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How far have we travelled on the road towards universal health coverage (UHC)? Are we on the right path?
On 22nd September 2019 in New York, the eve of the UN High Level Meeting on UHC, international partners launched the 2019 UHC Global Monitoring Report with alarming news: at current rates of progress up to 5 billion people will miss out on health care in 2030.
The World Health Organization prepared the report with contributions from the World Bank, the Organisation for Economic Co-operation and Development, the United Nations Population Fund and UNICEF. Findings showed good news that coverage of health services is increasing, in all regions and across all income groups, with lower income countries having made the greatest gains, although the poorest countries are still lagging behind, as are countries facing conflict. The bad news is that financial protection is not improving. Over 930 million people spent above 10% of their household budget on health care and 210 million spent more than 25%. Millions more end up in poverty as a result of seeking health care.
The report warns that the world will need to double service coverage between now and 2030 to achieve UHC and that if current trends continue, up to 5 billion people will still be unable to access health care in 2030. Most of those people are poor and already disadvantaged.
The launch event, moderated by Dr Githinji Gitahi, Amref CEO and Co‑Chair of the UHC2030 Steering Committee, took place at the Ford Foundation in New York and high-level speakers shared their concerns and perspectives on how to make progress on UHC.
Dr Tedros Adhanom Ghebreyesus, WHO Director General in launching the report shared concerns that gains in service coverage come at a high cost to individuals and families. He also highlighted a major recommendation from the report that investment in primary health care is the answer. Most countries can scale up primary health care using domestic resources, either by increasing public spending on health, or by reallocating spending. “That’s why we are recommending that all countries increase their investment in primary health care by at least 1% of their gross domestic product," he said. “Let’s be clear: primary health care is not about providing basic health services for poor people. Health for all is about rethinking health systems from the ground up,” he added.
Peter Salama, Executive Director, Universal Health Coverage/Life Course, WHO commented on the main findings from the report, which were presented in a video. He said, “We are now reaching the limits of existing global health models. Poverty due to health expenditure is now increasing. Primary Health Care provides the pathway to integration for UHC.”
Heads of agencies and their high-level representatives contributing to the report shared their perspectives on the report:
Henrietta Fore, Executive Director, UNICEF said, "If we can gather round PHC it is going to change our world. Inequities are still problem. We need all hands on deck - everyone needs to get it right around PHC. This is urgent."
Natalia Kanem, UNFPA Executive Director spoke about gender inequities and discrimination in relation to PHC and UHC. "We have to seize the moment for 2030 with an unprecedented amount of unity around PHC and paying attention to adolescent girls. Don't shame her when she comes to the clinic asking for services," she said.
Gabriela Ramos, OECD Chief of Staff re-emphasised this with a comment about poverty, gender and sexual and reproductive health and rights (SRHR). “We haven’t yet succeeded in delinking socioeconomic status with health outcomes. Poor people have poor health and have access to poor quality health services. When you look at the poorest and most vulnerable, it is a woman or a girl. SRHR needs to improve and gender is critical.”
Muhammad Pate, Global Director, Health, Nutrition and Population and Director, Global Financing Facility for Women, Children and Adolescents. World Bank said, “Business as usual will not get us to UHC and Health for all. We must all work together to solve it. Efficiency for quality PHC is critical where service coverage increased. We need to increase resources for health under government leadership.”
Several distinguished speakers were invited to share their reaction to the findings of the report, bringing in specific views from their own organisations or constituencies:
Anuradha Gupta, Deputy CEO, GAVI Vaccine Alliance said, “Some children never receive any vaccines at all; we call them ‘zero dose’ children. Our strategy is focused on reaching these zero dose children. We are committed to do this with health system strengthening and PHC.”
Marijke Wijnrocks, Chief of Staff, The Global Fund said, “We want to have a spillover effect that goes beyond AIDS, TB and malaria and we want to push for sustainable systems for health. We want to catalyze investments in sustainability.”
Vytenis Andriukaitis, Commissioner for Health and Food Safety, European Commission pointed out that this is also an important agenda for richest countries which also face challenges and are struggling to invest more in prevention. He asked, "Are we really going to achieve UHC by 2030? We need to do more! It is one thing for countries to sign the Political Declaration tomorrow, but it's another thing for them to have a strong action plan."
Alicia Ely Yamin, a member of the UN Secretary-General's Independent Accountability Panel (IAP) for Every Woman, Every Child, Every Adolescent said,“Good intentions and promises for delivering UHC are not enough. The people to whom these promised have been made are not beneficiaries of charity; they are holders of human rights. Accountability is crucial.”
Martin Chungong, Inter-Parliamentary Union said, "Tomorrow countries will adopt a Declaration on UHC but who is going to make that happen? It's the parliament who has to ratify it, approve a framework of implementation and allocate resources."
Civil society commentary on the Global Monitoring Report
The UHC2030 Civil Society Engagement Mechanism (CSEM) responded to the 2019 UHC Global Monitoring Report with its own specific commentary on the findings. ‘Leaving no one behind: delivering on the promise of health for all’ contains reflections, observations and recommendations.
Oahn Kuat, Executive director of SCDI Vietnam and CSEM member presented a key civil society view that while the 2019 Monitoring Report presents a very useful overall picture of UHC progress in the world, it fails to identify those people who are left behind. There is almost no data disaggregation by the key dimensions of equity such as gender, age, wealth, ethnicity, disability, geographic location, fragile states and conflict situations, nor analyses of inequity due to factors that cause marginalization such as migratory status, sexual orientation, gender identity or identification registration.
“We recommend that UHC as a movement should uphold the principle of leaving no one behind. We need to identify the specific needs of those most left behind,” said Oahn Kuat. She added, “The documented deterioration of financial protection is unacceptable! Governments, UN and international agencies should make every effort to cut down out-of-pocket costs.”
Dialogue on social participation for UHC
A panel discussion on social participation and accountability in the light of implementing UHC then took place with perspectives from civil society, governments and parliamentarian representatives. Key messages were that social participation must be real and democratised, not tokenistic, so that all citizens can own universal health coverage; that civil society organisations have a powerful role to play in data collection and accountability processes; and that parliament is fundamental to the allocation of resources and implementation of UHC.
Suwit Wibulpolprasert, Thai UHC board member, civil society organisation for the elderly in Thailand: "Thailand invites civil society onto the board members for UHC. We look at the benefit package, we sit on the procurement board and we have public hearings. Social participation is real. We own UHC."
Itai Rusike, Executive Director, Community Working Group on Health, Zimbabwe said, “The democratisation of community structures for participation is needed. Budget consultations are done in hotels rather than in the villages or communities where people live. This leaves out women and girls.”
Dr Subandi Sardjoko, Deputy Minister for Human, Social and Cultural Affairs, Indonesia said, “In Indonesia citizens can participate in verification mechanisms of data. CSOs can help improve the quality data and help ensure no one is left behind.”
Diana Nambutya Nsubuga, Deputy Country Director, Living Goods said, “Uganda grapples with a low per capita expenditure on health. It took a lot of hard work with parliamentarians and civil society to get political will to get the government to approve a national health insurance bill. If voices are not heard, we will keep the status quo.”To close the event, Professor Keizo Takemi, WHO Goodwill Ambassador for UHC took the floor. “The 2019 Global Monitoring Report on UHC is wonderful. Policy makers can use it to strengthen their own health systems for UHC. The final goal is to create more healthy societies and a healthy world. UHC is a tool to realise this,” he said.