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Blog: Universal Health Coverage - where did we get lost?

Photo (cropped): Health talk at the clinic. Credit: Community Eye Health/Flickr licensed under CC BY-NC 2.0.

Dec 2019

In the last few years, the global community has established a shared and widely accepted vision on the importance and significance of global goals, such as the SDGs and Universal Health Coverage (UHC). This vision has provided an opportunity to agree on what we can collectively aspire to achieve, and how these achievements are measured. However, the contextual significance of achieving these goals and objectives varies depending on the context.

Many people in the global south have never discussed or reflected on UHC. Instead, they face daily battles for survival in areas where guidelines and protocols for health promotion and coverage are available, but yet, the social, political and economic context and culture does not support their implementation. The gap between written policies and action is large between the north and south, but also within countries in the south, between policymakers and citizens. Access to resources provided for the promotion of UHC is also still limited.

UHC in theory but why not in practice?

We need to analyse the failures of health coverage promises as included in the primary health care agenda decades ago, and evidence shows that:

  • The interplay between countries’ complex and inefficient oversight and control structures, and politics and unequal accountability relations in the global south played a role in missing agreed health targets we set for ourselves;
  • The amount of international aid spent on health is not yet contributing enough to reduce inequalities;
  • Challenges with coordination, alignment and harmonisation fuels fragmentation of aid and of health programmes;
  • Multiple and parallel funding mechanisms, vertical programmes, the off budgets, as well as the conditionalities harmful to citizen’s access to health contribute to weakening the health system, thus perpetuating health inequalities.

Let’s explore a few other angles…

Politics do matter

We got lost in hiding the narrative of UHC in philanthropy, in solidarity and charity, while playing down the weight and importance of the political economy of health as a business. By politics I mean it in the broadest sense, including human rights, governance and transparency, as well as accountability.

It is widely known that within the political economy of health business, an entire industry is established and fueled on commercialisation of health, knowledge, science, skills, goods and products, which are essential for paving the way towards achieving UHC targets. The most drastic examples are related to conditionalities on procurement and acquisition of medicines, some of which are tied to bilateral and multilateral agreements between countries.

The political economy and the drain on resources

Within the political dimension, there are several other factors leading to a drain on resources, such as unequal treaties, trade mis-invoicing, weak country tax legislation frameworks, tax evasion and tax exemptions for multinationals. These all encourage illicit financial outflow from countries in the global south undermining economic and social rights. This was evident in Mozambique when an illegal debt crisis triggered a macroeconomic and social crisis.

In 2013, two London-based (Credit Suisse and VTB) banks lent $2 billion to three state-owned companies in Mozambique. The loans were not approved by the Mozambique parliament, breaking the countries’ constitution. Subsequent revelations have shown that much of the money was stolen, wasted and used to pay bribes and kickbacks to Mozambican government officials and to Credit Suisse and VTB bankers.

Sadly, at the local level, the political framework that creates the opportunity for resources drain is sustained by a repressive political culture. That culture impedes the development of institutional mechanisms and management structures that could be conducive to good governance and accountability for economic and social rights including health.

Another dimension is the role of INGOs and NGOs, as my own. Sometimes we are part of the structures which block the overall progress of this agenda by holding on to most of the resources we should be using to advance the agenda. At country level, this scenario is replicated, albeit on a smaller scale, by national organisations.

Unfavourable modalities of cooperation

We also need to look into the modalities of cooperation between the global north and  south, and specifically at the implications of the combination of aid and trade. Ignoring the dimension of the fairness of trade means losing sight of what is needed for countries in the global south to be agents of change towards UHC.

The paradox lies here. The actors who collectively support the achievement of global goals regarding UHC are unable to stop the draining of resources from the countries in the south. The international economic order remains blatantly biased against the interests and social-economic rights of the people.

Governments’ responsibility

But let’s not deceive ourselves. Our governments in the global south bear the principal responsibilities for failing to protect the right to health of our people.  We hide behind arguments related to historical and structural issues such as colonialism, neo-colonialism and the economic imbalance between the north and south refraining ourselves (and here I mean our governments) from the responsibility and obligation for good governance, transparency and accountability to citizens.

If we are honestly committed to UHC2030 our countries need to make a wholehearted commitment to creating a structure for a health system that is guided by a long-term vision. If we continuously insist on conveniently delegating most of the responsibility for funding the health sector to ‘international partners’ we will not succeed.

Re-thinking UHC

The shared vision for UHC 2030 is mainly focused on strengthening the health systems of countries that need to achieve the targets, placing a strong emphasis on specific systemic and operational challenges within the systems. While the principles laid down by this shared vision are crucial, our reflections should also focus on structural issues beyond the health systems. We need to:

  1. systematically mainstream equity, justice and human rights in the framework of the cooperation between the global south and north;
  2. change the global political, fiscal and the legal framework that supports tax evasion and illicit outflow of resources from the global south,
  3. strengthen state institutions at the local level to safeguard the collective interests and rights of its people;
  4. and finally, channel these resources towards the goals we are setting for UHC.

Without considering these critical aspects and effectively addressing them in the context of a global platform for justice and equity that can contribute to domestic resource mobilisation and allocation to health, we have no script in the short or medium-term that can lead us to the UHC that we all preach.

If we don’t think of health outside the broader context of socio-economic opportunities, we can hardly aspire to achieve the goals and outcomes of coverage and equity in a sustainable manner. I ask – is there an alternative model we can all agree with?


This opinion piece was originally published as Universal Health Coverage: Where did we get lost? by the Institute of Development Studies (IDS) on 9 December 2019.

The Impact Initiative blog posts are either from individual researchers or from major research programmes. Some of the blog posts are original source and are written by researchers and experts connected to the two research programmes jointly funded by ESRC and FCDO: the Joint Fund for Poverty Alleviation Research and the Raising Learning Outcomes in Education Systems Research Programme. Other blog posts are imported from related websites and programmes. 

The views expressed in these blogs reflect the opinions of each individual and may not represent the Institute of Development Studies, the University of Cambridge, ESRC or FCDO.


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