Invest more, invest better: Civil Society calls for clear UHC financing commitments to leave no one behind

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This blog is part of a series on Universal Health Coverage (UHC). The series includes contributions from external bloggers and reflects their views. Follow the conversation on Twitter #healthforall.

 

As we discussed at the 2019 World Bank Spring Meetings, civil society is mobilizing to ensure that discussions about universal health coverage (UHC) result in concrete commitments that leave no one behind. To ensure that all individuals and communities receive the health services they need without suffering financial hardship, we finally need to see the fundamental shift away from voluntary, out-of-pocket and private health expenditure to fair and sufficient public financing. According to a joint report from the World Bank and WHO, Tracking universal health coverage: 2017 global monitoring report, domestic funding for health has fallen in low-income countries and globally 808 million people suffer as a result of high out-of-pocket payments for health care. UHC is far from a reality for many countries, including for poor and marginalized citizens in many high-income countries.

In the lead up to the first ever UN High-Level Meeting (HLM) on Universal Health Coverage in September 2019,  UHC2030, the multi-stakeholder platform co-led by the World Bank and World Health Organization, developed its Key Asks from the UHC Movement through broad consultation with its members, including  “Invest more, invest better” which says: “set nationally appropriate spending targets for investments in health (e.g., ideally at least 5% of GDP on public health.”  Based on our consultations with over 350 civil society representatives on how to best advocate for the Key Asks, the Civil Society Engagement Mechanism (CSEM) for UHC2030 has been calling for specific targets for the UHC High-Level Meeting, including 5% of GDP as minimum government spending on health

The first draft of the Political Declaration for the HLM recognized that all countries should achieve a minimum of 5% of their GDP as government health spending by 2030. However, the 5% target has come under attack from a number of sources and has been removed from recent drafts. We understand that the African Union was not opposed to this target but the European Union, the World Bank, and WHO have all, perhaps for different reasons, been uncomfortable with a blanket target which may be unrealistic for low-income countries. Unfortunately, a different blanket target, calling more generally on governments to review whether their public health expenditures are adequate and to increase public spending by an additional 1% of GDP or more, if necessary, is being proposed.

An extra 1% is severely inadequate in many countries that can and should be collecting more tax and investing in public spending. In others, which spend over 5% of GDP but don’t spend it well, it may not be necessary. We believe that the benchmark of 5% of GDP is important to retain. It is supported by evidence and sets goals and aspirations which civil society can then work to publicize and advocate for (see our factsheet Why 5% of GDP?). We recognize the path to 5% will be harder and slower for the poorest countries and that interim targets may be needed for different types of countries. But a blanket target of only an extra 1%, presumably to be achieved by 2030, is writing off the chance of UHC in many countries and assuming that people will continue to be impoverished by trying to pay for healthcare which their government does not adequately fund.

For many low-income countries, 5% of GDP would be a transformational increase but would still be below recommended levels for achieving UHC. Donor governments should also commit at the HLM to invest at least 0.1% of their GNI on Official Development Assistance (ODA) for health, and to better alignment and coordination of financing mechanisms to support achievement of UHC (rather than provision of disease-specific funding that encourages fragmentation of health services and limits funding for primary health care).

CSEM members have been asserting these asks to the G20, at the interactive multistakeholder Hearing for the HLM, and at the World Health Assembly. We’ll keep up that drumbeat as negotiations on the Political Declaration for the HLM continue in New York, as governments prepare the commitments to UHC that their Heads of State will endorse in September. In addition to this global advocacy, CSEM members are engaging with their national Ministers of Health and Finance to discuss these asks and raising awareness at the community level about government commitments to achieve UHC so that promises that made in September in New York don’t just stay in New York, but become reality at the country level.

We hope that all stakeholders will join us in our advocacy to promote these health financing asks, and all of the Key Asks from the UHC Movement. Tools to help you do so are available on the CSEM website and the on the UHC2030 HLM campaign page. The theme of the HLM on UHC is “Moving Together to Build a Healthier World.” Let’s move together towards the reality of health for all, and a world where no one is ever again pushed into poverty by seeking the healthcare they need and deserve.

Topics

Authors

Simon Wright

Director of International Development Policy, Advocacy & Campaigns at Save the Children UK

Amy Boldosser-Boesch

Senior Director and head of the FCI Program of Management Sciences for Health (MSH)

Join the Conversation

Peter Ngo'la Owiti
July 29, 2019

The Abuja declaration had put the health budget to be at 15% of GDP. Now we are talking about 5%. May i get soemclarity

David
July 29, 2019

Nice

Mange Ram Adhana
July 29, 2019

Dear sir / Madam
Greetings from APSD
Our NGO is working on UN Sustainable development goals and targets and agenda 2030 for sustainable development. So we want to be engage with your programme, and activities. Please take a appreciate action in the subject. Thank you
Mr. Mange Ram Adhana President
Association for Promotion Sustainable Development

Stephen Jan
July 29, 2019

I agree with the general emphasis on the need to increase public expenditure in LMIC as a means of achieving UHC. However I want to highlight the problem of the 5% of GDP target and then suggest an alternative. The 5% figure can be broken down to two components. 1) % of overall expenditure of health as a % of GDP and 2) % of govt expenditure as a proportion of overall expenditure on health. (e.g. India spends 3.7% of its GDP on health, and 25% of this expenditure is govt. And so govt expenditure on health as a % of GDP is around 0.9 % - well below 5% target.)
For most LMICs, particularly LICs, the 5% target will be unrealistic. Even well performing LMIC countries (on the basis of UHC indicators) such as Thailand, Malaysia and Sri Lanka fall well short (e.g Thailand 3.7% of GDP on health, 78% of which is govt. Therefore govt exp as a % of GDP is around 2.9%.)
Generally speaking as countries increase in wealth, they will increase % of GDP spent on health (equation 1) AS A MATTER OF COURSE. For instance Rep of Korea in transitioning to being a high income country has seen with it a rapid increase in %of GDP spent on health e.g. from 4% in 2000 to 7.3% in 2016.
The problem with the 5% target for many LMICS is that spending too much of its GDP on health care risks distorting priorities and undermining the achievement of other development goals, as well as hampering investments outside health care sector which arguably have a greater role in promoting the health of populations. My suggestion is therefore focus more on equation 2 - a target of govt expenditure of around 75% of total health expenditure (which is the figure most HICs with UHC, and well performing LMICs such as Thailand have achieved, Sri lanka moving well towards with 46% in 2006 to 55% in 2016). This is a better target because it is agnostic to income level of a country and avoids potential for distorting priorities for the achievement of other SDG goals.