Last week, world leaders, global institutions, multinational corporations and NGOs came together in Tokyo around Universal Health Coverage day to (again) commit themselves to achieving ‘UHC’. This has to be good news, doesn’t it? After all, who could disagree with that vision of a world where ‘everyone has access to the high quality health services they need, without incurring financial hardship’?
There’s just one problem – until we demolish the neoliberal global political economy in which we live today, there isn’t a cat in hell’s chance that we can achieve UHC in the foreseeable future.
Just take a look at the numbers. According to the World Health Organisation (WHO), the annual cost to poor countries of meeting UHC targets by 2030 would be $112 per person. This is a significant increase on previous estimates, and would leave Poor countries facing an annual funding gap of up to $35 billion. The WHO estimates that poor countries will need to spend up to 20% of GDP on health in order to bridge this gap – but we know that during 2000-2014, public funds from domestic sources to finance health actually stagnated in these countries.
The generally agreed proposals for bridging this funding gap are fundamentally flawed, on (at least) three counts. First, the targets for increased health expenditure by poor countries – 5% of GDP is the most popular - wouldn’t come close to bridging the gap, even if universally adopted. Second, the targets won’t be achieved anyway, because they ignore the complexity of the political pressures impinging on poor country governments, and because they are based on unrealistically optimistic projections about the financial resources that they will have available.
And this brings us to the third flaw in the prescribed approach to achieving UHC. This is how the argument goes: the level of government health expenditure is a political decision; so if poor countries are not spending enough on health services, then that is the responsibility of their governments; therefore, we just need those governments to decide to spend more on health. (This might take a while – so we’ll continue to generously provide aid in the meantime.)
The problem with this argument – aside from ignoring the political and economic realities – is that it completely misrepresents who is really responsible for inadequate health expenditure by poor countries. A main reason poor countries don’t spend enough on health is that they can’t afford to. And a key reason they can’t afford to is that they are deprived of the necessary resources by unfair global trade and tax rules, debt repayments, repatriation of profits by multinational corporations, etc – that is, by the global financial system that has been established by, and in the interests of, rich and powerful countries.
The numbers on tax are particularly striking: the scale of annual global tax abuse has been estimated at $600-$650 billion.[1] But as I say, it isn’t just tax. Even when you exclude tax dodging and other illicit financial transfers, total outflows from sub-Saharan Africa to the rest of the world totalled $135.3 billion in 2015.[2]
Contrast these figures with the income that sub-Saharan Africa received that year in aid from OECD countries (a group comprising 35 of the richest countries in the world) - just $19.1 billion – and two things are immediately evident. First, aid isn’t going to make much of a contribution to achieving UHC. Second, and more importantly in terms of the pursuit of global justice, we need to drop the pretence that aid represents the generosity of rich countries towards countries that happen to be less fortunate. Aid should be seen for what it is – at best, a (wholly inadequate) form of reparations for the resources that multinational corporations and global elites, often based in or enabled by rich countries, steal from the poor.
The conclusion to all this is straightforward enough – we need to transform those aspects of the global neoliberal system that enable rich countries to continue to exploit poor countries. Returning to the particular context of health and the goal of UHC (and to the theme of an earlier Huffington Post piece from Health Poverty Action[3]), this means that we need to create an ‘NHS for the World’. The NHS was founded on the same principles as UHC: heathcare, available for all, tax funded and free at the point of delivery. Moreover, it was introduced at a time when the UK was facing desperate financial constraints.
So we know that it’s possible, and we know how to do it. Now that knowledge needs to provide the basis for our partnerships with other countries (not to mention for repairing our own corrupted healthcare system). That means ditching the failed model of privatisation which only benefits the rich and powerful, and instead pursuing policies that we know can deliver health for all.