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Countries across the world have committed to increasing access to health, including through the Sustainable Development Goals and the Political Declaration on Universal Health Coverage (UHC). However, commitments only take us so far.
Civil society and communities, including children, young people and those often excluded from decision making processes, play a critical role in demanding quality health services and ensuring health allocations prioritise their needs.
Our role is to make sure decision-makers honour their commitments and obligations, demand that investments translate into tangible results, and insist that that political leaders be transparent about what works or does not.
As UHC2030’s recent State of UHC Commitment report affirmed: ‘Global leaders and other stakeholders must come together to ensure coherent action and to build trust and accountability by widening participation in health governance at all levels.’
Health inequities – a widening gap on the road to UHC
The role of civil society and its ability to hold decision-makers to account is particularly important when it comes to tackling persistent health inequalities. Improving health outcomes and ensuring the most deprived and marginalised have access to quality health services is not just about how much money is spent- but how it is spent. Save the Children’s recent data analysis shows that in countries such as Colombia, Ghana, Indonesia and Mexico, the poorest groups of society have a disproportionally small claim on public resources for health.
In many low- and middle-income countries, out of pocket spending, the most regressive and inequitable form of health financing, makes up a huge proportion of total health expenditure. According to the latest Global Health Expenditure (GHE) report, Global spending on health: Weathering the storm, over 40% of total health spending in low- and lower middle-income countries comes from out of pocket spend. In lower income countries, out of pocket payments make up a staggering 60% of the domestic spend on health.
The dependence on out of pocket spending is especially concerning for the most deprived and marginalised populations, who must make difficult decisions about where to use their limited income and are often unable to afford healthcare. With the COVID-19 pandemic and its impact on economies, these financial constraints and inequality stand to worsen. Almost half of the over 400 State of UHC Commitment survey respondents stated that there had been no change or that there was an increase in user charges during the pandemic. In many countries, the most vulnerable groups are being left ever further behind as a result of the widening inequities due to COVID-19.
Recent data from the GHE report show that the share of health spending within governments’ total spending declined in poorer countries between 2000 and 2018; overall, the rate of growth of health spending has been at its slowest compared to the last two decades. This makes for a worrying picture as health budgets in the poorest countries are also expected to be the most affected by the macro-economic impacts of the pandemic. According to the report, countries that depend on out of pocket payments to finance their health systems and are also facing significant economic downturn are likely to be hit the hardest.
Now more than ever, increased or at least sustained public spending on health is critical to ensure that the burden of accessing health care services does not fall on the poorest members of the population and that countries meet their UHC commitments.
Efficient investments in primary health care and targeted interventions will be critical for reaching the most vulnerable. As recommended in the GHE report, health financing policy measures should include more explicit budget-funded coverage programmes, effective implementation and funding of policies to eliminate user fees, and targeted cash transfers to protect the poorest.
The case for available, reliable, and trackable health expenditure data
There is growing recognition that to meet the Sustainable Development Goals we need to know whether resources are being used to meet the needs of the poorest. Knowing how resources are spent and holding decision-makers to account is central to making sure that public resources reach entire populations, especially those children and communities who are most deprived and marginalised.
But, knowing and tracking where and how resources are spent depends on having access to easy to use, available, and reliable data. Currently, in practice, budget execution details can remain opaque, making it difficult for civil society to track efficiency of spend and to establish whether people have benefitted from the allocations, investment strategies have been appropriate, or whether funds have been misused.
The United Nations Statistical Commission recently approved a new indicator to measure whether public money is being spent on the world’s poorest people who need it most, highlighting just how important good data can be for advocacy and accountability. Governments have a responsibility to be transparent and share information on policy formulation, health planning and budgeting. They need to engage civil society and communities in monitoring how effectively the budget is used.
Governments must systematically collect and track health spending data to support inclusive decision-making, improved advocacy, and accountability on how money is spent in order to ensure no one is left behind and progress is made towards the achievement of UHC.
They must also step up — supported by donors, global health institutions and global civil society —to protect and expand the space for civil society and communities in health governance and accountability nationally and globally.
As civil society who work towards more equitable policies and public investments for health in the COVID-19 era, we welcome the WHO’s six recommendations to countries for charting a new health financing compact and particularly highlight three:
- Secure domestic public spending on health as both a societal and an economic priority
- Prioritize public funding to ensure equity of access and financial protection through a primary health care approach
- Fund national institutions for transparent and inclusive tracking of health spending at both country and global levels.
Photo: ©WHO / Eduardo Soteras Jalil