Universal health coverage, real or selective? Time for global health advocates to unite

By Gorik Ooms

About a year ago, at the AIDS 2012 conference in Washington DC, I wondered why the theme universal health coverage was virtually absent from the conference. It looked as if UNAIDS' universal test-and-treat strategy and WHO's universal health coverage plan were designed for two different worlds, as I argued in a blog post then. Such a division of global health advocates was bad news for global health, in my opinion, especially in light of the coming MDG negotiations. We should not count on three or more health-focused MDGs this time.

But I also understood why the AIDS activists at the conference were wary about supporting universal health coverage. The key UN resolutions about universal health coverage – the 2005 World Health Assembly resolution and the 2012 UN General Assembly resolution – hardly mention international responsibility or solidarity. The 2005 WHA Resolution mentions international assistance in its preamble – “Noting that some countries have recently been recipients of large inflows of external funding for health” – while the 2012 UNGA Resolution mentions “universal health coverage on the basis of solidarity at national and international levels”, but none of them admit that real universal health coverage will require considerable levels of international assistance during decades to come. With real universal health coverage, I mean "that people should have access to all the services they need".

Universal health coverage “developed within the particular epidemiological, economic, socio-cultural, political and structural context of each country in accordance with the principle of national ownership”, as it is formulated in the 2012 UN General Assembly resolution, could mean anything and everything. In low-income countries, it could mean something that looks a lot like selective primary health care, excluding antiretroviral treatment. For AIDS activists, universal health coverage could mean a giant step backwards, so even if I deplored the lack of support for universal health coverage by many of them, I didn’t expect them to change their position.

But I was proven wrong by the International HIV/AIDS Alliance that came out with a statement in support of "universal health coverage, including universal access to HIV prevention, treatment, care and support and universal access to sexual and reproductive health services via a rights-based approach" first, and for [universal health coverage as a "key mechanism for achieving the health goal"]( stories links/Eng Discussion paper on health target indicators in the post 2015 agenda (Sep 2013).pdf) more recently. The words that matter are “rights-based approach”, as universal health coverage anchored in the right to health requires at least comprehensive primary health care, with duty-based international assistance to countries that are unable to provide comprehensive primary health care without assistance.

Wishful thinking? The UN Sustainable Development Solutions Network (UNSDSN) doesn’t think so. A few days ago, it presented a draft report on health financing in the sustainable development framework, inviting everyone to comment before October 15, 2013. There’s a comment form to be used, but the UNSDSN will forgive me for using a different channel. The draft report proposes targets for “Public health care expenditure as a percent of GDP (Gross Domestic Product)” – 3% of GDP in low income countries; 3.5% in lower middle income countries; 4% in upper middle income countries; 5% in high income countries – and also for “ODA (Official Development Assistance) for health as percent of GNI (Gross National Income) – Minimum of 0.1% of GNI in high-income countries. When these percentages are applied to present GDP levels of all countries of the world, allocating international assistance on the basis of ‘poorest countries first’, universal health coverage at a minimum value of 50 US dollars per person per year becomes possible. That is still cheap, but it should allow financing comprehensive primary health care, including antiretroviral treatment.

The UNSDSN proposal will meet resistance, and not only from high-income countries, which are expected to double their international assistance for health – from about 0.05% to 0.1% of GDP (from 5 cent to 10 cent out of every 100 dollars). The net ‘cost’ of this proposal will be higher for low income countries, which are expected to increase their public health care expenditure from domestic resources with at least 1% of GDP - see World Health Statistics 2013, page 140.*

Not feasible? Well, that was also said when antiretroviral treatment was started in low income countries, or when user fees were removed. If all global health advocates unite, it is possible.

You have until October 15 to express your support for #RealUHC here. And on Twitter, of course. And elsewhere.


  • If you want to look it up, don’t get confused by the ‘total expenditure on health as percentage of GDP’ column. That is total health expenditure, which was 5.3% of GDP in 2010. You have to combine it with ‘government expenditure on health as percentage of total expenditure on health’: in 2010 that was 38.5% in low income countries. 38.5% of 5.3.% of GDP makes 2% of GDP – the UNSDSN wants that to increase to 3% of GDP.

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