|Year : 2013 | Volume
| Issue : 4 | Page : 236-241
Universal health care: The changing international discourse
Associate Professor, Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
|Date of Web Publication||18-Dec-2013|
Associate Professor, Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nearly 34 years ago, in 1978 in the face of a looming crisis in the health of the world's populations and rising health inequality, 134 countries came together to sign the historic Alma Ata Declaration where the idea of primary health care as the chosen path to "Health for All" was formulated. However even before the declaration and more so since, countries have diverse interpretations of Universalism, each setting it in the context of its own health care model. These have ranged from the minimalist to the more comprehensive welfare state. Today, as health statistics reveal, the crisis has deepened, not only in the developing world but also in the developed world. It is important to debate the nature of the crisis and understand current policy initiatives and their ideological legitimations. The paper attempts to trace, clarify and account for the shifts in international discourse on universal health care (UHC). It argues that the idea of UHC is still with us, but there have occurred substantial shifts in discourse and meaning, shaped by changing international and national contexts and social forces impinging on health systems. The current concept of universal health coverage has only a notional allusion to universality of Alma Ata and disregards its fundamental principles. It concludes that the shifts are detrimental and its value in promoting health for all is likely to be severely limited.
Keywords: Alma Ata, Discourse, Health for all, New universalism, Universal health care
|How to cite this article:|
Bisht R. Universal health care: The changing international discourse. Indian J Public Health 2013;57:236-41
| Introduction|| |
State involvement in providing for the basic needs of its citizens and the guiding principles behind state policy is enormously varied across countries. In the West, Keynesian welfare took various forms, expressing ideas of social justice, citizenship and inalienable natural rights. The emergence of the notion of the positive state that invests in its people, led to the formation of the welfare state. Provision of health services was a prominent issue within discourses of welfare in the post-war period. It was then that ideas that gave meaning to the notion of universalism were constituted within the multiple models of health care ranging from the minimal to the more comprehensive.
The constitution of the World Health Organization (WHO) adopted in 1946, was visionary in affirming that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. Two years later, this right to health was enshrined in Article 25 of the Universal Declaration of Human Rights and asserted by international law in the 1966 International Covenant on Economic, Social and Cultural Rights. The idea of universal health care (UHC) took root at the landmark Alma Ata Conference in 1978, where countries resolved to provide "Health for All." In accordance with the WHO definition, health was defined as a state of complete mental, physical and social well-being, with a strong focus on primary health care (PHC) and equity.
More than 30 years later, the idea of UHC persists. However, substantial shifts have occurred in discourse and meaning, shaped by changing international and national contexts and social forces impinging on health systems. Given that the principle of universality is closely knitted to the idea of social justice, it is important to understand the implications of the shifts for achieving the goal of health for all. This paper is an attempt to trace, clarify and account for these shifts.
| The Alma Ata Declaration: A Post-Colonial and Post-Revolutionary Consensus on UHC|| |
Prior to the Alma Ata Declaration, the idea of UHC embodied in national health systems was reflected in the plurality and diversity of health services systems. There is a clear dichotomy between the socialist and capitalist systems, but variations also exist within these categories. On one hand, there are examples of the erstwhile socialist countries that had completely statist universal health systems. On the other hand in capitalist countries like Britain, the establishment of the National Health Service provided for a high degree of state intervention and investment in health care, in response to widespread poverty, disease and malnutrition among the British working class. , Others, like Canada, provide UHC through a system of universal state insurance that covers services offered by private providers. The United States stands at the other extreme; UHC was never a guiding principle of the state's role and a dual health care system prevailed from the start.
Since the 1960s, newly independent developing countries sought to improve the health status of their people with professed developmental goals of growth with equity. Health development strategies focused mainly on building referral hospitals and establishing medical schools. These tertiary services, available mostly in urban areas, consumed the largest portion of the country's health care budget. For the rural majority rudimentary health infrastructure was created, which focused on vertical disease control and family planning programs. Donor nations and international development agencies providing technical and financial assistance played a crucial role in the development of health care.
By the seventies, there was a general rise in health inequalities in the developed world and developing countries failed to make much headway toward health goals. Experience the world over revealed unmet expectations, inadequate coverage and wide gaps in health status between regions. In view of the failure of even the developed world to address the issue of health inequity, there was a general feeling of helplessness.  There was a crisis of faith in medicine; rising costs of health care and of technology were not reflected in meaningful improvements in health.
However, the disenchantment was not without some successes. Programs initiated by China, Tanzania, Sudan and Venezuela to deliver a basic but comprehensive programme of PHC covering poor rural populations were successful. This new methodology for health care service delivery questioned the top-down approach and the role of the medical profession in health care provision.
It was in this historic context of a bipolar world that countries came together to sign the Alma Ata Declaration. It articulated a new philosophy, health for all and an approach towards achieving it that could be characterized as Universalist. It encompassed a commitment to equality and justice and made explicit various aspects such as whose and what health needs were to be met, by whom and how. It incorporates six key tenets:
The Declaration establishes access for all to PHC as the uniform direction for health policy. With emphasis changing from the larger hospital to that of community-based delivery of services, the strategy aimed at a balance of preventive and curative programs "made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination." 
- Equity is one of the basic pillars of universalism. Recognizing that disadvantaged groups have no access to health care, universalism stresses the need for making health a goal for everybody.
- Universalism as the goal of the whole population coverage.
- Comprehensiveness, i.e., coverage for all needs.
- Government responsibility for organizing and financing health services for meeting commitments and goals; being state supported and free, health services are available irrespective of one's ability to pay.
- Community participation in the planning and implementation of healthcare.
- Locally relevant technology.
Further, it recommended that all governments "formulate national policies, strategies and plans of action to launch and sustain PHC as part of a comprehensive national health system."  This refocus on universal public health systems with an enlarged role of the state, provided a historic opportunity to re-examine and reorient health services systems of developing countries.
| The Reality: From Comprehensive to Selective PHC|| |
Though formally accepted, the ideals of Alma Ata provoked early ideological opposition and were never fully embraced in market-oriented, capitalist countries. There was an immediate backlash from the medical establishment. There was also a widespread view that PHC was something relevant only to the developing countries. Although nobody really calculated the economic costs and political benefits of implementing the Declaration, widespread propaganda of scarcity of resources was used to scuttle the idea of UHC. In its place, a new concept Selective Primary Health Care (SPHC) was promoted, which was a compromise on several integral features of the original concept.
The advocates of SPHC argued that comprehensive primary health care (CPHC) was too idealistic, expensive and unachievable in its goal of the total population coverage. Countries could not afford health for all. ,, Contrary to CPHC, SPHC refers to the policy of selective interventions to deal with selective public health problems. Moreover, a core principle of the Declaration that communities in developing countries would have responsibility for planning and implementing their own health care services, was unacceptable to politicians and aid experts. SPHC took decision-making power and control, central to PHC, away from the communities and delivered it to foreign consultants these technical experts, often employed by the funding agencies, were subject to the policies of their agencies. 
SPHC, based on few important diseases and cost effective technologies such as the growth monitoring, oral rehydration, breastfeeding and immunization interventions that contributed to reducing child mortality rates, was seen as a logical first step towards achieving the Alma Ata vision. International agencies and bilateral donors, , who advocated SPHC, focused on a limited number of programs but left largely unspoken the implications regarding people's non-access to other services and the necessity of purchasing them from private providers.  However, while the inherent logic of non-comprehensive service was not compatible with the ideal of universality, SPHC still retained the possibility of state-run public health programs and equity for that set of interventions where cost-effectiveness was demonstrated.
In the 80s however, the ideological climate underwent a sea change, marked by the Washington Consensus doctrine ** . Thus, the growing attack on the PHC concept was neither accidental, nor did it arise amidst a set of fragmented policy prescriptions by multilateral agencies. As the following section argues, it was globally co-coordinated and found ideological legitimization in neoliberal economic theory and ideology.  A truncated model, with substantial private sector involvement, went on to dominate the development of health systems.
| Health Sector Reforms and New Ideas of 'Essential Health Care'|| |
As the most powerful economic organization, the World Bank (WB) gained authority in governing social policies of nations; new ideas and concepts developed by it attained hegemonic global dominance. The WB's Health Sector Reform became the dominant model for health service delivery based on an approach that changed state-private equations in favor of the latter. Most crucially, it marked a shift from SPHC to the notion of Essential Health Care to be delivered by the state. At the ideational level, it displaced the notion of state provision of all kinds of essential services for all people with that of state provision of those defined as "essential" few services - with the rest to be provided by the private sector on principles of competition and cost-effectiveness. 
The state's role was confined to providing an "essential clinical package" comprising of a small number of highly cost-effective public health and clinical services at the primary level. In all other spheres privatization was promoted, especially of secondary and tertiary health services. This ushered in the present age of user payments, cost recovery, private health insurance and public-private partnerships. The World Development Report 'Investing in Health' clearly articulated the new meaning attributed to health care delivery services.  They were seen in terms of the economic benefit that improved health could deliver, viz., improvement of human capital for development, rather than as a consequence and fruit of development. Further, the approach focused narrowly on health activities and gave scant recognition to the role of other sectors.
Third world countries, which had already reduced public expenditure on health as their foreign debts mounted in the 1980s and 1990s, had to contend with the new economic philosophy. International donors insisted these governments adopt market-driven economic reforms to receive foreign aid and debt relief. As a result, many developing countries disinvested in the public sector as part of structural adjustment programs. ,
Ironically, the WHO was reduced to playing a secondary role to the WB in matters of health policy. In a feeble attempt to claim continued allegiance to universalist notions, WHO coined a fresh concept of 'new universalism' in its 1999 World Health Report.  The report's recommendations constitute a plea to recognize the limits of state action and make room for the private sector. It toes the WB line that the most cost-effective services should be provided first by the state. It clarifies that coverage is for all - but not of everything. Free services are to be replaced by benefit packages based on assessments of services, inputs and people's willingness to pay. New universalism encourages competition in the provision of services. The private sector is welcomed in the clinical services and drug and equipment supply chain. Essentially, the new WHO philosophy seeks to legitimize WB action and is a far cry from universalism in the Alma Ata sense of the term, with its strategy of targeted essential health care being, in reality, a euphemism for the market. The importance of a minimum package of essential public health and clinical services was subsequently reinforced in 2001 by the Report of the Commission on Macroeconomics and Health. 
In the changed environment, even highly organized health systems began to experiment by changing the ownership and governance of hospitals, contracting-out some services, providing public funding to not-for-profit hospitals and so forth. The recognition that the government was no longer the sole provider and funder of health services contributed to the gradual emergence of the concept of stewardship or overall guide to the development of the health system.  Under this approach, the donors often bypassed the underfunded and underdeveloped public systems, in turn exacerbating the weaknesses of the public sector, while creating an unregulated private health care market.  The Health Sector Reforms provided further impetus to these trends through global, regional and bilateral trade agreements. These developments led to further inequality in the already segmented health care systems. Many of the countries experienced rapid growth in markets for health-related goods and services. , The presence of an unregulated private health sector and commercialization of public health care undermine whatever levels of solidarity and universality had been attained by public health systems. 
Currently, the market philosophy has crystallized and has rapidly changed the thinking of the state and elite sections of society to achieve a logic and tempo of its own. However, new problems and challenges in the world health scenario seem to have evoked a rethinking of this.
| Global Health Concerns and Universal Health Coverage: A Revival of Universalism?|| |
The first years of the new millennium, saw world-wide alarm at the rise of the global health problems of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), malaria and tuberculosis. The earlier phase of reforms did not take into much account the negative social consequences of economic and health reform. However, in the wake of global pandemics a new global discourse sought to address issues of increasing inequity, as also increasing social risks. This concern translated into a number of new Global Health Initiatives (GHIs) as well as a significant increase in development funds for health, especially for HIV/AIDS. The WHO was also focused on this change - with the first GHIs, Roll Back Malaria, established by Gro Harlem Brundtlandt at the end of the 90s *** . The Millennium Declaration, which was endorsed by 189 countries in 2000, to promote development and eradicate poverty, was given expression in eight millennium development goals - three of which focused on health and five dealt with social determinants of health. Through them, the disease-specific, vertical approach to resource mobilization has been reinforced by governments and United Nations agencies and this is now the de facto norm in GHIs.
In the context of the Millennium Declaration and people's/civil society's movements for revitalising PHC, there has been a change in how health is defined and understood. Along with health as a basic human right, it is now viewed as a global public good. It is no longer perceived as a national responsibility, but is also a matter of national self-interest on the part of developed countries to invest in the health of poorer countries. Failure to do so puts at risk life and well-being of citizens in the richer countries. Key documents highlighted how concerted global health action benefits those countries providing health assistance. Based on arguments that range from the reduction in the risk of spread of communicable diseases to reduction in political instability and armed conflict to aiding human security and even importantly being conducive to creating market for health goods and services, they argue for augmenting international financing for "essential health goods."  These concerns have led to increasing interest in health in foreign policy debates and performance of health systems. Discussions on health systems as the key to better health outcomes for all became the fulcrum of a new discourse on universalism.
The consequence of this new discourse was an articulation of a brand new, internationally applicable concept of universal health coverage, reflecting a concern for a "socially responsible" globalization. The World Health Report 2008 provides a comprehensive analysis of health inequalities and its determinants and also expresses concern for the excluded and marginalised sections of society. It advocates complete dedication to universal health coverage and suggests that this should be achieved through the creation or strengthening of "networks of accessible quality primary-care services that rely on pooled pre-payment or public resources for their funding." Most importantly, it adds, "Whether these networks are expanded by contracting commercial or not-for-profit providers, or by revitalizing dysfunctional public facilities is not the critical issue. The point is to ensure that they offer care of an acceptable standard."  It is unequivocal in its endorsement of the mixed-model of delivery, justifying multiple providers and making the system plural. It places faith in private providers to tackle long standing inequalities. A quick reinforcement of the new doctrine came in the World Health Report 2010, which provides a road map for countries to adapt their financing systems to requirements of universal health coverage ** .  Thus, the current discourse on universal health coverage is different from universalism of health for all.
The new doctrine continues to endorse a reduced role for the state, criticizing earlier attempts at implementing PHC through "government-funded and delivered services as a centralized top-down management" and explicitly suggests that focus be shifted to "pluralistic health systems operating in a globalized context." This "requires delicate trade-offs and negotiation with multiple stakeholders that imply a stark departure from the linear, top-down models of the past."  The new doctrine conveniently forgets that state provision of health, education and other services was taken for granted in most welfare capitalism countries, not to mention socialist economies. Political ideology and interests have served as a catalyzt to health development.
The new WHO discourse is contradictory - while it talks of health needs of the excluded and marginalized, it isolates health problems of these populations from the social and political reality in which they are living. UHC was reaffirmed by the 2008 Commission on Social Determinants of Health and the subsequent World Health Assembly resolution on that topic and at the World Health Assembly resolution in 2009. , As observed from the World Health Assembly 2011, "the emerging model for organizing health care is that of integrated service delivery networks. It is argued that "these networks depend on linking up the diversity of public and private providers" and that "in pluralist, mixed health systems these policies, strategies and plans have to relate to the entire health sector and cannot be limited to "command- and-control" plans for the public sector." 31
| Conclusion|| |
I believe, it is no exaggeration to say that the Alma Ata Declaration represented a great intellectual and moral leap forward for humankind, defining health as a fundamental human right, adopting a holistic framework of caring and mutual responsibility and advocating the empowerment of people to live healthy lives. The current concept of universal health coverage has only a notional allusion to Alma Ata and disregards its fundamental principles, merely supporting/strengthening the neoliberal model of health-care development. Thus, its value in promoting health for all is likely to be severely limited.
** The term equity is not specifically used but it can be interpreted as a core principle of Alma Ata.
**** The current momentum behind UHC is also evident from recent efforts like the Taskforce on Innovative International Financing for Health Systems (TIIFHS) 2009. Several other events like 63rd meeting of WHO's Regional Committee for South-East Asia on September 7-10, 2010 adopted a resolution calling for the creation of a regional roadmap for achieving universal health coverage. Similarly on November 16-19, more than 1000 researchers and practitioners from over 100 countries gathered for WHO's first Global Symposium on Health Systems Research, which featured science to accelerate universal health coverage as its key theme. There is even a Task Force for Universal Health Coverage in developing countries led by the Rockefeller Foundation, BRAC University (Bangladesh), Results for Development Institute (Washington DC) and Thailand's Ministry of Public Health. Government of India also set up a High Level Expert Group (HLEG) in 2010 on universal health coverage.
| References|| |
|1.||Doyal L, Pennell I. The Political Economy of Health. London: Pluto; 1979. |
|2.||Leichter H. A Comparative Approach to Policy Analysis: Health Care Policy in Four Nations. Cambridge: Cambridge University Press; 1979. |
|3.||Newell KW. Selective primary health care: The counter revolution. Soc Sci Med 1988;26:903-6. |
|4.||World Health Organization. Primary Health Care: Report of the International Conference on Primary Health Care. Geneva: World Health Organization; 1978. Available from: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf. Last accessed on July 22, 2013. |
|5.||Rifkin S, Walt G. Why health improves: defining the issues concerning 'comprehensive primary health care' and 'selective primary health care'. Soc Sci Med 1986;23:559-66 |
|6.||Carpenter M. Health for some: Global health and social development since Alma Ata. Community Dev J 2000;35:336-51. |
|7.||Labonté R, Schrecker T, Gupta AS. Health for Some: Death, Disease and Disparity in a Globalizing Era. Toronto: Centre for Social Justice; 2005. Available from: http://www.socialjustice.org/uploads/pubs/HealthforSome.pdf. Last accessed on July 22, 2013. |
|8.||Hall JJ, Taylor R. Health for all beyond 2000: The demise of the Alma-Ata Declaration and primary health care in developing countries. Med J Aust 2003;178:17-20. |
|9.||Litsios S. The long and difficult road to Alma-Ata: A personal reflection. Int J Health Serv 2002;32:709-32. |
|10.||Cueto M. The origins of primary health care and selective primary health care. Am J Public Health 2004;94:1864-74. |
|11.||Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease control in developing countries. N Engl J Med 1979;301:967-74. |
|12.||Representatives of Civil Society. Civil society report to the commission on social determinants of health. Soc Med 2007;2:192-211. |
|13.||Akin JS, de Ferranti D, Birdsall N. Financing Health Services in Developing Countries: An Agenda for Reform. Washington: World Bank; 1987. |
|14.||World Bank. World Development Report: Investing in Health. Washington, DC: Oxford University Press; 1993. |
|15.||Cornia GA, Jolly R, Stewart F, editors. Adjustment with a Human Face: Protecting the Vulnerable and Promoting Growth. Oxford: Clarendon Press; 1987. |
|16.||Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final report. Geneva: World Health Organization; 2008. |
|17.||World Health Organization. World Health Report: Making a Difference. Geneva: World Health Organization; 1999. |
|18.||Commission on Macroeconomics and Health. Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization; 2001. |
|19.||Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull World Health Organ 2000;78:732-9. |
|20.||Oxfam. Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries. Oxford: Oxfam; 2009. |
|21.||Mackintosh M, Koivusalo M. Commercialization of Health Care. Basingstoke: Palgrave Macmillan; 2005. |
|22.||Bloom G, Champion C, Lucas H, Peters D, Standing H. Making Health Markets Work Better for Poor People: Improving Provider Performance. Working Paper No. 6. Baltimore, MD: Future Health Systems; 2009. |
|23.||Homedes N, Ugalde A. Why neoliberal health reforms have failed in Latin America. Health Policy 2005;71:83-96. |
|24.||Italian Global Health Watch. From Alma Ata to the global fund: The history of international health policy. Soc Med 2008;3:36-49. |
|25.||Ooms G, Van Damme W. Global responsibilities for global health rights. Lancet 2009;374:607. |
|26.||World Health Organization. World Health Report: Primary Health Care Now More Than Ever. Geneva: World Health Organization; 2008. |
|27.||World Health Organization. World Health Report: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010. |
|28.||Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva, World Health Organisation; 2008 |
|29.||Resolution WHA62.12. Primary health care, including health system strengthening. In: Sixty-second World Health Assembly, Geneva, 18-27 May 2009. Geneva: World Health Organization; 2009. |
|30.||Sengupta A, Prasad V. Developing a truly universal Indian health system: The problem of replacing "Health for All" with "Universal Access to Health Care". Soc Med 2011;6:69-72. |