Gravitating towards universal health coverage in the new WHO era

Lancet Global Health
Jul 2017 Volume 5 Number 7 e633-e726

Gravitating towards universal health coverage in the new WHO era
The Lancet Global Health
Open Access

After a year of intense campaigning not devoid of controversies, WHO has a new leader. The election of Tedros Adhanom Ghebreyesus is the culmination of a series of firsts: he is the first Director-General elected via a more inclusive and transparent election process, the first African to be elected head of the agency, and the first non-physician to take the helm of the world’s foremost health institution. The excitement around this level of novelty is palpable: as Africa rejoices and congratulations converge from all sides of the global health political and technical communities, the overall sentiment wants to be one of hope—hope for the future of the embattled organisation at the hands of an experienced and successful technocrat and diplomat, and hope for renewed impetus to address the most pressing issues threatening the health of populations around the world.

The new WHO DG has laid out his priorities and first on the list is a familiar challenge: advancing universal health coverage (UHC). He has made clear that UHC is to be the “centre of gravity” of WHO’s work under his leadership. As such, he is picking up a process that—as laid out in Margaret Chan’s final report as WHO DG—started with the 1978 Health for All declaration of Alma-Ata and the push for primary health care, and through the ups and downs of an initially misunderstood and several times renewed concept, found a most vibrant expression in the 2010 “World Health Report on Health systems financing: the path to universal coverage”, which concentrated on demonstrating the financial feasibility of UHC. The concept crystallised as a development issue with the 2012 UN General Assembly resolution on UHC, and finally the inclusion of UHC in the 2030 Agenda for Sustainable Development, in SDG3, target 8. A place has been carved for UHC on the global agenda, and Tedros has committed to making it happen. We look forward to seeing how he will tackle this challenge.

And a challenge it will be. The economic case for UHC has been well discussed, the notions of equity and rights seem acquired, and studies are providing increased granularity to the monitoring of the health benefits of UHC. A recent article in The Lancet on an index of health care quality and access based on amenable mortality shows, among other things, how countries such as Tedros’ own Ethiopia, while still not performing well on this index, have been able to go beyond expectations between 1990 and 2015 in terms of access and quality. But clearly progress has been variable and there are gaps in coverage across and within countries. The new DG himself has acknowledged that while UHC has been the focus of the global health community for some time, progress has been slow. He has done so indirectly in our pages during his campaign, in his careful response to an open letter to the DG candidates on a patient-centred R&D agreement, where he recognised that one aspect of UHC—the delivery of quality health products for diseases affecting the most vulnerable population—remains poorly addressed, evoking market failures and lack of political will. Indeed, he has qualified the lack of political commitment, rather than lack of resources, as the biggest constraint for progress in UHC.

Obviously countries moving towards UHC face a number of choices, from policy negotiations and decisions to financing and implementation, that are inherently political. Conflicting priorities between ministries of finance and ministries of health can, and often do, clash. Ideological struggles and political interests also slow down or hamper progress. A case and point is that of the USA, where Barack Obama’s UHC-friendly Affordable Care Act is being hammered down by Donald Trump’s policy proposals.

Venturing into politically-charged terrain is tricky for WHO. The level of comfort is high on technical issues like financing and governance, but work on the political determinants and the political economy of UHC, while key for successful reforms, is not as conspicuous. Yet advocating for the outcome rather than the means to get to UHC, as Tedros has said should be WHO’s strategy, requires it. As Ethiopia’s former Minister of Foreign Affairs, he has undoubtedly gained key experience in high-level political engagement. Those sharp political skills will be invaluable in forging the new road ahead.