[This article is published as the first part of a series in the January 2013 issue of Infomed (pgs:12-15)]
The 20th century: 1948-2000
International accreditation of the right to health was first achieved in the Universal Human Rights charter in 1948. This position was ratified again in 1966 by the International Covenant on economic and socio-cultural rights. These then were followed by the Alma Ata Conference in 1978 that defined health, for the first time in a positive context, as, ‘a state of wellbeing and not merely the absence of infirmity’. Alma Ata also captured the public health goal for nations in a Declaration: “Health for All”. It brought Comprehensive Primary Health Care (CPHC) to the centre of health reform and stressed a holistic approach that integrated social development with health.
Hardly was the agenda set at Alma Ata, when a movement that shifted focus from CPHC to Selective Primary Health (SPH) took shape; first in a conference in Bellagio in 1970 and later endorsed by both the UNICEF and the World Bank. SPH rejected the holistic approach of CPHC and launched instead the GOBI program that focused on four vertical and distinct child interventions: Growth monitoring, Oral Rehydration, Breastfeeding and Immunization. A few years later, in 1982, it was expanded into the GOBI-FFF to include food supplementation, family planning and female literacy.
Many nations followed the lead established by the international organizations and accordingly, shifted priorities from CPHC to SPH. Two decades on, the consequences were visible. While there was definite improvement in these predetermined areas of interest; overall public health metrics had deteriorated and the move towards ensuring the universal right to health for populations was severely derailed. SPH had translational difficulties too. The standardized implementation models of SPH ignored local sociocultural determinants of health, critical determinants of health policy success and therefore, its goals struggled to translate into positive outcomes.
The 21st century:
By 2000, many lessons had been learnt The UN once again included the universal right to health and CPHC in its millennium development goals. From thereon, the WHO has taken the lead in setting the public health agenda of nations by issuing two major statements. In 2005, it passed the UHC resolution, defining UHC as the international standard for progressive reform and development in health and in 2008, the WHO annual health report brought CPHC back to the core of its global health program. Despite these laudatory efforts, international organizations like the WHO and the UN have normative functions of setting agendas and directing efforts. The ground reality is that both UHC and CPHC are political processes and require political and governmental will for success.
The road travelled by nations:
Apart from and alongside these institutional efforts, individual nations have charted their own course towards fulfilling their responsibilities to the health of their peoples. The country experience with UHC is long and varied. National aspirations for UHC preceded the international impetus. Nationwide health insurance was set in motion by Germany in the late nineteenth century. The UK followed this example by instituting NHS in 1911. Today, both these robustly far thinking systems continue to thrive and sustain their populations. Further, all the OECD (save the USA) nations have followed suit and provide near total health insurance coverage (of some sort) for their populations. At the present time, 58 countries around the world have achieved and delivered on UHC and 23 more have legally mandated it.
Criteria of coverage: What comprises the criteria of coverage? How is a country determined to have achieved UHC?
Since coverage cannot include 100% of the people for 100% of services, UHC is accepted as achieved when: 1) more than 90% of the population has insurance coverage and, 2) more than 90% of the population has access to maternal skilled health workers.
UHC broadly encompasses two themes: population coverage with access to an affordable package of healthcare services and, the infrastructure for delivery with an adherence to a minimum quality standard. Simple coverage of a population does not mean much unless it comes with the guarantee of quality and services. It is easier to define what constitutes population coverage than to agree on the package of services that insurance will cover and the quality of delivery. At this level, the decisions become intensely political and local and no one blanket model or system can be laid down across cultures and continents. The most that international organizations can do is lay down the norms for practice and work with national ministries to develop a health system that best suits their needs and sets them firmly on the UHC road.
Can governments of poor countries afford UHC? The general consensus and the empirical evidence says, yes. Poverty, per se, is not seen as a deterrent. Contrariwise, inaccessibility to health is one of the factors contributing to poverty. A more-true deterrent to the implementation of UHC is the lack of functioning systems and/or the infrastructure that will ensure delivery and guarantee outcomes. Much of the success of UHC is therefore in the domain of the political will and muscle of the government to implement true reform. In this regard, Mexico, Thailand and Chile are shining examples of success.
Health has thus moved into the purview of universal fundamental rights. The dramatic progress in treatment options (drugs, devices and procedures) has increased the potential for cure, extended lifespans and enhanced quality of life despite disability. Every individual has the right to expect to avail of the benefits of these advances in science. Health is a need, not an entitlement. Not an avoidable item in a consumer’s budget. It is fundamental to living and ranks high amongst people’s priorities for a good life and for a measure of happiness.
(This is the second article in a series. The next will focus on the India experience)
1. The long road to Universal Health Coverage, The Rockefeller Foundation: http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf
2. HLEG report on UHC for India: http://uhc-india.org/
3. Universal Declaration of Human Rights: http://www.un.org/en/documents/udhr/
4. The world health report 2010 on Health Systems Financing. http://www.who.int/whr/2010/en/index.html