Opinion: People’s voices must guide the road toward universal health coverage

Devex
By Flavia Bustreo

Mothers with their babies at a health post in Begoua, a district of the Central African Republic’s capital Bangui. Photo by: Pierre Holtz / UNICEF / CC BY

Imagine for a moment you are a young mother in a village somewhere in South Asia. What does universal health coverage mean to you? Or perhaps you are an adolescent boy in Africa, or a little girl with a physical disability in South America. Does UHC mean the same thing whoever you are and wherever you live? The answer, almost certainly, is no.

While a core set of health needs undoubtedly exists for every person in every place, we all have unique requirements depending on our age, sex, and circumstances. But not all of these needs are recognized equally.

The needs of some groups, such as women, children, adolescents, the poor, and the disabled, have often been under-recognized — and their voices have not been heard. To be fair and effective, UHC must give everyone, in all sections of society, equitable access to appropriate and affordable health services. This should be non-negotiable.

Fortunately, contemporary thinking in global public health already points clearly in this direction.

Targeting inequities

One of the most influential ideas is the concept of “progressive universalism,” as articulated by The Lancet Commission on Investing in Health. This states that, when designing UHC systems, countries should target inequities from the outset. This early hardwiring of equity into the system is vital to ensure that UHC does not further entrench existing inequalities, but instead begins by trying to balance the scales.

This balancing is particularly important in relation to the cost of health care at point of use, where women frequently have to pay more than men for the services they need, among other examples of inequality. Take, for example, a health scheme in India offering cash incentives to women to deliver in health facilities. While a great idea in principle, only women giving birth to their first or second child were eligible, effectively excluding poorer women, who as a group tend to have more children.

On the flip side, when people are engaged and their voices are heard, we see positive change. There is mounting evidence of the effectiveness of community engagement; for example, women’s groups in Bangladesh, India, Malawi, and Nepal have contributed to improved maternal and newborn health outcomes.

Progressive universalism is geared toward helping people who need it most, because it targets health investments where they are needed most. As a result, its impact is most strongly felt among people facing several types of inequality — so-called intersectional discrimination — such as women who are both poor and from a minority group.

Of course, countries have to make hard choices when deciding where and how to invest limited resources to achieve UHC, and they should be guided by the unique health priorities of their populations. But their decisions will be based on sound principles if they set out to listen to and prioritize the needs of their most disadvantaged people.

Global consensus

There is a growing agreement at the highest level around progressive universalism when planning for UHC — and this often means a strong focus on the health needs of women, children, and adolescents.

In a recent speech, WHO Director-General Tedros Adhanom Ghebreyesus described UHC as “the center of gravity of global health” and women’s, children’s, and adolescents’ health as “the center of gravity of universal health coverage.”

His thoughts reflect the conclusions of numerous other global leaders. For example, The Elders have stated unequivocally that “women, children, and adolescents must be covered [by UHC] as a priority.” Former WHO Director-Generals Margaret Chan and Gro Harlem Brundtland have described the scaling up of primary health care services to meet the needs of groups such as the poor, women, girls, and adolescents as “a vital first step” toward UHC.

Eminent advocates such as these strongly reinforce the view of Dr. Tedros that “all roads lead to universal health coverage.” Some countries’ roads will be more direct than others, depending on circumstances and available resources.

But one thing is clear: the voices of their people — including women, children, and adolescents — are sure to point out the best route to achieving health for all.