Shadow boxing in the Universal Health Coverage debate
Sep 21, 2023
Shadow boxing around “universal health coverage” instead of “universal access to healthcare” in the UN General Assembly reflects deeper tensions around the direction of the world economy.
At the high-level meeting of the UN General Assembly on Thursday, 21 September the delegates will consider a compromise document on universal health coverage (the 1 September draft political declaration) which a number of countries have already denounced (because of the non-consensual removal of a paragraph deploring unilateral coercive measures).
Nevertheless, the draft political declaration does not obscure the shortfalls with respect to the commitments in the 2015 Sustainable Development Goals regarding access to services and financial protection. Rather, the draft declaration invites the delegates to recommit to those targets without a full analysis of why the UHC goals are not being achieved.
Driving the policy movement for UHC are the denial of access to health care (because of out-of-pocket costs) and the frequency of health care impoverishment in many low and middle income countries (L&MICs). To some degree the concern regarding access barriers and healthcare impoverishment reflects the accountability of governments to their peoples but at the level of high geopolitics, there is also a concern to defend the legitimacy of capitalist globalisation.
Behind the flow of rhetoric around UHC is a deep tension between two models of healthcare delivery: universal access to healthcare through publicly funded and publicly administered healthcare services versus universal coverage (meaning publicly sponsored health insurance with strategic purchasing of a ‘basic package of essential services’ from a mix of service providers) complemented by a market place of private health insurance plans and private providers for services beyond the package.
In part the proponents of UHC are focused on keeping space for corporate suppliers of services, medicines, and equipment (led by the World Bank, Rockefeller, and various USAID funded think tanks). However, the drive for UHC (rather than universal access) is also about restricting the need for public spending by imposing limits on the basic package. Behind these debates looms the inadequacy, in many L&MICs, of public funding for health care generally (whether for publicly provided services or for subsidised insurance coverage).
What this draft declaration does not do is to ask why public funding for health care is so inadequate in so many L&MICs. References to debt burden (and restructuring or cancellation) and a reference to illicit financial flows in an earlier draft have been removed from the draft now presented to ministers. There is no discussion of tax avoidance or the extortion of tax concessions as a condition for foreign investment. Most critically there is no consideration of the global economic regime of unequal exchange and deepening inequality.
In view of the repeated use of Section 301 of the US Trade Act to prevent countries from fully deploying the flexibilities allowed for in the TRIPS Agreement, the insistence (by US, UK, EU, Switzerland, Canada, Australia, New Zealand and Ukraine) on the removal of the reference to unilateral coercive measures is cynical in the extreme.
As a policy forum, the UNGA provides space for L&MICs to be heard but, outside the General Assembly, policy implementation is largely driven by the World Bank, the big US philanthropies, the G7, and the big bilateral aid providers.
However, the governors of the global regime remain concerned about the perceived legitimacy of this regime and the need to (at least appear to) address denial of access and healthcare impoverishment. PHM calls upon civil society organisations and social and political movements to amplify their critique of the failures of the UHC promise (and the promise of the SDGs more broadly) but to link this critique to an explication of the ways the current regime of capitalist globalisation reproduces global inequality and unequal exchange. Political leaders in the global South must be encouraged to stand aside from the shadow boxing and demand real action on health care access, including the structural reforms needed to ensure adequate health care budgets.
David Legge is a scholar emeritus in the School of Public Health and Human Biosciences at La Trobe University in Melbourne and a founding member of the People’s Health Movement.
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