Policy and Politics Journal

Is universal health coverage possible without strong public presence in its provision?

Volkan Yilmaz, Assistant Professor of Social Policy at Boğaziçi University, Turkey

As part of the Sustainable Development Goals, a United Nations (UN) initiative covering a broad range of development issues, all members of the UN set an ambitious and greatly welcomed target to be achieved in healthcare policy by 2030: achieving universal health coverage. The World Health Organisation (WHO) defines universal health coverage as a set of policies ensuring everyone in need of healthcare services and medications receive a quality service yet without facing financial hardship. This notion of universal health coverage leaves no room for denying services and medications to people in need.

However, as is often the case, the devil is in the detail. As far as indicators for monitoring progress towards universal health coverage are concerned, it turns out that this is a broken promise. Two indicators are in use: the share of population that can access ‘essential’ healthcare services and the share of population that spends a large amount of its income on healthcare. The second indicator is estimated on the basis of households having to spend a disproportionate amount of their total income on health, measured as 25 per cent or more of their total household expenditure.

The first indicator in particular seriously limits the scope of universal health coverage by leaving out healthcare services that are not defined as essential. For example, while cervical cancer screening is listed among essential services, cervical cancer treatment is not. The second indicator may help by putting an upper limit on the proportion of total household expenditure to be spent on non-essential health services, but it may still fail to capture how many people don’t seek medical help for these services.

Dr Margaret Chan, Director General of World Health Organization, clearly suggests that free markets do not work in health care. Chan’s emphasis is on the financing component. Specifically, if public funding of healthcare is weak, achieving universal health coverage is generally not possible. Therefore, she identifies increasing public expenditure on healthcare as the only way towards universal health coverage, which will result in less reliance on out-of-pocket payments.

But healthcare systems have two major components that are of importance in achieving universal health coverage: financing and provision. To achieve universal health coverage, while public funding of healthcare is key, exclusive focus on the financing component in ensuring universal health coverage might be misleading. I believe the significant role that the public sector can play in healthcare provision – and has already been playing in some countries – has been long overlooked. Failing to pay enough attention to the role of the public sector in healthcare provision can pose two obstacles in monitoring progress towards universal health coverage.

First, this focus may blind us to how the dominant role of private sector or privatisation trends in healthcare provision restrict access to healthcare services that are deemed non-essential. On the one hand, exclusive focus on essential health services may be interpreted as rationing, which is indeed necessary for all public policies due to budget constraints. On the other hand, the restrictive definition of essential health services may go beyond rationing especially for middle income and upper middle income countries with historically strong public provision systems. This restriction of the scope of universal health coverage to essential services may take the form of people’s aversion to seek medical help due to financial hardship and/or increasing expenditures on health as a proportion of total household incomes. In this regard, the proposed strategy of WHO to achieve universal health coverage may be implicitly granting approval to the privatisation of non-essential health services in countries with strong public actors in provision.

Second, this disregard for the ownership of providers in healthcare leaves out the possible impact of private sector dominance on provision in healthcare financing. Not all market designs foster competition and lead to lower prices for services. Not all countries have strong public regulatory capacity to protect patients from possible abusive practices of private providers. Finally, not all political actors in power are willing and strong enough to block private providers’ demand for higher out-of-pocket payments and/or switch to private health insurance based financing models. Concerning these, WHO’s strategy falls short of addressing these concerns which may well affect the prospect or viability of universal health coverage in different countries.

My forthcoming book entitled The Politics of Healthcare in Turkey demonstrates that despite significant achievements towards universal health coverage in Turkey in the last decade, a country that Dr Chan also lists among best performers, striking the right balance between public sector and private sector in healthcare provision remains a challenge for Turkey. Passive privatisation in healthcare provision and the political dynamics it has generated, cast doubt on viability of universal health coverage.

Setting a target for all countries is not easy, especially given the vast differences among them and the presence of strong global interest groups against reforms towards universal health coverage. But these challenges should not lead us to settle for a narrowly defined version of universal health coverage as a global policy direction for all countries. I suggest therefore that the lack of focus on the provision component of healthcare systems in the global health policy debate must be re-thought, especially if we want to reclaim the proper meaning of universal health coverage.

If you enjoyed this blog post, you may also like to read When collaborative governance scales up: lessons from global public health about compound collaboration by Chris Ansell.