BERLIN — Advocates for universal health coverage this week lauded the way that global political agendas have integrated health issues in recent years. But participants in this week's World Health Summit in Berlin — including Nobel laureates, health ministers from around the world, and leaders of international agencies — warned that, without political will, few countries will be able to deliver on those pledges.
As part of the Sustainable Development Goals, all United Nations member countries committed to reaching UHC by 2030. Specifically, they pledged to ensure access to a range of health services — from promotion to rehabilitation — at costs that are affordable.
That task is formidable, especially in low- and middle-income countries, speakers at the three-day summit cautioned. Political leaders must confront issues such as health worker shortages and spotty information systems, even as they try to construct financing schemes to fund UHC. They must make concrete plans and financial commitments, advocates said.
"It's a political choice," said Dr. Rüdiger Krech, the director of health systems and innovation at the World Health Organization. "It's not a technical choice. The technical means are there. We can do it, if we really want it."
The critical issue at the moment, experts said, is translating these commitments to achieve UHC into concrete actions. If countries are to achieve UHC by 2030, they said it needs to happen now.
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At the country level, advocates are looking for political leaders to introduce and implement overarching plans that include domestic financial commitments and identify opportunities for donors and other partners to assist in shoring up health systems. Most critically, they are pushing for strategies that will make UHC sustainable over the long term.
"It's difficult to come to this political commitment," Krech said. "But it's even more difficult to fully implement your conviction."
The technical challenge
While the SDG indicators for UHC are straightforward, the pathways to achieving them can take any number of forms.
"There's not one size fits all" for UHC, Krech said. "Every country in the world, be it the richest or the poorest, faces serious challenges with regard to health systems and with regard to meeting the goal of universal health coverage."
Those challenges are particularly abundant in low- and middle-income settings. UHC requires access not just preventative and curative services, but also health promotion and rehabilitative and palliative care. That will be a big ask for low- and middle-income countries struggling to provide basic health care, amid shortages of health care workers and facilities.
At the same time, countries face an expanding list of health needs. Health care in the developing world has often been built around responding to infectious diseases. But as lifespans lengthen, countries are seeing a rise in noncommunicable diseases such as cancer and diabetes.
"Many countries tend to focus much more on treatment, the health system side of things, at the cost of focusing on prevention and health promotion," said Katie Dain, the chief executive officer of the NCD Alliance. "For NCDs, you've got to have both."
Administrative capabilities also need upgrading. Health information systems, for example, are vital to long-term planning, as well as outbreak detection. Public health officials will also have to create systems for delivering drugs and other health commodities.
UHC requires government decisions about where and which resources to deploy, said Saadiya Razzaq, a health systems expert at the Sustainable Development Policy Institute in Islamabad, Pakistan. This includes both domestic capabilities, as well as donor and partner activities.
"It is really important to have one common agenda and the different donors and development partners pitch in to different parts and not have parallel activities," she said.
States can use the UHC goals as an opportunity to get their health policies in order. Governments can outline their financial commitments and highlight where they could use support from donors — for example, in the construction of facilities. They may also consider aligning regulations to reduce corruption and facilitate private sector investment.
"It's creating legal environments that stakeholders can move in and do their work and can grow," Krech said. "It's also that the private sector can grow within this, under the condition that there's a very clearly set legal framework."
Iran offers a case study of UHC policy, with the introduction of a Health Transformation Plan in 2014. The upper-middle-income country has seen significant improvements in its health indicators over the past decades, according to the WHO, and it introduced the plan to ensure that those advances were equitably distributed. Dr. Amir Takian, deputy for international affairs for the Iranian Ministry of Health, told Devex the government is slowly integrating a premium-based insurance system to help offset the costs of UHC.
"If you went to people and asked them to pay a premium, you would have failed," he said. Instead, the government used tax revenue to begin underwriting health care for some of its citizens and then, over time, began asking them to contribute.
"We were saying to people, 'You're seeing this is good. This is bringing out-of-pocket costs down. If you want to continue, you need to contribute.'" Early evaluations of the program's success are mixed, though Takian cautioned that it will take time to see the full benefits.
Question marks also linger about the sustainability of the program. Making it work in the long term will require flexibility, he said, and a willingness to survey the landscape for how innovations can be integrated into the system. Iran is looking into home care opportunities, especially for people with chronic conditions, who might be able to monitor their own status under the supervision of a health official.
"Unless we can empower our citizens for health care, having more home care, we cannot afford the health system," Takian said.
Political will is fickle, and requires constant vigilance to sustain, Razzaq said. Especially in low- and middle-income settings, governments face myriad competing priorities.
One work around is to build opportunities for political pressure into the system. In Iran, for example, Takian pointed to the introduction of an annual national health assembly, which allows the government to hear regular feedback about the health system from citizens. Razzaq highlighted the importance of high-level task forces within parliaments and other bodies on issues such as UHC and the SDGs to keep progress on track and generate political will.
NGOs, advocacy groups, and international organizations also have a role to play in calling attention to persistent inequities and to other issues that are detracting from UHC.
"It's not just the government or the politicians that are responsible," Razzag said. "We are all responsible. Everyone has their role in translating these commitments into action."
How do we ensure that people worldwide get the care they need without the risk of being pushed further into poverty? Devex explores the path to universal health coverage. Join us as we ask what it will take to achieve UHC for all by visiting our Healthy Horizons site and tagging #HealthyHorizons, #Health4All and @Devex.