Driving universal health reforms through crises and shocks

Crises and shocks – including disease outbreaks, financial crises and conflicts – can create windows of opportunity to trigger universal health reforms. This report examines when and how such reforms have occurred, and what lessons can be drawn by leaders currently considering UHC reforms.Universal health coverage (UHC) is achieved when everyone receives the health services they need, without suffering financial hardship. In principle, all countries are committed to achieving UHC by 2030, in line with Target 3.8 of the Sustainable Development Goals. But global indicators for health coverage and financial protection have been lagging since 2015. The series of crises and shocks the world has suffered in recent years – including the 2008 global financial crisis, the COVID-19 pandemic, new or protracted conflicts, rising food and energy prices, and the deepening impacts of climate change – have raised fears that commitments to UHC will be seriously undermined. In light of these concerns, Chatham House established the Commission for Universal Health in 2022 to look at ways to maintain and accelerate progress towards UHC. The commission’s research, which underpins this report, suggests, perhaps counter-intuitively, that in many countries transitions towards UHC have occurred during times of national crisis, including fiscal crises. Notably, conditions of crisis and shock have had a catalytic role in precipitating UHC reforms. Crises can often create a ‘window of opportunity’ for transformational reforms that require a particular combination of political, social and economic imperatives in order to be brought to fruition. The commission based its findings on a review of secondary literature relating to UHC and crises and shocks. It also conducted case studies of countries where, in the last 30 years, political leaders have launched substantial UHC reforms at least partly in response to different crises. The case studies – which are to be published as a supplementary annex to this report – describe the nature and benefits of the changes to these countries’ health systems, and how policy in each case was influenced by the relevant context of crisis or shock. The commission also reviewed the literature on the wider benefits, beyond health, that UHC reforms can deliver. These include faster economic growth, increased labour productivity, higher levels of employment, improved social cohesion, and reduced levels of poverty and inequality. Improving access to quality health services and reducing financial burdens on households is also extremely popular, especially with previously excluded population groups, and so UHC reforms can deliver significant political benefits to the leaders that implement them. Our report does not suggest that shocks or crises are either necessary or sufficient to set in train a move towards UHC. Several countries are suffering crises that seem very unlikely to trigger health reforms. Others have achieved reforms without undergoing shocks. And fiscal or economic shocks can threaten existing healthcare policies, including UHC, as demonstrated by Greece following the financial crisis of 2008. Neither does the report find good evidence that UHC is unaffordable for most countries, or that there are cheaper ways to provide healthcare by relying on private health insurance for the better off and concentrating public financing on the worse off. The latter type of schemes – as have evolved in the US and South Africa, for instance – are usually highly inequitable and not cost-effective. The universal entitlement is key to both equity in access and cost-effectiveness in provision. By pooling resources, UHC offers the possibility of providing better healthcare for more people more cost-effectively than alternative models. The affordability of UHC is nonetheless a legitimate concern, particularly for low-income countries and others (such as those with ageing populations), where healthcare needs are rising fast. The report finds that extra resources are indeed required to move sustainably towards UHC, and, based on its research and case studies, endorses the World Health Organization’s estimate that an additional 1 per cent of gross domestic product (GDP) for primary healthcare is a realistic target for countries transitioning to UHC. The multiple crises of the early 2020s, including the COVID-19 pandemic, provide a window of opportunity to generate increased political will and public financing that are the foundations of successful UHC reforms. The commission finds that, as in the past, some leaders are currently considering launching or expanding ambitious UHC reforms. These tend to be middle-income countries that now have at least the potential fiscal capacity to make the transition to a predominantly publicly financed UHC system. Recent examples of this phenomenon include, in Africa, Egypt, Kenya, South Africa and Tanzania; and, in South Asia, Bangladesh, India and Pakistan. Drawing on key lessons from our case studies and other post-crisis UHC reforms, the report offers five overarching policy recommendations for political leaders contemplating launching new UHC reforms in response to today’s crises. These are:Prioritize reaching full population coverage rapidly, by providing a universal entitlement to a comprehensive and affordable package of publicly financed health services.Increase public health financing by around 1 per cent of GDP to expand the supply and quality of services and generate additional demand by removing financial barriers to services. This will support efforts to ensure universal entitlement to services becomes a reality rather than remaining an aspiration.Concentrate additional public expenditure on improving cost-effective primary care services and strengthening health systems in areas such as human resources, essential medicines, infrastructure, information systems and governance.Remove or drastically reduce user fees so that health services in the agreed package are provided free at the point of delivery, including ensuring that essential medicines and diagnostics are available free of charge.Promote universal health reforms as a flagship policy of the government, and build on the popularity of UHC measures to facilitate government revenue generation policies in other areas, for example through raising taxes and cutting inappropriate subsidies (e.g. reducing funding of fossil fuels). Linking popular UHC reforms to broader fiscal reforms may enable governments to raise more revenue than the additional 1 per cent GDP needed to kick-start their health reforms.