The Politics of Health Systems and Universal Health Coverage
In this final lecture on health systems I want address a topic that’s often neglected in these discussions and that concerns the politics of health systems and universal health coverage. Universal health coverage and health systems reforms are fundamentally political. One could see this all over the world, not least in the United States, which is having great debates how it moves towards universal health coverage.
But this is true in every country across the world. Now why is it that this issue of health coverage and universal health coverage is so political? It really is for a variety of reasons. Firstly, everybody wants good quality health services with financial protection. Universally it comes out in polls that this is the expectations of people across the world. So it matters a lot to people that they get this financial protection and they get the health services they need. Secondly, it’s actually a very easy concept to understand. And politicians find it therefore very easy to sell to electorates that this is something they’re going to bring to them. And in fact people demonstrate specifically for universal health coverage and an expectation that the states will deal with the healthcare financing. Now as I’ve mentioned in the previous lecture, universal health coverage requires public financing and a lot of it as well. It also must be done progressively with the healthy wealthy cross-subsidizing the sick and the poor. Now delivering this is inherently political. Finally, universal health coverage and health systems reforms can actually bring nationwide results very quickly. This is quite unusual for a government policy to have an impact right across the country, benefiting virtually all households so quickly. It doesn’t happen with infrastructure reforms and other economic reforms. Therefore it can bring very quick political benefits to people and that’s really why politicians are so interested in it. Now because it is so important to so many people, and it is so political, it’s absolutely essential that health reforms like this are led by the head of state. If it’s just done by the ministry of health, often this doesn’t work. There are so many political benefits to be gained, but also costs to be taken care of that this really is a head of state’s issue. Also, successful universal health coverage reforms really need the full cooperation across all of government. It’s way beyond just the remits of the ministry of health to deliver on this, but across cabinets and local governments as well. Often what you find though is ministries of health are actually often rather weak ministries within the cabinets. And ministries of finance often actually don’t want to suddenly increase public financing, maybe doubling the health budget. And really the only way they’ll be persuaded to do so is when they’re instructed to do so by the head of state. We’ve mentioned that big UHC reforms require significant increases in public financing. And the decision on, on doing that is therefore one that must be taken right across government. And in particular, the head of state, needing to take control of the situation, mobilizing supporters behind this political strategy, making sure that the public financing is, is raised properly, but also tackling the opponents which there will undoubtedly be for these reforms. What’s also interesting to note is that universal health coverage reforms are particularly popular in post-conflict states, or in new democracies.
And this is really for the reason around the quick wins that these policies can deliver. And new heads of state are often looking to demonstrate to the population that they brought around change that’s benefiting everyone. So universal health coverage could be quite a good way to legitimize the state and particularly a new state, because it provides tangible benefits to the population very quickly. And here’s some examples of countries that have done this, include the, the United Kingdom in the immediate aftermath of the Second World War, in introducing the National Health Service. Also right across Latin America, in the, in the last 20 or 30 years where there have been transitions, particularly from military dictatorships to democratic governments, often one of the first things the governments have done is introduce massive universal health coverage reforms. And other examples include Nepal in 2008. The new ANC governments in South Africa in 1994, one of their first policies was universal free healthcare for pregnant women and children. In Liberia, Sierra Leone, Burundi and Rwanda, these are all countries that have come out of periods of conflict and one of the first major policies they’ve introduced is universal health coverage reforms. Now looking at the transition that countries make from a system of privately financed system where there isn’t universal coverage to one where there is, what are the economic and political determinants of that process? Well firstly it’s undoubtedly the case that it’s economic growth and more resources that drives up health spending. Not surprisingly, as countries get richer, they spend more money on health. But what’s interesting to note is that as a proportion of GDP that rises as well. As countries get richer, people want more money to be spent on health. But another thing happens as well, which is very interesting is that as countries develop, the proportion of the financing of the health sector, that is public financing usually increases as well. You get this switch from a private voluntary financing system to one that is more governed by the state. Now that process is inherently political. And we’ve seen this process happening in countries all across the world, particularly in making the transition from being low income to middle income countries. But this process isn’t a slow and gradual linear process, what you tend to find happens is that suddenly there’s a step when countries make this transition to covering the entire informal sector, which as I mentioned before, invariably requires a big increase in public financing. Typically in the order of about 1% of GDP, which is a lot of money.
Now what prompts that is usually political windows of opportunity. A new government coming to power, a contested election. When a politician announces that they’re going to run on this platform and you see this sudden transformation. And therefore these processes are very associated with particular individuals and very strong charismatic leaders. And it’s very striking that across the world one can name almost the year and the politician that prompted these reforms. So for example, Nye Bevin in 1948 in the U.K. President Park in Korea in 1977. So if this is a good idea to move towards universal health coverage through a publicly financed system, why is it so difficult? Why do you find these processes are so contested? And really it’s because in making that move towards universal health coverage, there are undoubtedly winners in terms of people who are now covered, but also financially there are losers, people who now have to pay more into the public pool. The costs and the, the…associated with that transition tend to be concentrated in organized groups who possess a lot of political resources. Powerful groups like the medical profession like pharmaceutical industry and insurance companies and the urban elite who will have to, to pay more for their health services. Whereas the beneficiaries, the people who really like these transformations tend to be more in unorganized groups, lacking political resources, particularly the rural poor population. Now I’d like to describe one or two countries that are making this transition to illustrate these, these points. One country where there’s been a fascinating transformation or ongoing transformation of the health sector is Indonesia which recently elected a new president, President Joko. Now he previously was the governor of Jakarta and in becoming governor of Jakarta only in 2012, one of the first measures he introduced was universal health coverage in the city of Jakarta. And it was largely on the basis of the popularity of that scheme that he became so popular nationwide and in the election campaign announced that he was going to extend the benefits of this to the, the whole Indonesian population. And he was elected president only in July and has already started implementing this universal health coverage program. Now interestingly he’s financing this through increased tax revenues that he’s secured by reducing fuel subsidies. Indonesia had very high fuel subsidies. In fact they were spending three times as much on subsidizing fuel as they were on their health system. And now by removing these fuel subsidies he has the resources to be able to pay for universal health coverage. Now this is quite an interesting political tactic which seems to be followed by other countries as well and makes a lot of sense in terms of the broader sustainable development goals. Because many governments have found themselves historically now subsidizing fuel which they recognize isn’t a good idea economically and it’s also not a good idea for the environment as well. But unfortunately, these fuel subsidies are very popular and the population have got used to them. So therefore, in removing these subsidies, one needs to give something back to the population in return and give them benefits that they see relatively quickly. Governments therefore looking for quick win policies that can benefit all households and people being able to make the tradeoff between having subsidized fuel and other services. Now universal health coverage reforms fit this bill perfectly because all households require health services on a pretty regular basis. And governments are very cleverly looking now at linking increasing access to health services, in particular, access to medicines with removing fuel subsidies. So this is happening in Indonesia, but it’s also happening in Iran which has recently introduced universal health coverage reforms and likewise is linking these reforms to reducing fuel subsidies. So maybe this might be a trend for us to encourage thinking about the sustainable development goals. Other countries where this could be highly relevant are Nigeria, where there are to be elections in February, 2015, which now has a GDP of $3000 dollars per capita, relatively high and higher than Thailand had when it introduced universal health coverage 12 years ago. And Nigeria has a lot of oil resources that really one feels ought to be made available for providing universal health coverage. India is another country that spends a lot of money on fuel subsidies and surprisingly little on its health sector. Only about 1%, 1.2% of GDP. And it would be interesting to see as a, as a political strategy where the Indian population would be like other countries in recognizing that them getting better access to health services is a good deal as fuel subsidies are removed. Now one can’t really talk about health financing and universal health coverage without mentioning the United States as well, where President Barack Obama has invested enormous amounts of political capital in trying to improve the health financing situation in the U.S.’s notoriously inefficient and inequitable health financing system. And he’s taken big steps moving towards more of a mandatory health financing system which may indeed form a precursor towards more of a socialized health financing system in the future. So in concluding, universal health coverage is really as political as it is anything to do with technical issues, especially in moving towards a more equitable public financing system. Universal health coverage is also popular with people and politicians across the world. It really brings politics in to the health systems debate. And worldwide political actors and not really technocrats are the driving force behind universal health coverage. And really looking to the future that health developmental agencies should engage much more in the political economy of these health reforms and promote these health benefits and political benefits to political leaders.
OpenEdition sugere que esta publicação seja citada da seguinte forma:
Pedro Pereira Leite (18 de Maio de 2015). Health Systems – IV. Global Heritages. Recuperado em 15 de Dezembro de 2025 de https://doi.org/10.58079/p2p7