/ 12 December 2018

Public finance is key to delivering the human right to health

'Despite spending 17% of its gross domestic product
'Despite spending 17% of its gross domestic product (GDP) on health, 30-million Americans are without health insurance, and many more are underinsured and don’t use the services they need because of high copayments,' writes Ban Ki-Moon

Health is a human right. When people are not able to access the healthcare they need, especially if this is for reasons of cost, their human rights are denied. It is vital for the wider fight for rights, justice and sustainable development that policymakers’ actions are informed by this linkage.

The world has just marked Human Rights Day on December 10. Today, December 12, is an equally significant date: the very first official Universal Health Coverage (UHC) Day endorsed by the United Nations.

Universal health coverage is built on principles of equity and fairness, with health services allocated according to people’s needs and the health system financed according to people’s ability to pay.

As secretary general of the United Nations, I was proud to launch the Sustainable Development Goals (SDGs) in 2015 as a road map to a better planet for current and future generations. All world leaders committed to delivering UHC when they signed up to the goals, and they now have 18 years to deliver on their promise.

After stepping down from the UN, I joined The Elders, a group of independent world leaders set up by Nelson Mandela who work for peace, justice and human rights.

I am delighted that UHC is one of The Elders’ top priorities. As a young man growing up in the Republic of Korea, I witnessed our transition to UHC when in 1977 president Park Chung-Hee launched nationwide health reforms that meant that everyone could access life-saving healthcare.

This process is now occurring across the world at all income levels, as governments realise that to reach UHC it is necessary to replace private voluntary health financing with compulsory public financing.

The only wealthy country yet to make this transition is ironically the world’s biggest economy — the United States. Despite spending 17% of its gross domestic product (GDP) on health, 30-million Americans are without health insurance, and many more are underinsured and don’t use the services they need because of high copayments.

When I lived in the US I was frequently amazed by how expensive health services were and how unfair it was that the services my family and I used weren’t available for everyone.

Sadly, the present administration’s determination to derail former president Barack Obama’s Affordable Care Act is only going to make this situation worse. This will take the US further from the global UHC goal.

Yet on two occasions over the past year, I have participated with my fellow Elders in health events in New York and California, which suggest that, at a state level, there is an appetite to move more quickly towards UHC. With health now at the top of the political agenda across the US, there is a real chance for progressive states to launch publicly financed health systems that might catalyse similar reforms nationwide. Ultimately, I believe they will.

But progressive states in the US are not the only places striving to make progress towards UHC. Many middle-income countries that historically had inequitable, privately financed systems now have the financial resources to switch to a publicly financed system. What is required to catalyse this change is genuine political will, like we saw in Korea in 1977.

Over the past three years, The Elders have been working with leaders to encourage them to bring publicly financed UHC to their people. President Joko Widodo of Indonesia is a good example of a leader committed to UHC, who is using savings from cutting fuel subsidies and increasing tobacco taxes to finance UHC.

India is another country on the verge of massive health reforms and it was a privilege for me and fellow Elder Gro Harlem Brundtland to visit Delhi and Ahmedabad in September to witness progress being made at a national and state level.

After decades of underfunding, it is commendable that Indian Prime Minister Narendra Modi has committed his government to more than double public health spending to 2.5% of GDP by 2025. But we were concerned to see that the main emphasis seems to be on ensuring people against expensive inpatient tertiary hospital care rather than investing in more cost-effective primary care services.

We saw these primary care services (PHC) working very well in Delhi, where people are returning to the public sector to access free PHC services in the state government’s impressive Mohalla Clinics. This is a tried and tested strategy to improve access for the poor that has brought UHC to China, Sri Lanka and Thailand.

Finally, we are also very excited by recent developments in Africa, where in the past few months the presidents of South Africa and Kenya have made UHC a top priority for their governments. In both cases, the presidents themselves are overseeing reforms that will use mostly tax financing to bring universal free health services to everyone.

All countries on the path to UHC face a crossroads: one path leads to a US-style, privately financed, fragmented health system, in which the rich have unlimited choice of expensive services but the poor fail to access care or suffer bankruptcy if they do. The other is the path increasingly being taken in the rest of the world, where even in highly capitalist economies everyone gets access to care because the state makes the rich pay for the poor.

Our advice to US states, to India, Indonesia, South Africa, Kenya and other countries approaching the crossroads, like Nigeria and Pakistan, is to take this path, as this is the only navigable route to health for all and just, stable and prosperous societies.

Ban Ki-moon is the former secretary general of the United Nations