Public Health, Universal Health Coverage, and Sustainable Development Goals: Can They Coexist?

Abstract

In her 2012 reconfirmation speech as WHO Director-General, Dr Margaret Chan asserted: "universal coverage is the single most powerful concept that public health has to offer. It is our ticket to greater efficiency and better quality. It is our saviour from the crushing weight of chronic noncommunicable diseases that now engulf the globe ". The UN General Assembly is currently considering proposals for Sustainable Development Goals (SDGs), succeeding the Millennium Development Goals. SDG, focusing on health, specifically includes universal health coverage (UHC) among its targets.

Unquestionably, UHC is timely and fundamentally important. However, its promotion also entails substantial risks. A narrow focus on UHC could emphasise expansion of access to health-care services over equitable improvement of health outcomes through action across all relevant sectors — especially public health interventions, needed to effectively address non-communicable diseases (NCDs).

WHO first endorsed UHC in its 2005 resolution on sustainable health financing, calling on states to provide "access to [necessary] promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost". The resolution and its UHC concept firmly and narrowly centre on health insurance packages financed through pre-payment. This narrow understanding is echoed in major recent reviews of 65 empirical studies on UHC progress. The proposed SDGs also separate population-level public health measures from UHC, addressing the former as distinct targets, not under UHC. Yet, a broader understanding encompassing non-clinical measures can also be found in relevant WHO documents. Independent of UHC's conceptual in-determinacy, clinical health services are an essential part of UHC, and are likely to dominate post-2015 state health system improvements. In implementing UHC, how can we ensure continued emphasis on the full spectrum of public health interventions?

Unmediated, a narrow UHC focus risks that five distinct pressures prioritise expanded curative clinical services at the expense of individual and population-level health promotion, prevention, and action on social determinants of health. The risk is that this focus leads to more health-care services, but worse overall health outcomes, with less equitably distributed benefits.

First, unbalanced, the introduction of UHC usually increases inequity by disproportionately benefiting the wealthiest groups. Although there are some exceptions, UHC progress analyses from 11 countries at different levels of development suggest poorer people often lose out initially. UHC expansion generally begins with civil servants or urban formal sector workers; wealthier, well connected urban populations demand and receive clinical services, while poorer and rural populations do not. Some public health interventions — such as nutrition labelling, or information campaigns on behavioural NCD risks — also tend to disproportionately benefit wealthier groups, raising similar concerns. But other population-level measures such as clean air acts or road-safety improvements benefit the whole population from the outset, ensuring greater equity. Targeted population-level measures can balance temporary or persistent inequities arising from the introduction of UHC.

Second, the clinical sector commonly tends to emphasise specialist curative over health promotion or preventive primary care. Interventions such as dialysis, organ transplants, or new cancer therapies — frequently introduced under UHC — often have the irresistible aura of the rule of rescue, enabling the instant saving of otherwise doomed lives. But as the addition of dialysis to the public benefit package in Thailand illustrates, doing so can entail substantial budgetary opportunity costs with unclear sustainability.

Keywords: Public Health, Public Health Law, Sustainable Development, Universal Health Coverage