From the Rohingya exodus to Bangladesh to the deaths of children due to acute encephalitis syndrome (AES) and the current health situation in Kashmir. From the relentless conflict, cholera and food crisis in Yemen and the war, forced migration and hunger in Africa to the economic crisis in Venezuela – all these and many other contexts in the world today reflect the centrality of health. These examples draw attention to the health situation as a consequence of the inequitable distribution of social, economic and political power, the contours of which are increasingly shaped by neoliberal policies.
Most of the world today is in a constant struggle to gain access to the determinants of health, including gender and social justice, food security and sovereignty, safe drinking water and sanitation, housing, education, reduction of poverty, gainful employment and equitable and inclusive development, better working and living conditions, and an end to various forms of violence, conflict, war, militarisation and discrimination, etc.
Moreover, healthcare continues to be accessible only at extremely high economic costs and social hardship to a vast number of people, a majority of whom live in lower- and middle-income countries, and comprise primarily of girls, women, children and others marginalised due to race, caste, ethnicity, disability, sexuality, etc. Access to the determinants of health and quality and accountable healthcare is thus a global emergency.
Coverage sans care
Many of these concerns were acknowledged and sought to be addressed by the Alma Ata Declaration on Health for All more than 40 years ago. However, there has been an evident shift in the health discourse from universal care to universal coverage over the past decade or more. Universal healthcare is built on the concept of health as a human right; the right to health and healthcare as universal, inalienable, indivisible and interdependent. The focus on “coverage” and not “care” is a serious concern.
As Dr Amit Sengupta, well-known activist and a coordinator of the People’s Health Movement (PHM) argued:
“UHC is essentially designed to universalise ‘coverage’ rather than ‘care’ which is built on, and lends itself to, standard neoliberal policies, steering policymakers away from universal health options based on public systems,” and “in glossing over the importance of public provisioning of services, many proponents of UHC are actually interested in the creation of health markets that can be exploited by capital.”
UHC, especially in a number of lower- and middle-income countries is often translated into state-funded health insurance schemes, which has furthered the privatisation of the public health services. The coverage model does not envisage provisioning of comprehensive healthcare nor its quality; its focus is on a pre-defined package of services that excludes a bulk required to address the health needs of the people.
Also read: Who Is Paying for India’s Healthcare?
Further, evidence of these insurance schemes indicates that they have neither provided protection from high out-of-pocket healthcare expenses, nor have they facilitated equitable access to quality healthcare. On the contrary, evidence reiterates that strengthened public-sector financing and provisioning, and ‘care’ not ‘coverage’ along with access to the determinants of health, are necessary to transform people’s health and lives.
UN meeting on universal health coverage
The UN High-Level Meeting (UN HLM) on Universal Health Coverage, which is to take place on September 23 during the United Nations General Assembly (UNGA) high-level week in New York, is the culmination of this shift. The UN HLM is being seen as the ”last chance” before 2023, the mid-point of the Sustainable Development Goals (SDGs), to mobilise political endorsement of the universal health “coverage” discourse to further the global health agenda.
While such political mobilisation on health is deemed necessary, the assumption that health coverage is sufficient to build a healthier world is terribly misplaced. In this context of SDGs, it is extremely probable that the health sector’s role will be limited to the SDG 3.8, i.e. achieve universal health coverage (UHC), and will exclude its role in other SDGs that are relevant to health – such as SDGs two on ending hunger, four on mitigation of climate change, five on achieving gender equality, 6 on access to water and sanitation, ten on the reduction of inequality and 12 on the promotion of environmentally responsible consumption/production patterns on the reduction of inequality.
The Political Declaration on UHC, which has been negotiated over the past months, is going to be accepted at the HLM on September 23. Several civil society organisations (CSOs) and networks have attempted throughout this process to flag concerns and recommend alternative content and language to strengthen the Declaration.
The Declaration has now assumed a final form, which unfortunately is a far cry from efforts necessary to “build a healthier world” that was articulated by the HLM theme.
The Declaration does not place the much-needed emphasis on inequities in access to healthcare and withdraws from addressing the causes of inequitable access to the determinants of health. It distances itself from the recognition of health including healthcare as a human right and does not sufficiently reinforce even existing agreed language and content recognised by existing human rights covenants.
The Declaration’s repeated framing of access to health services as “nationally determined sets” is concerning as it increases the probability of a limited range of health services provided by governments. This is contrary to the concept of universality – which implies universality of healthcare, i.e. all health services being made available, accessible and acceptable to all people, with steps undertaken to ensure that those in marginalised and vulnerable positions are not excluded.
The danger of such framing lies in permitting limited services made available as are “nationally determined”, while the rest would have to be procured by the people from the private sector. Moreover, in terms of universality, there is a high likelihood of the limited “nationally determined” services excluding healthcare for sexual and reproductive health needs for some of the most marginalised.
The neglect of gender, sexuality, caste, race, ethnicity, ability, etc., in the Declaration which have an overwhelming impact on access to the social determinants of health as well as healthcare, is apparent and disappointing.
The Declaration’s recommendation of investment of an abysmal 1% (or more) of the GDP by countries additionally is grossly inadequate and undermines long-drawn struggles for a substantial increase in public expenditures on health based on the needs of respective countries.
Even when the UHC Declaration has referred to climate change, for example, it has been merely in the context of mitigating some of their consequences on health. However, there is no intent to address the “causes of the causes” or the social, economic and political dimensions that are the root causes of the deteriorating environment and of climate change.
Further, the declaration remains conspicuously silent on one of the most striking phenomena of the current times: migration. One would have hoped such a declaration would address the structural causes of migration, which includes exclusion of people either by an inequitable economic model or conflicts around plundering of resources, and the effects of migration policies on health.
Reclaiming universal healthcare
The social logic of public health services needs to be reclaimed if a real difference in health outcomes are desired. Moving toward ‘health for all’ or ‘building a healthier world’ require transformations not only in the area of healthcare but also in a wide range of determinants of health. This is an impossible task unless the role of transnational influences and forces, including that of the private sector, multi and bilateral trade agreements that impact health outcomes – especially of the most marginalised – are challenged.
The reality of a healthier world is extremely distant until peace, equality, justice, democracy, human rights are restored and protected and unless countries agree to public health systems that are accountable to all people and communities they serve.
Until then, the struggle must continue.
Sarojini Nadimpally and Deepa V. work on public health and are a part of Sama Resource Group for Women and Health and Jan Swasthya Abhiyan.