Is Universal Health Care an Attainable Goal?

The latest UN development initiative calls for achieving universal health coverage by 2030, a goal widely supported in the global health community but one that is possibly too ambitious, writes CFR’s Laurie Garrett.

September 11, 2015

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The United Nations will soon exchange one set of eight aspirational goals for the world for a far more sweeping list that includes slowing climate change, providing universal health care coverage, and ending severe poverty in all nations.

The end of this year marks the deadine for  the Millennium Development Goals (MDGs), which will show a mixed record of success. The new Sustainable Development Goals (SDGs) focus on seventeen themes to be embraced by all world governments, along with a gamut of UN agencies and their closely allied multilateral institutions and bilateral donors, including the United States’ global health and development agencies. 

A child receives a polio vaccination during an anti-polio campaign on the outskirts of Jalalabad, March 16, 2015. (Photo: Parwiz Parwiz/Reuters)

At first blush, the SDG picture appears irrational. In addition to the seventeen goals, the SDGs involve 169 targets and 1,063 indicators that serve as metrics for measuring achievements. The United Nations broadly imagines that the SDGs will “end poverty in all its forms everywhere.” When combined, the seventeen SDGs aspire to a world in 2030 in which no human being lives on less than $1.25 per day and everyone has access to primary education, safe drinking water, affordable basic health care, ample food, education, and job opportunities devoid of discrimination based on gender or race.

A report prepared last year for the UN General Assembly projects that full implementation of the SDGs will be astoundingly expensive, totaling between $90 trillion and $120 trillion. In contrast, MDG spending by 2015 was roughly $400 billion, about half of which came from the U.S. government and the Bill and Melinda Gates Foundation. Most of the MDG spending occurred after 2005. Locally, countries committed from their own resources about $110 billion over the same period.

‘Well-Being for All at All Ages’

Scrutinizing the chief global health aim for 2030 offers insights into the scale of efforts that will be involved in just one of the SDGs. Under SDG 3, nine targets are listed to reach the stated goal to “ensure healthy lives and promote well-being for all at all ages.” One of these  targets is essential to fulfillment of all of the others: “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.”

The seemingly overambitious pursuit of universal health coverage has wide support in the global health community. There is particularly strong support among those who focus on chronic diseases (cancer, diabetes, stroke, mental illness), traffic accidents and injuries, and maternal mortality, all of which are states of ill health that require access to emergency treatment and around-the-clock routine care. A key criticism of the health-oriented MDGs is that they have fostered a silo approach to the funding, human resources development, and structure of health delivery that is disease-focused on malaria, HIV/AIDS, tuberculosis, infant mortality, and pediatric care.

In poorer countries, resources have been allocated accordingly: Patients are too often viewed via disease-specific clinics, rather than in holistic medical facilities. In wealthy countries, people visit a clinic without necessarily knowing the cause of their ill health, and may receive attention for multiple problems in a single facility. But in poor countries, individuals must self-diagnose and travel, often by foot or at great expense, to one place for their TB care, another for prenatal check-ups, and still elsewhere to mend a broken leg.

UHC does not guarantee state-of-the-art medical care to every human being, but it does aspire to remove the bankrupting impact that illness and injury can have on those who are uninsured or inadequately insured, thus aiding in the overarching SDG aim of eliminating extreme poverty. A review of national health policies indicates a range of different approaches that could be employed to reach universal care. Under the Affordable Care Act, for instance, the United States has sought to reduce the individual financial burden of illness through a mix of reforms in both public and private financing of health insurance. A recent Harvard/Gallup survey found some sixteen million Americans had, by spring of 2015, gained coverage under the ACA. Within the first year of activation of the ACA, the number of Americans saying they couldn’t pay their medical bills fell from seventy-five million in 2012 to sixty-four million in 2014, and the overall percentage of medically covered Americans rose from 79 percent in January 2012 to 85 percent by January 2015. By mid-2015 just 13.2 percent of Americans still lacked coverage. Achieving coverage for every single American by 2030 would mean that the United States reached the SDG target for UHC.

The UN does not say what form UHC should take–whether it is like the Canadian single-payer system, the U.S. mixed-payment approach, or systems of Rwanda-style vouchers for women and children. Such issues are country and culturally specific. But UHC does insist that everyone have some form of health coverage.

Too Few Health Care Workers

Health coverage leads to increased demand for medical services, which will pose the greatest obstacle to UHC. The World Bank estimates that roughly twelve percent of the global labor force is already employed in the health enterprise in some capacity, yet demand for the most skilled tier of doctors, nurses, dentists, pharmacists, midwives, and technicians far eclipses that of supply. At a minimum, the World Health Organization says, there must be 3.4 skilled health workers for every 1,000 people, a level so far above current global numbers that reaching it will require a rate of training that increases personnel eleven percent annually until 2030. No one has offered a scheme for such an extraordinary scale of annual matriculation, though the World Bank is trying to develop more modest approaches toward training lower-tiered health workers for provision of very basic primary care.

Current annual global spending on health is about $6 trillion, with nearly half of that sum spent in the United States. If health coverage and utilization were to expand worldwide at the desired UHC scale, spending in 2030 would reach at least $15 trillion per year, and could go as high as $25 trillion if sophisticated tertiary care were to be broadly provided.

If health coverage and utilization were to expand worldwide at the desired UHC scale, spending in 2030 would reach at least $15 trillion.

Proportionally, the burden of spending would greatly differ from one country to the next. For example, before the civil wars in the 1990s, Liberia spent about $110 per capita on health, when GDP per capita was merely $140 (or about 79 percent of GDP). Across the OECD, health spending in 2014 averaged just 6 percent of GDP; India is currently devoting only 1.3 percent of its GDP to health. These differences reflect political priorities and population expectations.

Political disputes about UHC are simmering. One economist has labelled pursuit of universal health coverage “irresponsible,” claiming it will undermine government and private-sector spending. Conversely, physicians have described UHC as a “moral imperative,” worrying only that emphasis on provision of medical care might come at the expense of general public health services such as provision of clean water and outbreak surveillance. Regardless of the expert perspectives, public demand is rising worldwide.

The fastest growing health spending and popular citizenry demand for health is in the APEC nations, where Asian economic growth is fueling both dramatic improvements in life expectancy and health care utilization. Many Asian nations already have some form of UHC, and now seek to expand the range of services covered by insurance and the quality of care. Since its post-WWII recovery period, Japan has considered health as a matter of personal and national security, and has steadily expanded not only its nation’s medical services and access, but also declared global UHC a pillar of its foreign policy under the Shinzo Abe administration.

Health Care as Human Right

Across the Americas, the UHC as “moral imperative” point of view is shared, linked to essential human rights. The extent of government (versus private or individual) expenditure on health in the region ranges from a public-sector low of 35 percent in Guatemala to a high of 95 percent in Cuba. Across the entire region, premature mortality rates have plummeted since 1990, life expectancies have risen, and utilization of health services show a steady upward trend. Politically, all of the democracies in the American hemisphere have demonstrated that voters expect the improvements (and expenditures) to continue rising well into the twenty-first century.

Demand for the most skilled tier of doctors, nurses, dentists, pharmacists, midwives, and technicians far eclipses that of supply.

In 2013, the British medical journal the Lancet assembled an elite commission of experts, led by economist and former U.S. Treasury Secretary Lawrence Summers, to parse both the costs of vastly increasing global access to health care, and the benefits, or financial returns that might be garnered. The commission concluded that “reductions in mortality account for about 11% of recent economic growth in low-income and middle-income countries” over the last twenty years, and recommended $530 billion in spending on global health by 2035, with about $6 billion per year coming from donors and the rest generated by countries and from innovative financing schemes.

With sufficient investment in UHC and health systems, including personnel training, the commission said a “grand convergence” would be reached by 2035, closing the now enormous mortality gap between the rich and poor populations of the world. Most of this convergence would be achieved by targeting the low-hanging fruit of public health: vaccination, child nutrition, prenatal screening, access to safe drinking water, treatment of pediatric infectious diseases, and prevention of cardiovascular ailments. After substantial investment, the commission said, global health would reach a stable, sustainable level, with annual health expenditures arriving at an average three-percent-of-GDP increase over current spending. For some countries, spending might increase by eight or nine percent of GDP, while others would achieve convergence with far smaller margins of spending.

As the world’s leaders gather for the September 2015 UN General Assembly session, the SDGs, including those devoted to health, will receive formal ratification. And then the hard part will commence: finding human and financial resources for implementation, solidifying political commitment to SDG strategies, and building popular demand inside of every nation for the changes necessary to realize the seventeen goals. 

This publication was made possible with the generous support of the Rockefeller Foundation.

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