Audrey R. Chapman
The draft Sustainable Development Goals (SDGs), which are likely to be adopted at the September 2015 UN summit, identify achieving universal health coverage (UHC) as one component of the omnibus health goal, “to ensure healthy lives and promote well-being for all at all ages.”1 UHC was not mentioned in the Millennium Development Goals (MDGs), but it has subsequently gained support in international health policy circles. The components of UHC specified in goal 3.8 of the SDGs reflect World Health Organization’s policy documents and include financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all.2
On the positive side, UHC can be considered to be an expression of the right to health. Indeed, several health and human rights advocates had earlier proposed replacing the various health-related goals in the MDGs with the single overarching health goal of UHC in the SDGs, provided that it specify that international assistance is essential, not optional, for countries otherwise unable to pursue UHC.3 Significant progress toward UHC, consistent with the requirements of the right to health, would have the potential of enabling the one billion people currently estimated to not have access to the health services they need each year to obtain them.
But there are many reasons to be very cautious as to whether the identification of UHC as one component of Goal 3 will in fact contribute to the right to health. In place of the eight MDGs, the SDGs list 17 goals, each of which has many components. Goal 3, for example, has 13 subcomponents , including several which previously were separate MDG goals. None is prioritized. It is likely that both funders and the governments responsible for implementation will be overwhelmed by this list, and many goals and subcomponents risk being neglected or forgotten. Moreover, although the preamble to the Agenda affirms the importance of the Universal Declaration of Human Rights and other instruments relating to human rights, the document does not frame any of the goals as human rights. Nor is the international obligation of affluent countries to provide the necessary financing for poor and lower-middle income countries otherwise unable to pursue the goals specified.
Furthermore, the identification of UHC as a subcomponent of Goal 3 does not necessarily mean there will be meaningful progress toward this goal, even when there are nominal policy commitments in a country to do so. Moving toward UHC entails a long-term process of progressive realization that requires advancing on several fronts: increasing the proportion of the population that enjoys health protection and access to health services, particularly the population groups that hitherto have lacked access; improving the available range of health services provided to address people’s health needs effectively; and increasing the proportion of the costs covered through government funding. After four decades of neoliberal policies that have commercialized and privatized health services, many countries will require a fundamental reform of their health system and changes in government policies in order to pursue UHC.
Moreover, there is the possibility that efforts to move toward UHC may not result in the establishment of an equitable health system. As health policy analysts Gwatkin and Ergo warn, “beware-universal coverage is much more difficult to achieve than to advocate. And people who are poor could well gain little until the final stages of the transition from advocacy to achievement, if that coverage were to display a trickle-down pattern of spread marked by increases first in better-off groups and only later in poorer ones.”4 This has been the pattern in the MDGs: many countries have improved their statistics by focusing on coverage in better developed areas without much progress in poorer and less developed communities. In such a situation, especially if the expansion were to stall, as has happened in a number of countries, the health status of vulnerable communities could even grow worse, absolutely or relatively.
Importantly, not all potential paths to a universal health system are consistent with human rights requirements, even ones that result in some expansion of health coverage. For that reason it is important that health and human rights advocates and scholars identify the essential features of UHC and policies for advancing toward this goal from a human rights perspective. There will be a special section of the December 2016 issue of the Health and Human Rights Journal which will address this issue. Papers for this section are to be submitted by 28 February 2016 – for further details see here.
Audrey R. Chapman is Healey Professor of Medical Ethics, UConn Health. Please address correspondence to firstname.lastname@example.org
1 Transforming Our World: The 2030 Agenda for Sustainable Development. Available at https://sustainabledevelopment.un.org/sdgsproposal.
3 G. Ooms, L.A. Latif, A. Waris, C.E. Brolan, et al., “Is universal health coverage the practical expression of the right to health care?” BMC International Health and Human Rights, 14:3 (2014). Available at http://www.www.biomecentral.com/1472-698X/14/3.
4 D. Gwatkin and A. Ergo, ”Universal health coverage: friend or foe of health equity,” The Lancet 377:2160 (2010).
Recent publications by Audrey Chapman in Health and Human Rights Journal: