UHC: A spoonful of sugar to ensure health care for everyone

A woman at a clinic in Ghana. There exists extreme inequality around access to health care in developing countries, where the poor pay for ill health with their lives and the rich can afford the best quality treatment. Photo by: MamaYe Africa / CC BY-NC-ND

Babena Bawa was a farmer from Wa East District in rural Ghana, an area where there is only one nurse for every 10,000 people. In May last year, he died from an easily treatable snakebite while racing to his nearest hospital 120 kilometers away for anti-venom serum.

The choices available to Babena stand in stark contrast to Ghanaian presidential candidate Nana Akufo-Addo, who was able to fly to London for specialist treatment for heart problems in 2013.

This may be just two people, but their experiences exemplify the extreme inequality around access to health care in developing countries. All too often the poor pay for ill health with their lives, while the rich can pay for the best quality treatment.

However, health care does not have to be a luxury. An opportunity to redress such stark imbalances on people’s ability to receive medical treatment presents itself in 2015. The inclusion of a target in the proposed sustainable development goals to achieving universal health coverage — where all people are able to access high-quality health care without fear of falling into poverty — could have a momentous impact.

In order to achieve UHC in developing countries, health systems must be financed and delivered in the right way. Countries making the most progress toward this — such as Sri Lanka, Thailand, Malaysia and Brazil — use general taxation to fund public health care.

Many alternative ways of paying for health care have been shown to punish and exclude the poorest people, the most inequitable being charging them out-of-pocket. Three people every second are pushed into poverty as a result of having to make direct payments for medical services.

Voluntary health insurance has also fallen short because private insurance usually has expensive premiums, while community-based schemes rarely reach more than small segments of a population. One study of over 250 schemes found that more than half had a membership of fewer than 500 people — an unacceptable level of exclusion. Social health insurance also tends to provide coverage for people working in the formal sector first, leaving informal sector workers behind.

All this leaves tax revenues as the most effective way of financing UHC. However, while taxation is the largest, most sustainable and predictable solution, tax revenues earmarked for health care are continually being eroded by illicit financial flows. Corporate tax avoidance and exemptions are estimated to cost developing countries around $100 billion annually. This is more than 250 percent the amount spent on health by all sub-Saharan African governments combined in 2011.

Finally, to genuinely tackle inequality, health services must be delivered in a way that benefits everyone fairly. Significant involvement of the private sector in providing health care has been linked with poor people being excluded from using medical services. For example, recent evidence from India has shown that among the poorest 60 percent of women, most turn to public sector facilities to give birth, while the private sector primarily serves those in the top 40 percent.

Public-private partnerships can prove to be a dangerous diversion of scarce public funds away from the more proven ways to reach the poorest, such as rural health clinics. In 2014, Oxfam found that a new PPP hospital in Lesotho’s capital Maseru — the Queen Mamohato Memorial Hospital — was costing the government over half of its annual health care budget, and is three times more expensive to run than the old public hospital it replaced. The scheme diverted urgently needed resources away from rural areas, where three-quarters of the population live.

Achieving UHC requires balancing out the inequalities that distort people’s ability to access health care. If governments create health care systems that genuinely help everyone — including the poorest people — a UHC target within the new sustainable development goals could inspire the improvement of millions of lives across the globe.

This piece is part of a series of articles to be published in “Health Matters,” a news bulletin commissioned by Action for Global Health for European Health Month, as part of the European Year of Development 2015. The paper brings together key stakeholders working on health to confront the challenges of the post-2015 framework, provide recommendations on the means of implementation, and raise awareness on the importance of health for all.

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About the author

  • Winnie Byanyima

    Winnie Byanyima is the executive director of the Joint United Nations Programme on HIV/AIDS. A grass-roots activist, human rights advocate, and world-recognized expert on women’s rights, she began her career as an engineer in her native Uganda. Appointed to the diplomatic service in 1989, she represented Uganda in France and at UNESCO. She was a member of parliament for 10 years in Uganda, and thereafter served at the African Union Commission. She was UNDP’s director of gender and development between 2006 and 2013.