Universal health coverage – but mind the equity gaps

4 June 2014
“The essence of a satisfactory health service,” wrote Aneurin Bevan, the founder of Britain’s National Health Service, “is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”

That vision underpins the idea of universal health coverage (UHC) – a theme that is back with a vengeance on the international development agenda.

Governments are issuing stirring declarations of intent to provide health coverage for all citizens. Aid donors are promising to back their efforts. UHC has even made it on to the short list for adoption as a post-2015 goal.

All of which should be good news for the world’s poor. Ultimately, UHC is about ensuring that all citizens have access to accessible, affordable, quality health provision, regardless of their wealth, gender or other circumstances. We are a long way from that destination. Each year, around 100 million people are driven into poverty by health costs. Some 46 million women give birth without skilled attendance and 26 million children are left unvaccinated against killer diseases. And health inequality remains a life-and-death issue: being born into a poor household in sub-Saharan Africa typically raises the risk of child mortality by a factor of three.

Finance is at the heart of the problem. Governments in low income countries spend too little of their limited resources on health. The upshot is limited and poor quality services that people have to pay for when they fall ill. Around two-thirds of health spending takes the form of out-of-pocket payments – and no money means no treatment.

So progress towards UHC must be a prescription for better health and reduced inequality, right?

Well, yes and no. In health provision as in wealth creation the benefits of national progress often trickle down to the poor very slowly. Unfortunately, progress towards UHC is often governed by the rule of ‘inverse equity’, with those most in need benefiting last and least.

An excellent new paper by Adam Wagstaffe and colleagues at the World Bank demonstrates the point. The authors use survey data to examine national progress towards health-related Millennium Development Goal targets across 64 countries. They then disaggregate performance between the richest 60 per cent and the poorest 40 per cent – an application to health of the World Bank’s ‘shared prosperity’ goal.

The results are instructive. Most countries are making overall progress and relative inequality is falling – on average the poorest 40 per cent are registering faster rates of progress. However, the average obscures as much as it reveals. In almost half of the countries covered inequalities in child survival and malnutrition are growing. Inequality in immunisation was also increasing in around 25 countries. The report builds on a growing body of research evidence on the persistence of health disparities.

Allowing the poor to fall behind in the midst of progress towards UHC is not compatible with basic principles of fairness, equity and social justice. That is why UHC reforms should be guided by the principle of progressive universalism – a commitment to ensure that the poor benefit as least as much as the non-poor from increased coverage.

How should this principle be applied to the post-2015 framework? A thoughtful recent World Bank/WHO paper addresses this question. It argues that policy makers should monitor progress among the poorest 40 per cent – an approach implicitly endorsed in the new World Bank paper.

This is where I part company. Why the ‘bottom 40’? One potential pitfall of this metric is that it potentially diverts attention from the most marginalised. My own preference would be to set explicit equity targets for closing gaps in outcomes and coverage. These could include halving gaps in infant mortality between the richest and poorest 20 per cent, between urban and rural areas, and between ethnic groups

Of course, no amount of quibbling over targets will deliver UHC. One of my frustrations with much of the current debate is the triumph of technical detail over politics. Ultimately, progressive universalism required a mix of public finance, compulsory pooled insurance and equitable public spending. What are the political coalitions and alliances needed to drive change?

There are no blueprints – but experience points to some useful guidelines. Countries such as Thailand, Brazil and Mexico have introduced highly progressive universal health insurance coverage. They did so initially by focussing resources on the poor before expanding the insurance pool to cover the middle class. The reforms survived sometimes turbulent political transitions, in part because they delivered benefits to a broad constituency; and in part because reformers were able to generate a political consensus.

Research at ODI is throwing some useful light on approaches to progressive universalism. One recent report on Mozambique charts the country’s record in halving infant mortality since the mid-1990s


The deepest cuts have been registered among the poorest people (see Figure) – and the rural-urban disparity in child survival has fallen dramatically. Supported by aid donors, political leaders in the country have prioritised health financing, focussed resources on rural areas, and invested in skilled health workers. Another report on Nepal looks at the role of health ministry officials and community-based organisations in driving reforms that have reduced maternal mortality, despite civil war and slow economic growth.

Other ODI research provides insights on how not to pursue progressive universalism. India has invested heavily in health insurance programmes ostensible aimed at the poor. But as a (must read) report by our social protection team documents, these programmes have done little to reduce out-of-pocket payments or reduce health disparities. Poor design and chronic under-financing of primary health care help to explain why.

One parting thought. Aneurin Bevan saw health disparities as a source and symptom of deeper social inequalities. His NHS remains a model for progressive universalism. Yet Britain has some of Europe’s deepest health disparities, as captured in this slide from the King’s Fund. So how about some post-2015 health equity targets for the UK?