Will UHC be PHC Redux or Have Lessons Been Learned?

In their August 2013 Viewpoint article in The Lancet, O’Connell et al[1] made the compelling comparison between the current chorus of calls for universal health coverage (UHC) and those that lead to the Alma Ata Declaration calls for “Health for All” through primary health care (PHC) in the late 1970s. While PHC became a focal point for high-level advocates and declarations of support at the time, it failed to achieve widespread implementation and eventually became an example of failed public health advocacy.

O’Connell warn that the lack of a clear definition and of widespread policy and budget changes doomed the PHC clarion call from achieving its goals, features also apparent in the discussion around UHC. Two other components highlighted in the Lancet series on UHC in September 2012 appear to be crucial risks to UHC’s ability to avoid the same fate as PHC: 1) political mobilization of demand for UHC and access to basic health services, and 2) governance capacity at the national level. Both of these are currently dramatically under-present in many of the countries whose populations could benefit most from UHC, and as such may well be components that determine the success or failure of UHC.

Savedoff et al[2] argue that domestic political pressure is one of the common patterns apparent across all countries that have effectively implemented UHC. Without adequate demand for UHC, not only will the likelihood of domestic policy changes suffer, but so will the key link between coverage and expansion and health improvements—utilization.  Savedoff et al also show that “the only countries in the world to achieve [UHC] have done so through strategies based on a prominent and active public role.”2This requirement for active public implementation has a corresponding necessity of good governance. As argued by Moreno-Serra and Smith, the effectiveness of additional pooled spending often depends on the quality of governance and institutions.”[3]

 If these two components—public mobilization and governance/institutional strength—receive adequate attention and support in the high-level conversations around UHC, it may enable UHC to avoid the fate of PHC in the 1980s, making “UHC a practical guide for policies instead of an aspirational slogan.”1 Global health advocates should take the lessons of PHC, into account in discussions of UHC to avoid squandering this opportunity for systemic improvements in health equity.

[1] T O’Connell, K Rasanathan & M Chopra. (2013) What does universal health coverage mean? The Lancet. Online publication August 15, 2013: http://dx.doi.org/10.1016/S0140-673(13) 60955-1.

[2] W Savedoff, D de Ferranti, AL Smith & V Fan. (2012) Political and economic aspects of the transition to universal health coverage. The Lancet (380): 924-32.

[3] R Moreno-Serra & PC Smith. (2012) Does progress towards universal health coverage improve population health? The Lancet (380): 917-23.


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