As discussions of the post-2015 development agenda continue, leading economists have expressed concern about the deep structural crisis of rising social inequality and the dangers of seeing more and more of the world’s wealth and opportunities concentrated in a shrinking number of privileged hands. I agree. I also regard universal health coverage as one of the most powerful social equalizers among all policy options. Countries such as Japan, which introduced universal health coverage in 1961 under a struggling economy, did so in a deliberate effort to promote social cohesion and boost growth of the middle classes as the backbone of a democratic society.
In just the past three years, the World Health Organization (WHO) has been approached by more than 80 countries seeking technical support in moving their health systems towards universal coverage. This trend gives me cause for great optimism: governments value a fair society where everyone has access to essential health care, no one is left behind, and no one pays for health with financial ruin.
Universal health coverage is not a cheap policy option, but, when well-managed, is affordable. Political commitment – not wealth – is the critical determinant. Any country that really wants to can raise more money for health. I have visited numerous resource-poor, landlocked countries with good quality, inclusive health care and the health indicators of a much wealthier nation, because this is what the top political leadership decided to do.
Countries have several options for raising additional revenue for health. Direct taxation is an obvious one, but depends on the country’s level of development and the percentage of workers engaged in formal employment. In countries, where smallholder farming remains the backbone of the economy, including many in sub-Saharan Africa, external financial support for health will be needed for some years to come. As another source of revenue, WHO strongly supports taxes on products that are harmful to health, especially tobacco and alcohol. A recent review of 22 low-income countries showed that, collectively, these countries could raise more than $1.4 billion through a 50% increase in taxes on tobacco products alone. In addition, evidence shows that higher taxes translate into lower consumption, benefitting health as well as wealth.
Making this world a fair place for health depends on more than raising revenue. Revenue needs to be raised in the right way, through prepayment and pooling, and not through direct out-of-pocket payments at the point of care. As vast experience shows, user fees punish the poor. WHO estimates that health costs plunge more than 100 million people into poverty every year. For households living on the margins of survival, even the costs of essential medicines can push them over the edge.
I have also visited countries with rapidly growing economies but levels of poverty and poor health that do not improve. In my view, economic growth is not the best indicator of a nation’s progress. What matters most is the rate at which wealth is converted into less poverty, more opportunities, and better health. The world does not need any more rich countries full of poor people. As a policy option, universal health coverage can do much to correct the world’s vast – and growing – inequalities. A world that is greatly out of balance in matters of health is neither stable nor secure.
