Forum introduction: Moving the UHC agenda forward without waiting for the next health crisis

We dedicate this Forum to Peter Salama and David Sanders – fighters for the right to health care for all.

Only 4 months after the world community reiterated its commitment to universal health coverage (UHC) with the political declaration on UHC at the United Nations (September 2019), the world once again faces a health emergency of international concern, as COVID-19 continues to spread in all regions.

In our interconnected world, such health events are happening with greater frequency. In recent years, we have seen the emergence of SARS (severe acute respiratory syndrome), swine and avian flu, and zika virus, along with the re-emergence of Ebola, among others. With equal regularity, the same key insight concerning systems of social protection for health is reiterated: the coverage, quality and accessibility of health systems make a major difference in fighting such diseases. This is more than a statement about an individual’s right to health; it is a concern for global public health and health security as key public goods. During the Ebola outbreaks, global health experts lamented the poor health systems in the worst-affected countries, a decline rooted in the reduction of health systems support and partnerships. However, as Ebola did not spread uncontrollably to high-income countries, there was little push for systemic change. COVID-19 is now providing that wake-up call: it is spreading more dramatically, more widely and with more varied impacts in countries depending on their governance systems, health infrastructure and comprehensiveness of health care coverage. The countries of the Global South are yet to experience the full impact of COVID-19, but there is little doubt it is coming.

Through the World Health Organization (WHO), the international community has requested US$675 million to support states with weaker health systems in responding to COVID-19. ¹ A country like Iran, with a relatively weak health system coupled with its exclusion from international trade and thus limited access to critical supplies, is in need of considerable support and is less able to control the spread of the disease than high-income countries. For African countries, Nkengasong and Mankoula (2020) summarise what needs to be done now, before the virus spreads, including working collectively at the regional level, supported by international agencies and donors. We need not wait long for the early papers documenting the emergence of COVID-19 to reinforce the point, once again, that better health systems and universal health coverage would have made a difference!

It is therefore timely that this Forum focuses on the renewed upsurge in support for UHC. In the following short papers, a number of researchers, policy makers and policy entrepreneurs, civil society activists and practitioners reflect on how UHC returned to the agenda, globally and in specific national contexts; the varied experiences of different countries as they make efforts to establish universal access to quality care, free from financial risk; and who is being left out of these processes. The Forum explores how UHC – a quintessential global social policy – has evolved into its current form after decades of shifting and contested definitions and concepts. The papers examine the re-emergence of the principle of universalism in access to health care; the role of international organisations as well as civil society, academia and technical experts in mobilising around the renewed agenda, giving it particular prominence within Sustainable Development Goal 3 (SDG 3) on health; and the varying pathways towards implementation. They also consider some of the risks and obstacles to realising and sustaining the goal of UHC while drawing attention to who is excluded from current formulations of universalism.

Tim Evans and Ariel Pablos-Mendez, two individuals at the heart of this agenda, trace the journey taken by leading international organizations (IOs) – WHO and the World Bank– to position UHC as an ‘apex goal’ and bring it back to the mainstream policy discourse. They note that UHC made complex ideas around health systems more tractable, reinforcing key values of universal access to care when needed without the risk of financial hardship and building on widespread evidence that health care needs are one of the major pressures leading to impoverishment of families in many countries. The kinds of policy, technical, and advocacy networks described are reflected also in the cases presented in subsequent papers. The agenda they describe will demand new forms of finance and mechanisms of provision. They also warn that, by becoming a highly visible agenda and particularly one that is pivotal to the SDGs, UHC will be open to additional scrutiny and criticism; this demands vigilance about the strategies pursued in its implementation.

From the perspective of the International Labour Organization (ILO), UHC is integrated within its broader social protection floor (SPF) agenda, as discussed by Xenia Scheil-Adlung. SPFs are designed to ensure universal health care alongside other programmes to address poverty, lack of income or contingencies across the life-course. In linking to a broader range of social policy and protection mechanisms, the author emphasises the need for coherence in the policy approach, recognising that many of the challenges and obstacles to UHC, including the broader social determinants of health, lie outside the health care system and will need to be tackled through multiple social and economic policies. While the ILO SPF starts from an initial minimal package or ‘floor’ as a route to universalism, several of the papers also remind us that UHC must not get trapped in delivery of only essential services to the poor.

Underpinning the current wave of support for UHC (as the above papers illustrate) is a decade or more of technical and political work – defining UHC, simplifying the concept, experimenting and building on positive examples and cases, and drawing lessons to show what can work. The case of Thailand has been particularly widely cited, scrutinised and shared with other countries. Somsak Chunharas – a key player in Thailand’s push towards UHC as a medical practitioner, researcher and from within the government – reflects on critical elements of that journey. He notes that UHC is not something to be achieved – rather, it will continuously evolve as needs, politics and resources change, and must involve domestic leadership and resources, reinforced by international support. The technical mechanisms for financing, strategic purchasing and motivating an appropriate health workforce are all critical elements that can only be determined domestically. He emphasises a key principle that what is delivered through a UHC approach must aspire to be more than a minimal package of services delivered to the poor. In Thailand, the global attention it has received as a ‘model’ for the international community has helped in maintaining pressure domestically to retain the universal values that underpin the system against political pushback.

India also has a significant history of attention towards provision of health care for all, as Mirai Chatterjee outlines. Building on efforts that started around independence, India has charted its own path, most recently drawing on the experience and expertise of Thailand as well as the international organisations. From 2014, the reaffirmation of this commitment to UHC has led to new programmes and initiatives. However, Chatterjee demonstrates that the system is not yet reaching the vast majority of the poorest and most excluded population – informal workers, and especially women. Documenting the advocacy and mobilisation work of the Self-Employed Women’s Association (SEWA), a union representing these women and of which Chatterjee is a prominent leader, and their work with government, communities and other organisations, as well as the women themselves, the paper reports practical reasons for exclusion – timing of clinics, the nature of services provided and the lack of health workers, for example. Through consultations with such women and communities, the paper suggests concrete ways to extend coverage while also highlighting the importance of mobilising bottom-up demand for health as a right.

Masuma Mamdami, writing about the situation across East and Southern Africa, also emphasises the need for mobilisation, advocacy and political leadership around the right to health. As a researcher actively engaged in civil society mobilisation for health, she reflects on progress and limits in countries across the sub-region, the ways in which each country must chart its own path but the lessons that can be shared among them. Some key areas for learning are summarised in a set of key questions, many of which reflect issues illustrated in other papers in this forum – including the role of civil society participation, the need to address wider social determinants of health, mobilisation of resources and how to ensure movement from a minimum package to comprehensive benefits.

The limits of, and challenges to, universality are also illustrated in the final contribution. In most contexts, health systems are set up largely to address the needs of stable populations. But most under-served populations are found in contexts of high population mobility, within countries as well as those who move across borders, and often among disaster- or conflict-affected and displaced populations. The paper by Mosca, Vearey, Orcutt and Zwi – academics and policy workers on migration and health – highlight ways in which migrants, refugees and other displaced or on-the-move populations are largely neglected or hidden in this universal agenda. The authors identify clauses within key documents that allow states to pull back from universality and equity principles, often hiding behind specific descriptions of national contextual constraints. The authors also draw attention to the need for international organisation negotiations to cut across important sectoral divisions to ensure greater complementarity and policy coherence in both the migration and global health governance arenas. The tragic experience of Syrian and Afghan refugees seeking to transit through Turkey to Europe, being met by harsh forms of policing and violence, highlights once again a lack of solidarity and universality. The authors provide a useful guide to what is needed if migrant-friendly health systems, better for all, are to be promoted.

All papers thus reflect in distinct ways the need to recognise differing health needs of diverse populations; the construction of pathways towards universality, recognising local contexts but seeking to overcome their constraints including the politics of vested interests; and the range of obstacles to access and quality health care that are invariably present. They point to the importance of technical and managerial skills for developing a complex system and the importance of a health workforce and infrastructure that fits local circumstances. In the current global context, the need for health systems that provide universal access to all at times of need and free from financial risk is both obvious and urgent. Only with such systems in place can global health emergencies or health security threats be adequately contained and managed.

Unsurprisingly, Thailand, mentioned in several contributions to this Forum as an exemplar of a middle-income country UHC system, has quickly been able to make the connection between COVID-19 and UHC, incorporating it ‘under the Universal Health Coverage – from prevention and diagnosing to healthcare and rehabilitation’. ² Had the global community made greater progress in strengthening health systems around the world, we might be better placed to cope with the anxiety or even panic associated with the spread of yet another highly infectious, disruptive and potentially deadly disease. The renewed commitment to UHC provides the basis for moving this agenda forward.

Last but not least, pushing such agendas even (or especially) at times without a global health crisis requires powerful voices. Sadly, one of the most passionate and compassionate among those voices, Peter Salama, passed away on 23 January 2020 at the age of 51 while we were writing this Forum. Pete was Executive Director of WHO’s Division for UHC/Life Course and had planned the work of bringing UHC to a billion more people over the coming few years (Green, 2020). He had previously led UNICEF’s response to Ebola, and most recently was supporting the government of Somalia on a roadmap for delivering UHC. With him, the world has lost a tireless and committed fighter for UHC.