Universal Health Coverage: A Reprise of Health for All by the Year 2000
WHO inaugurated the concept of Health for All by the Year 2000 at Alma Ata, Russia in 1977. According to the Development Assistance Committee (DAC), during the period 1990-2000, donor contributions were: $23 billion in health; $7 billion in population & family planning; and $30 billion in water supply and sanitation. More money was spent in the interim period of 1977-1990 which would bring total estimated spending to $90 billion. These initiatives were launched by WHO in disregard of a large body of excellent research into the relationship between health, poverty, and growth in developing countries. This research shows that economic development is the main driver in improving health, and that pouring money into public health spending rarely solves the problem.
To show progress on the money spent, WHO expended another $2.5 million to produce a new report in 2001: Macroeconomics and Health: Investing in Health for Economic Development, under the direction of Prof. Jeffrey Sachs. The main text is entirely bereft of any references to Health for All. There is no mention of it even in the Appendix or Glossary. Nothing to inform the global health community of how money was spent.
The basic thrust of the 2001 report was a formulaic expression: pour money in and stir. By expanding coverage for essential health services to the world’s poor through scaling up resources, poverty would be reduced, economic development accelerated, and global security advanced. This “could save at least 8 million lives each year by the end of the decade”.
However, previous research has clearly shown that pouring money into health is not the answer. This research could have provided more balance to new initiatives, allowing a sense of imputed legitimacy to the propositions being advanced.
- In the World Bank’s Development Research Group’s Child Mortality and Public Spending on Health: How Much Does Money Matter, authors found that the major drivers on reductions on infant mortality are economic and educational: public health investments account for 5% of this decline;
- In Bulletin of the World Health Organization, the author wrote: “a 1997 examination of cross-national variation in child and infant mortality found that 95% of the differences could be explained by differences in income, income distribution, women’s education, ethnicity, and religion”;
- Furthermore, “public spending on health was statistically insignificant at conventional levels and total public spending explained less than one-tenth of 1 percent of the observed differences”. (for more details see here, here, and here)
None of these facts have deterred 110 civil society organizations in 40 countries from sending an open letter on November 2 to the World Bank, calling on it to advance Universal Health Coverage. They stated: “underlying all its demands—is that strong and equitable health systems are the key to achieving universal coverage”. The letter’s “first ask is for the Bank to help countries remove out-of-pocket fees”.
Within these two sentences the organizations managed to establish a principle of equity, then subordinate it with a demand that the Bank remove a country’s sovereign right to impose fees on health services. They are challenging the Bank’s new president, Dr. Jim Kim, to change its traditional role as a bank to one of an implementing institution.
The removal of out-of-pocket payments would likely bankrupt many private health care systems in the developing world. In the largest countries by population size, the private sector is the dominant provider of health as a percentage of total national expenditures. It is 70% in Bangladesh; 82% in Cambodia; 65% in China; 83% in the Democratic Republic of the Congo; 60% in Egypt; 77% in India; 67% in Indonesia; 64% in Kenya; 55% in Mexico; and others. In these countries, patients are exercising one of the most fundamental precepts of democracy: choice. Why should the World Bank be complicit in silencing their voices!
The civil society organizations advocating Universal Health Coverage cite the example of Sierra Leon, a failed state, as the exemplar. Here, the World Bank “played a helpful role, alongside other donors, in providing financial support to the country’s successful free care policy for pregnant women and children”!
Like Health for All, Universal Health Coverage requires that donors support the initiative with ever increasing resource flows. However, the donors are in deep debt trying to forestall a journey over the fiscal cliff in their own health care systems. If they were to remove out-of-pocket payments in Medicare and Medicaid, a financial chaos would result affecting 16% of the US economy alone, while roiling through the service sector with untoward macroeconomic consequences.
The failure of Health for All and the 2001 WHO report on economics and health reinforces the notion among skeptics that donors have a major influence on allocating resources to new program initiatives but only a limited ability to stay the course of their actions. Neither initiative has earned a footnote from the 110 civil society organizations that are now advancing the notion of Universal Health Coverage.