. The financing gap for UHC in low-income countries comes to just 0.18% of their income.
In addition to the global solidarity in bridging the UHC financing gap, sustained health for all in LMICs also requires more egalitarian terms for nonaid-related international cooperation rooted in equity.
Those include the revision of the global economic policies that currently deprive LMICs of significant financial resources. For example, governments of sub-Saharan Africa paid $18 billion in external debt service in 2015; and lost a further £34.4 billion ($42.8 billion) that same year through the repatriation of profits by multinational companies. Illicit financial flows sucked away even more, up to $650 billion annually via global tax abuse.
Clearly, UHC will not be achieved by nations alone or on their own timelines and with a limited affordable set of health services. Without significant and sustained external funding, and in an era of globalization, there needs to be an increasingly globalized notion of who bears responsibility for protecting and fulfilling the right to health.