Solidarity, equity and rights-based approaches to health provision The goal of universal health coverage (UHC) has risen to prominence in global debates, comprising the core of the World Health Organization’s (WHO) key proposals for a post-Millennium Development Goals agenda (WHO, 2012). There are two main elements to UHC: the provision of necessary health services and expansion of insurance coverage. UHC proposals are gaining traction as countries at varying levels of economic development, including Rwanda, Thailand, China and the USA, have undertaken significant coverage reforms. While there is currently significant consensus and momentum pushing UHC to the forefront of global health policy, its meanings and implications have not always been clear. UHC may be taken to mean that all medical services should be available at no cost or low cost; it may refer to comprehensive, unified health services, such as the UK’s National Health Service, or it may simply mean that every individual should have health insurance (IOM, 2004), without specifying particular principles or entitlements. How the term ‘UHC’ is used is highly dependent on the specific policy context surrounding the policies being advanced under its banner. On her appointment to a second term as Director-General of the WHO in 2012, Margaret Chan declared UHC to be ‘the most powerful concept that public health has to offer’ due to its ability to function as an ‘inclusive umbrella’ for different programmatic interests in global health reform. According to the WHO (2014), UHC reforms entail four priorities: 1. The development of strong, efficient and well-run health systems able to meet priority health needs and practising people-centred, integrated care, including health promotion, prevention, early detection, and capacity to treat and rehabilitate. Non-health sectors, such as transport, education and urban planning, also make important contributions to this goal 2. The development of financing systems that help people avoid financial hardship if they incur health costs 3. Access to essential medicines and technologies to treat and diagnose conditions 4. A sufficient capacity of well-trained and motivated health workers to provide the needed services Reichlin (2011) sets out three relevant bioethical principles of equity, rights and solidarity. This article asks if these fundamental ethical principles are in place, and revisits the UHC concept in light of them. This discussion will focus particularly on dimensions of solidarity in health and human rights, arguing that health solidarities need to be better understood in both global health reform and human rights advocacy. Solidarity takes us beyond narrow concepts of financial sustainability to reconnect the current goals of human 128 Commonwealth Health Partnerships 2015 health and well-being to those of future generations. Solidarity is thus an important consideration underpinning the centrality of health in the pursuit of the ‘triple bottom line’ of social, ecological and financial sustainability. A transformative agenda for global health equity In 2005 the World Health Assembly (WHA) resolved to develop health financing systems enabling UHC. The 2010 World Health Report subsequently highlighted health-systems financing as ‘the path to Universal Coverage’. In 2011 the WHA called upon Margaret Chan to bring the UHC issue to the UN General Assembly, which she duly did on her appointment to a second term as WHO Director-General in 2012. However, it must not be forgotten that Chan had championed primary health care (PHC) as the global health priority several years earlier (WHO, 2008). The 2008 World Health Report represented an important moment, returning the focus of global health governance to the transformative agenda for health equity advanced three decades earlier at the International Conference on Primary Health Care, Alma-Ata, with the popular slogan: ‘Health for All’ (International Conference and WHO, 1978). The language of rights and equity connected the WHO leadership to a broad social movement of professionals, researchers, institutional and government reformers, progressive civil society and grass-roots organisations collectively aiming to tackle the ‘politically, socially and economically unacceptable’ health inequalities in all countries, and to effect a value change towards people-centred health care based on ‘social justice and the right to better health for all, participation and solidarity’ (WHO, 2008: p. 1). Surveying the challenges for global health three decades later, the 2008 World Health Report revived the PHC agenda to address the major deleterious global trends of growing inequalities; ‘inverse care’ (disproportionately focused on high-cost, specialist, tertiary interventions); fragmented care (due to the multiplication of vertical health programmes and projects); and the problems posed by the commercialisation of health care. It noted the trends of urbanisation and ageing, and the policy realities of globalisation, cost-containment and deregulation (WHO, 2008: p. 11). Four main types of reforms were proposed: • UHC to improve health equity • Service delivery reforms to make health services more peoplecentred • Public policy reforms to prioritise community-based health protection and promotion • Leadership reforms to make health authorities more answerable and reliable Su-ming Khoo
Commonwealth Health Partnerships 2015
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