More countries move towards universal health coverage
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, distinguished delegates, ladies and gentlemen,
I thank the government of Mexico for organizing this international forum on universal health coverage. The timing of this meeting could not be better.
When covering health news, the media tend to shy away from anything so mundane, lacklustre, and unappealing as health systems. But recent experience tells us that universal coverage is a notable exception.
I can think of at least one reason why. Last year’s massive and widespread protests made the consequences of social inequalities patently, publicly, and painfully clear. Protests against inequalities, in income levels, in opportunities, especially for youth, and in access to the benefits of globalization, destabilized societies and toppled governments.
This was the tipping point, when the world woke up to the dangers of assuming that market forces, all by themselves, will solve social problems. They will not.
This was when the world opened its eyes to the need for policies that address societal concerns. This was when words like “equity” and “social justice” made the headlines and entered the vocabulary of world leaders and policy analysts.
This world will never become a fair place all by itself. Fairness, especially in matters of health, comes only when equity is an explicit policy objective. Universal coverage is a clear pursuit of equity and social justice. Universal coverage is also a powerful equalizer.
According to a recent report from the Organization for Economic Cooperation and Development, or OECD, income inequality in wealthy nations has reached the worst levels seen in nearly 25 years.
That report further concluded that societies with the least inequality had the best health outcomes, regardless of the levels of spending on health. In other words, money alone does not buy better health. Good policies that promote equity have a better chance.
Abundant evidence tells us that health systems that are well-managed and properly funded contribute to social cohesion and stability.
As I said, the timing of this ministerial forum is extremely opportune.
Last year, the New York Times featured a story about Mexico’s drive to reach universal health coverage. That story portrayed Salomon Chertorivski, Mexico’s Secretary of Health, as an optimist committed to a vision, but also as a pragmatic and strategic thinker fully alert to the challenges.
We would be wise to adopt a similar approach during this forum. This was the approach taken in the 2010 World Health Report on health systems financing.
Moving towards universal coverage is never easy, but every country, at any level of development, and with any level of resources, can take immediate and sustainable steps in that direction.
Ladies and gentlemen,
I personally find this meeting extraordinary.
It gives us an opportunity to voice commitment, spread optimism, and share pragmatic experiences. But it also serves as a powerful and motivating symbol.
What is happening with health care, right now, goes entirely against the grain of history. During times of economic downturn and financial austerity, history tells us that budgets for health care will shrink, with market forces, user fees, and care by private practitioners taking up the slack.
You need to think back no further than the 1980s, that so-called “lost decade for development”, when structural adjustment programmes imposed budget cuts for social services, including health.
While economic performance in some countries improved, the performance of health systems generally did not.
During that decade, privately-run health services, usually beyond the government’s regulatory control, also of prices, grew in importance, while publicly-funded services lost staff, lost quality, lost public confidence, and lost patients.
For their part, governments lost public confidence in their ability to look after the health of their citizens.
This is a clear failure of duty, at least as set out in the WHO Constitution. I quote:
“Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.”
As the quality of care in the public sector declined, people began flooding emergency rooms, even for routine complaints.
And in most cases, they paid for these services out of their own frayed pockets.
People, intimidated by user fees, began waiting to seek care until their condition was far more advanced, complex, and costly to treat, if treatment was still an option.
The pattern being seen today is entirely the opposite. Health care coverage is being deliberately and systematically expanded, instead of being allowed to shrink to a form that is accessible only to those who can pay.
I am greatly encouraged by the number of countries that have embarked on the path to universal coverage. The list is long and growing.
In an important moment for the people of India, the government announced, earlier this month, its plans to move towards universal health care for all, together with a massive increase in spending on health.
As I said, this is not easy. Current efforts to reach universal coverage must overcome a stubborn legacy from misguided policies of the past.
This legacy includes an absence of sustainable mechanisms for providing social protection or safety nets that cushion the financial blow of catastrophic illness.
It includes publicly-financed services that have crumbled to a shambles and are largely shunned by the people, no matter how poor.
It includes perverse incentives in the private sector that drive up prices with no guarantee of either quality or safety.
It includes vastly underserved rural areas, a crippling shortage of health care workers, and weak infrastructures, whether for procurement, delivery, laboratory back-up, or the collection and analysis of basic health data.
All too often, this legacy means that access to life-saving or health-promoting interventions is denied for unfair reasons, including an inability to pay.
This is profoundly unfair. Worldwide, the poorest people pay the highest percentage of their income for health care. They have the greatest need for health care and pay the highest price.
Ladies and gentlemen,
As we share experiences and best practices, we can make only a few generalizations about the best route to universal coverage.
We know that reforms of health systems must be context-specific, culturally acceptable, aligned with a community’s self-defined priorities, and fully owned and operated by national health authorities. Beyond these well-known prerequisites for success, there are virtually no other generalizations.
Every situation is unique. Every solution must be tailor-made.
And yet despite the diversity of needs and challenges, I believe that countries moving towards universal coverage share much common ground and many common assumptions.
First, health officials seeking reform know that “business as usual” is simply unsustainable. It cannot be financed. It cannot be afforded.
Budgets are under threat. Public expectations are rising. Health care costs are soaring.
New technologies come with big price tags. And more and more people are being pushed below the poverty line by catastrophic medical bills.
This unsustainable situation is set to become much worse with the rise, now virtually universal, of chronic noncommunicable diseases.
In developing and emerging market nations, the costs of managing these diseases can easily devour the benefits of modernization and economic progress. Something must change.
We cannot allow patients to miss early screening, early detection, and prompt management for lack of access or fear of the costs.
Second, many reformers recognize the need for a phase-wise approach, with objectives gradually rising and priorities gradually expanding.
For example, South Africa’s recent move towards universal coverage is expected to span 15 years.
In Mexico, in 2000, just 3 years before reforms were introduced, catastrophic illness was bankrupting 3 to 4 million people each year.
In its move towards universal coverage, Mexico initially targeted the most vulnerable, that is, unemployed people and those working in the informal economy or as smallholder farmers.
I am pleased to hear that Mexico is achieving its goal, with health care available to everyone in the country.
This gives the world an outstanding example of what can be achieved through high-level political commitment. I extend my sincere congratulations to President Calderon.
Third, we see a very welcome emphasis not only on access to care, but on access to high-quality care.
This time around, no one wants to see second- or third-rate care for the poor.
As is the case elsewhere, South Africa is re-engineering primary health care to make it first-rate professional care, and not the kind of third-rate care that populations rightly shun.
We see an equally welcome emphasis on sustainable solutions. Mexico, for example, is fully aware that reforms must be cemented, bolstered against volatile economic and political situations.
We see full recognition of the need to build capacities, notably information capacity, which is so vital to the monitoring of progress and the introduction of corrective strategies, and regulatory capacity, which is the bedrock of quality assurance and cost control.
South Africa’s plan introduces packages of essential services, clinical protocols, and quality standards, and includes provisions for enforcement of compliance with these standards through regulations and inspections.
Finally, we see a growing recognition that, when the aim is to do more with less money, greater efficiency, aided by innovation, really is the smartest way forward.
Some innovations simply make perfect sense.
Many governments have introduced centralized procurement services to ensure that the right essential products are purchased at the best possible prices.
In Thailand, so-called “sin taxes”, which are surcharges on the sale of tobacco and alcohol, are earmarked for the country’s Health Promotion Fund.
The Thai scheme also includes bonus payments for preventive services, such as cervical screening, where demand is considered inadequate.
Mexico uses an earmarked contribution on cigarette sales to finance expensive interventions that are nonetheless given priority, such as treatment for childhood cancer.
I am certain that this forum will deliver many more experiences and best practices that spur innovative thinking and further feed our shared optimism.
Ladies and gentlemen,
I have a final comment, which expresses my own personal conviction and optimism. It is this: If health authorities want to do the right thing, the fair and efficient thing, the ethical and moral thing, it can be done, even at a time of global economic upheaval.
It can be done, and it will be done.