The value of universal health coverage investments

Pursuing universal health coverage is an investment in a future built on responsive health services and defined by the well-being and safety of all

In September 2019, at the United Nations, world leaders endorsed the most ambitious and comprehensive political declaration on health in history. However, progress on universal health coverage is not on track, and the Covid-19, monkeypox and other pandemics are moving the world further away from the 2023 targets set by the political declaration. Those targets include covering 1 billion additional people, with a view of covering all people by 2030, and reversing the trend of catastrophic out-of-pocket health expenditures and eliminating impoverishment due to health-related expenses by 2030. Gaps persist between policy, implementation and results. Nonetheless, both rights holders and duty bearers share the urgent need to accelerate investments to close those gaps. We need to highlight the imperative for intentional investments for universal health coverage with a view to identifying the barriers and enablers.

Prospective investments
A review of Ghana’s flagship health financing interventions underscores the value of investing in universal health coverage to improve population health. Ghana has defined universal health coverage as: “All people in Ghana should have timely access to high-quality health services irrespective of the ability to pay at the point of use.” In 2003/2004, Ghana began implementing the National Health Insurance Scheme. Skilled care coverage increased from 44% to 57.6% in 2019, and maternal deaths declined from 199.7 per 100,000 to 139 per 100,000 livebirths in 2019. Life expectancy at birth also improved from 56.4 in 2005 to 64.74 in 2019. These statistics, while not sufficiently robust, show some association between the programmatic investment and key health outcome indicators.

The burden of non-communicable diseases is rising, in addition to our infectious disease burden, especially in low- and middle-income countries. Other health system challenges include inequitable training and deployment of essential health professionals to needy areas, low and erratic health sector funding, infrastructure deficits, suboptimal use of information and communications technologies for health, and low health literacy. Thankfully, the government recognises health as an instrument of wealth creation by human capital development, productivity and poverty eradication, which provides the impetus for scalable investments.

Barriers to coverage

The Covid-19 pandemic has exposed deficits in our fragile health system and affirmed the importance of investing in health. It amplified the connection between health and socio-economic security. It exposed the siloed thinking and years of disinvestments in the health sector. Evidence shows that countries that approached Covid-19 management from a systems perspective were better able to contain or mitigate the unintended consequences of the pandemic. Beyond the limited fiscal space is the issue of political leadership’s interest and appreciation of the health sector as a high priority input for socio-economic development. A study conducted from 2010 to 2018 assessed the performance of the 15 West African countries on universal health coverage, focusing on governments’ priority to spend domestic resources on health care. It found that no West African country beat the minimum 15% on a health priority index. The top three countries were Ghana (8.4%), Cape Verde (8.3%) and Burkina Faso (7.5%). The study concluded that West African governments and relevant stakeholders must prioritise health in their political agenda, thus highlighting the essence of governments’ budgetary commitment to health and universal health coverage.

Furthermore, suboptimal investments are often undermined by two key factors. First, the health sector is often limited by inadequate technical skills (health economics, policy analysis), advocacy pitch (negotiation lexicons) and lobbying gravitas (networks, clout) to present the health sector as a vital socio-economic development instrument to the finance ministry. Second, because the concept of primary health care is overlooked, citizens remain passive in demanding accountable investments in providing equitable quality health services. Thus, limited household inclusion and community participation in health do not promote enhanced self-care and self-reliance as part of health promotion and disease prevention services.

These factors often culminate in suboptimal investments in core pillars of health systems strengthening: leadership and governance, health service delivery, health resources, health financing, medicines and technologies, health information and research, community participation and partnership development.

Health enablers

The paradox of the Covid-19 pandemic is that it presents rare opportunities for some catalytic investment in health. At the dawn of the pandemic, Ghana’s national response was anchored in a whole-of-government and all-of-society approach. Suddenly, this government-led and country-owned approach to pandemic containment proved critical in effectively managing the response. Political leaders, faith-based leaders, corporate entities, civil society organisations and the entire citizenry now realise that health is everyone’s business. Perhaps there could be no more opportune moment to galvanise investments from all sectors (public and private) for health. Indeed, it would be a catastrophic missed opportunity not to consolidate the legacy of this state–society partnership as a platform for the mobilisation, optimisation and accountability of resources for health in a sustainable manner.

Call to action

The lesson of the Covid-19 pandemic is clear: health is an investment in the future well-being and safety of all. There should be a renewed focus on the ‘Keys asks from the UHC movement’: ensure political leadership beyond health, leave no one behind, legislate and regulate, uphold the quality of care, invest more, invest better and move together. Translating political will into positive health impacts must be accelerated to achieve universal health coverage. In many ways, UHC2030 presents an optimistic outlook and performance framework for improved health outcomes. It validates the African Union members’ commitment to the 2001 Abuja declaration, which enjoins countries to allocate 15% of their government budget to health. External development assistance, although indispensable with its own trajectories and conditionalities, should complement intentional country efforts to attain universal health coverage, especially as donors transition from low- and middle-income countries such as Ghana. Given the value of investing in universal health coverage, the health sector requires a sustained push and pitch from all stakeholders and coordinated action from frontline actors – public, private, partners and top-level political leadership – to push health onto the high-level national investment radar. This shared responsibility must be anchored in the three key pillars of universal health coverage – inclusive population, responsive range of quality health services and financial protection – which require equitable financial contributions to national investment mechanisms.