Is universal health coverage the practical expression of the right to health care?

Many scholars and global health practitioners express their opinions about what the right to health or UHC entails. Although these opinions are valuable, they do not carry authoritative weight. If we want to compare the normative content of the right to health with the normative content of UHC, we have to agree first on the authoritative sources.

With regards to the right to health, the authoritative sources are fairly easily identifiable. The human rights mentioned in the Universal Declaration of Human Rights (UDHR) was further elaborated in two primary covenants that together with the UDHR make up the International Bill of Rights: the International Covenant on Civil and Political Rights [9], and the International Covenant on Economic, Social and Cultural Rights [10]. The right to health is included in the International Covenant on Economic, Social and Cultural Rights (International Covenant) [10]. To monitor compliance with the International Covenant, a Committee on Economic, Social and Cultural Rights (Committee) was created, which issues authoritative interpretations of rights included in the International Covenant, the so-called ‘general comments’. General Comment 14 clarifies the scope and the content of the right to health [11].

With regards to UHC, authoritative sources are less easy to identify. There are no treaties about UHC. The 2005 World Health Assembly resolution on “Sustainable health financing, universal coverage and social health insurance” (2005 WHA Resolution) [12], has been accepted by the World Health Assembly, where almost all countries are represented and each country has one vote. We can therefore consider it as similar to a declaration by the United Nations. The same can be argued about the United Nations General Assembly resolution on “Global health and foreign policy”, adopted in December 2012 (2012 UNGA Resolution) [5]. But both resolutions are relatively short and may not fully reflect the concept of UHC that the WHO has in mind when proposing it as the ‘single overarching’ new health goal. As there is no real equivalent of a general comment for UHC, we decided to include the 2010 World Health Report on UHC (2010 World Health Report) [13], and the WHO discussion paper on health in the post-2015 agenda (2012 WHO Discussion Paper) [4] in our analysis as well, assuming that they are both approved by the leadership of the WHO.

We faced an additional problem because the right to health is, according to General Comment 14, “an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health” [9], whereas UHC is focused on health care – including “prevention, promotion, treatment and rehabilitation”, as the 2012 WHO Discussion Paper clarifies [4], but focused on health care nonetheless. We therefore decided to limit the scope of our comparative normative analysis to the right to health care, although we acknowledge that the absence of broader health determinants within UHC does limit its ability to practically express the right to health in totality.

To be sure, our ambition was not to provide a complete account of the comparative advantages of two different norms – or two different sets of norms; we merely tried to find and expose the main differences.

As mentioned above, the WHO considers UHC “a practical expression of the concern for health equity and the right to health” (emphasis in original) [4]. The concept of equity may help to understand and explain an essential difference between UHC – as it is being considered at present – and the right to health.

Equity is a concept to be handled with care. Equity refers to justice: the term inequity refers to “differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust” [15]. It takes a concept of justice to qualify measurable inequalities as inequities.

At the national level, there is a widely accepted concept of justice in health. In the 2005 WHA Resolution, it is formulated like this: “with a view to sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care” [12]. If inequalities between different population groups within the same country – like a difference in maternal mortality ratio between the poorest and the richest quintile of a population – can be attributed to insufficient ‘risk sharing’ – and if a result of this insufficient risk sharing is women not delivering their babies in health facilities due to costs they cannot easily afford – then the inequality is also an inequity.

But at the international or global level, there is no such widely accepted concept. If we would insert the word ‘global’ into the 2005 WHA resolution – which would then become “with a view to sharing risk among the global population” – than the huge health inequalities between countries could be qualified as inequities, because attributable, to some extent at least, to the lack of substantial cross-subsidies between wealthier and poorer countries that global risk sharing would imply. However, the ethical imperative of international transfers for health is not widely accepted.

International human rights law, and the right to health in particular, entails a somewhat conservative but nonetheless meaningful concept of global justice in health. The focus of international human rights law on obligations of states towards people under their jurisdiction, and its tolerance – acknowledgment without condemnation – of resource constraints that limit the practical implementation of state obligations, gives rise to a state-centric version of global justice that tracks rather well with nationalist interpretations of social justice. But its inclusion of shared responsibility – of the obligation “to take steps, individually and through international assistance and co-operation” – supports a certain level of cosmopolitan interpretations of global justice. While the extent of the obligation to provide assistance remains controversial, it covers at least minimum core obligations.

If the international community were to adopt UHC instead of the present MDG4, MDG5 and MDG6, then the post-MDG agenda would arguably move closer towards the right to health, if only because UHC promotes a comprehensive package of health care, while even the sum of efforts required to achieve MDG4 (child mortality), MDG5 (maternal health), and MDG6 (HIV/AIDS, malaria and other diseases), does not, for example, include treatment of non-communicable diseases for adults other than soon-to-be mothers. However, the 2005 WHA Resolution and the 2012 UNGA Resolution only briefly refer to international assistance, and where they do, they do not imply that sufficient international assistance ought to happen to ensure at least the basic level of UHC. 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” without clarifying the extent of expected solidarity at the international level. International assistance for UHC seems to be viewed as a windfall for some poorer countries, at the discretion of some wealthier countries – not something included in UHC per se. That may be a correct reflection of the present political reality, but is not a practical expression of the right to health, and it leaves global health inequalities standing as inequalities – not inequities. In low and lower middle income countries, UHC could mean access to a very cheap and incomplete package, not including antiretroviral AIDS treatment, for example.

However, UHC is a ‘work in progress’. In September 2013, the United Nations Sustainable Development Solutions Network (UNSDSN) presented a draft report on “Health in the Framework of Sustainable Development” for public consultation [16]. The UNSDSN proposes “Achieve Health and Wellbeing at All Ages” as the new health goal, and adds that “[t]o accomplish this objective we propose that all countries achieve universal health coverage at every stage of life, with particular emphasis on primary health services, including mental and reproductive health, to ensure that all people receive quality health services without suffering financial hardship”. Considering “Universal Health Care as being built on the foundation of human rights and equity”, the UNSDSN proposes a set of financing targets: public health care expenditure should be 3% of Gross Domestic Product (GDP) in low income countries; 3.5% of GDP in lower middle income countries; 4% of GDP in upper middle income countries; 5% of GDP in high income countries, and high income countries should furthermore allocate the equivalent of 0.1% of GDP to international assistance for health. According to our estimates, that would allow even the poorest countries to finance UHC at a level of US$55 per person per year. At present – estimates for 2010 – public health expenditure in low income countries is on average US$10 per person per year [17].

Would the equivalent of 0.1% of GDP of high income countries, shared in a reliable manner, make such a difference – a difference sufficient enough for the UNSDSN proposal to be considered a practical expression of the right to health care? As explained above, it would make a huge difference in low income countries. But for people who remember the Declaration of Alma-Ata [18], and who know that General Comment 14 was influenced by this declaration, 0.1% of GDP is like the “crumbs from the rich man’s table” [19]. The Declaration of Alma-Ata did not ask for more international assistance than 0.1% of GDP, on the contrary, it argued that primary health care should be at “a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” [18], section VI, i.e., without international assistance. The Declaration of Alma-Ata instead claimed a “New International Economic Order” [18], section III which would allow all countries to provide a decent level of health care. But the International Covenant and General Comment 14 do not go as far as the Declaration of Alma-Ata – even if General Comment 14 refers to it. Furthermore, even 0.1% of GDP, if provided in a reliable manner, could be the beginning of global redistribution, and thus contribute to a new international economic order. Therefore, we conclude that UHC, as proposed by the UNSDSN, can be called a practical expression of the right to health care.