The subtitle of the First Global Symposium on Health System Research, which is currently underway in Montreux, Switzerland is “Science to Accelerate Universal Health Coverage (UHC)”. There has been a lot of talk about the concept of UHC specifically of what we mean when we use the term, how much it would cost to scale it up, and what are some of the potential benefits from widespread adoption of UHC in many low and middle income countries. While there is no one common definition of what we mean when we say UHC (in fact, one of the background papers for the conferenced identified over 20 different definitions) the basic idea is the concept that citizens having access to essential health services with no major financial obstacles – but you can see how complicated it becomes when we try to apply this definition to the plethora of countries approaches to UHC.
Definitions aside, one of the things I have been struggling with throughout these discussions is the idea that the adoption of UHC in these countries can be “accelerated”. One of the goals of the conference is to “develop a global agenda of priority research on accelerating progress towards universal health coverage”. The way people talk about UHC around here it is as if it is something that can be “scaled-up” or “implemented at the national scale” or “promoted for widespread adoption” – you’d think we were talking about adding another vaccine to current immunization schedules or adopting a new drug. It seems achieving UHC is the latest and greatest health intervention that needs to be rolled out.
But how does one even begin to try to answer the question of what can be done to try to accelerate health coverage in countries where UHC is not currently the norm? Well, one quite logical approach could be to look at the countries that have achieved UHC, or at least have made important steps in the direction of UHC, and ask what they did right. I’ve seen a lot of good research that has been presented here that have looked at this question. But of this course this research methodology might lead us to very biased perspectives about what works if we don’t also include the countries that have attempted to implement UHC but have failed. There are some good examples of those countries as well, but those discussions have been much less prominent during this week’s conference. I think this is a mistake – we need to be more rigorous in our anaylses.
Another methodology that could be useful, and perhaps one that has been underexploited in the area of global health policy is to use history to inform our perspective. Jesse Bump, a historian and a current a fellow at the Harvard School of Public Health, presented a fascinating paper on this topic yesterday at the conference. Using the case of Germany, the United Kingdom, and the United States he explores what historical lessons can be useful to inform current debates on UHC. As well, in his paper, he also explore how efforts to promote UHC through external assistance and influence have succeeded or failed using the social medicine movement and the Bandoeng Conference of 1937, the Primary Health Care movement and the Alma‐Ata Conference of 1978, and the Selective Primary Health Care movement of the 1980s as case studies.
Briefly, Bump finds that the successful UHC efforts in both Germany and United Kingdom were driven largely from internal efforts that had to do with broader social changes and happened at the times where there were opportunities for large scale renegotiations of the social contract within these countries. Also worth pointing out, these were very lengthy and complicated processes within each of these countries – it took well over a hundred years in Germany. I learned on Tuesday that it took nearly 27 years to do the same in Thailand. Finally, he also finds that all 3 externally driven efforts have failed and that “so far all countries that have achieved UHC have done so through organic, domestic processes, which necessarily reflect local historical, cultural, and institutional legacies”.
The main criticism that can be lobbied about historical perspectives is the generalizability of previous experiences with future experiences. Although he does include both successful and non-successful efforts, it is never clear how much context in the past is relevant today. But his work raises some really interesting questions regarding the idea of promoting or accelerating the adoption of UHC. I am left wondering to what extent UHC efforts be promoted by external actors and what place they should play in this processes? To what extent do countries need to be ready – whatever that means – to promote UHC? Are we once again setting ourselves up for failure by setting unrealistic goals of achieving really large and complicated health reforms in a short time period? History suggests that the journey to UHC, if such a path could be traced out, is likely to take place a long and bumpy road. Perhaps a more realistic area of research is what can the research community do to at least make this trip a bit more enjoyable and to avoid some inevitable wrong turns – and road kill.
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