Pursuing health-for-all is one of humanity’s most stubborn aspirations. Perhaps because it is rooted in the values of all world faiths. From this derives health care’s core ethics: beneficence (do good), non-maleficence (do no harm), autonomy (give patients freedom to choose), and justice (be fair).
Codified as far back as 500-300 BC in the Hippocratic Oath, it is extraordinary that these notions persist unchanged in all healthcare systems worldwide.
Good health is universally recognised as an intrinsic good as well as the essential precursor for all well-being. Thus, the nobility of health is referred to in the 1948 Universal Declaration of Human Rights, recognised as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights, and enshrined as Goal 3 of the 2030 Agenda for Sustainable Development.
The World Health Organisation was created in 1946 with marching orders to achieve the “highest attainable standard of physical and mental health”. More than seven decades later, how are we doing with advancing universal health coverage (UHC)?
UHC means people everywhere being able to access quality health care when needed, without enduring personal financial hardship.
That includes cradle-to-grave disease prevention and health promotion, illness and injury treatment, as well as rehabilitative and palliative care. Progress is measured by a UHC coverage index on a 100-point scale that advanced from 45 in 2000 to reach 68 in 2019. That is where it is stuck now, suggesting that our growing world – now 8.1 billion – is going backwards.
It means that 4.5 billion people are not fully covered by essential health services. Two billion face financial hardship, including a billion experiencing catastrophic out-of-pocket health spending – that is, they are desperate enough to spend more than 10 per cent of their household budgets on buying health care. That has tipped about 350 million deeper into extreme poverty.
The health targets of the SDGs are unlikely to be achieved.
Why is global health progress faltering? Service disruptions from the Covid-19 pandemic are easy to blame in the short term, but UHC was stalling before that.
At the base is demography. Average global life expectancy has climbed to 73.4 years today from a mere 56 years in 1960. As we rejoiced at adding years to life by conquering the communicable diseases that carried off our predecessors, we are struggling now to add life to years.
Seven of the top 10 causes underlying 67 million annual deaths are non-communicable diseases (NCDs) such as cardiovascular, lung and kidney conditions as well as diabetes, cancers and dementia. Globalised lifestyle factors such as unhealthy diets that cause obesity and hypertension, polluted environments and smoking underlie premature mortality. Managing NCDs is a costly, lifelong business of testing, treating and monitoring millions of at-risk people.
Meanwhile, low-income countries suffer the double whammy of the continuing conditions of poverty such as diarrhoea, malnutrition and maternal and child ailments, on top of rising NCDs.
As hospitals struggle with expanding disease burdens, they are also in the crossfire of 100-odd armed conflicts raging or smouldering around the world. These may last for decades, as in Syria, followed by chronic fragility as in Afghanistan.
The WHO surveillance system has registered nearly 1,200 attacks on health care this year, killing and injuring more than 2,000 staff and patients. Images of hospitals under attack in Gaza have filled our TV screens and earlier we saw similar incidents in Yemen and elsewhere. Meanwhile, vaccinators have been assaulted in Pakistan, Congo and Nigeria.
UHC is not possible without peace, but valiant efforts with health as a bridge to conflict resolution have met limited success.
The UHC goal is also receding because of accelerating climate change impacts with at least 250,000 additional deaths predicted annually, between 2030 and 2050, by the WHO. Our overheated world is bad news for frail human bodies due to heat stress, and through environmental shifts causing the resurgence of old pathogens and rise of new bugs.
That suggests more pandemics ahead such as Ebola and Covid-19. Further, the direct climate damage to health is estimated at $2 billion to $4 billion every year.
That will stretch health budgets even further. Progressing UHC requires steady public health expenditure of 7 per cent of gross domestic product or higher. But although global average health spending touches 11 per cent and some advanced economies exceed 15 per cent, lower-income countries barely reach 5 per cent of even smaller GDPs.
Meanwhile, advances with diagnostics, medicines and vaccines are improving disease management and raising public expectations. But they are costly, especially in their initial monopoly production phase, setting up dilemmas on what already-stretched UHC budgets should cover.
The UHC dream is further impeded by labour shortages. There are about 65 million health workers worldwide, rising to 84 million by 2030. That will still leave a shortfall of 10 million. Available skills are unfairly distributed with medical migration a serious problem as expensively trained doctors, nurses and therapists from poor countries seek better opportunities elsewhere.
Consequently, there is a six-fold difference in health worker density between high- and low-income countries.
However, the health systems of rich countries are also creaking.
Twenty-seven million Americans are uninsured even as the nation spends 18 per cent of GDP on health care. About 7.7 million people are currently waiting – for an average of 14 weeks – to get attention from the UK’s once-envied National Health Service. And the French health system – ranked top in 2000 – struggles with crisis after crisis.
Inefficiency is partly to blame, but more troubling is the decades-old model that cannot keep up with a changed world.
In this bleak context, should we abandon the pledge to leave no one behind in bringing health-for-all? No, but a shift is needed – not in technical terms but in a paradigm shift that re-visualises UHC delivery.
First, as institutionalised health care is expensive, greater self-care becomes essential. Citizens should be educated to look after self-limiting ailments and empowered with extended first-aid techniques, as well as self-screening for dangerous conditions such as certain cancers.
They can be guided digitally by experts situated remotely as was pioneered during Covid-19 times. This could also save more lives in conflicts and disasters when trained professionals are not handy.
Second, we need more task-shifting so that the more expensive specialists do not spend time doing what lesser skilled workers can do. That can be allied with fast-evolving AI that also brings greater precision in diagnosis and treatment with associated waste reduction and greater efficiency.
Third, health financing models must innovate to incentivise good health behaviours and penalise bad habits, going beyond current sugar, fat, tobacco and alcohol taxes. But this should not stigmatise or inflict more burdens on the poor who find that living healthily is more difficult due to circumstances they cannot control.
Fourth, we still need effective national health ministries and evidence-based policies. But do we need the straitjacket of centralised control of hierarchically arranged hospitals?
They range from poorly resourced primary health centres at the base and shiny state-of-the-art hospitals at the top. Referrals up the chain are slow, bureaucratic, open to corrupt influences and dysfunctional, as desperate people flood to wherever they think they will get better care.
Allowing people to go where they want, and rewarding popular facilities with more funding would stimulate productive competition, improve quality of care, and bring greater patient satisfaction.
The difficulties of achieving UHC are, therefore, a wake-up call for doing better – not by doing more of the same but doing differently. It requires a new conceptualisation of healthcare provision, not as a top-down gift from authorities and institutions but a choice and responsibility to be grasped personally, to achieve the best health status we deserve.
