Getting to universal health coverage: the importance of deep politics
Edward Laws is an independent research consultant who has written extensively on political settlements in fragile and conflict-affected areas and is a Research Associate of the Developmental Leadership Program and has undertaken research with the Overseas Development Institute.
Since ratification of Sustainable Development Goal 3.8, momentum has been building for a big global push towards universal health coverage. Whilst this widespread support for access to health care for all is encouraging, it is important to be aware that reforming how health care is financed poses not only a technical challenge, but also political one.
The World Health Organization implicitly recognises these challenges, but what is less clear is what universal health coverage (UHC) actually means in practice for those working to achieve health reform in low- and middle-income countries.
With this in mind, research published by the Overseas Development Institute looks at six case studies to examine whether the underlying power relationships between elites in a country – or its ‘political settlement’ – has any bearing on how UHC is achieved. We found some cautious support for the hypothesis that progress is likely to be optimised when advocates for UHC choose a strategy that ‘fits’ the political settlement.
Our case studies suggest that countries with a politically dominant elite (in the sense of having a very firm grasp on power) tend to make better progress towards UHC than countries where there is a greater degree of political competition.
Our research indicated that Vietnam, Kyrgyzstan and the Democratic Republic of Congo have made progress towards achieving UHC.
Firstly, Vietnam has made strong progress on service coverage and quite strong progress on reducing out-of-pocket expenditures, especially since 2000, thanks to strong national ownership and sustained political commitment and leadership.
Similarly, Kyrgyzstan is a strong performer for its level of income, thanks to consistent presidential commitment, strong leadership in the health sector, and supportive multi-stakeholder partnerships.
The Democratic Republic of Congo, while still performing poorly on most health outcomes, has actually made rapid progress since 2003 in service coverage and reducing out-of-pocket expenditure, thanks mainly to a large injection of donor funds and some innovative development partner and non-state initiatives.
In contrast, Myanmar, Bangladesh and Indonesia present a different picture.
Myanmar presents a more mixed case. Having neglected health provision and financing for the majority of its independent existence, the country has, since transitioning to a nominally civilian government, committed to UHC and made rapid progress on service coverage indicators, with signs that out-of-pocket expenditures are also coming down.
Bangladesh has a highly competitive political environment. Despite achieving quite good health outcomes for its income level, it performs poorly on certain service coverage indicators, and on out-of-pocket expenditures, thanks partly to the inability of government to follow through on commitments in a health sector riven with patronage and interest group politics.
Likewise, Indonesia, for its income level, is a relatively poor performer, having been slow to pass UHC legislation and with progress varying considerably according to the nature of ‘local’, decentralised political settlements.
Progress can happen in unlikely circumstances, as we found with the Democratic Republic of Congo. Once considered a model for the African continent, its health system suffered near total collapse during the protracted civil war between 1995 and 2001. This deterioration has been compounded by years of government mismanagement and neglect. In spite of this, the Democratic Republic of Congo has made the most progress of all the countries we looked at – but largely as a result of increased donor assistance. This suggests it may be easier to make rapid progress, at least at lower levels of UHC, in a country with a strong ruling elite that has surrendered its health sector to donors, than it is in a more competitive political context.
Our research points to some broad conclusions about the politics of UHC:
- The nature of the political settlement in a country is likely to affect the desire and ability of governments to commit to UHC, and, perhaps more importantly, to implement it.
- UHC advocates need to start with a detailed analysis of a country’s underlying politics, at both the national and more local levels, and understand how these arrangements might determine more and less feasible pathways to reform.
- Armed with this understanding, advocates for UHC should structure their efforts accordingly. For example, in countries like the Democratic Republic of Congo, which has a dominant, highly predatory ruling elite, it may be sensible to look for non-state and market solutions to provide the essentials of a public health bureaucracy.
- In more competitive political environments like Bangladesh and Indonesia, policy design and adoption can be frustrated by vigorous interest-group politics. In this context, UHC champions may need to focus more on connecting the more effective parts of the state and policy with the more effective elements of the market and civil society.
- In countries like Vietnam and Kyrgyzstan, where the dominant ruling elite is prepared to take the lead in designing and implement UHC policies, the best-fit strategy is likely to involve providing technical support and funding for a predominantly state-centred pathway.
What is clear is that, as a growing number of low- and middle-income countries set out to make quality health care universally available, UHC advocates cannot afford to ignore politics when designing their programmes.
To view the article by the Overseas Development Institute, please click here
This was a joint post, with Tim Kelsall and Tom Hart from the Overseas Development Institute
- The challenging quest for universal health coverage | Opinion
- PPE: the Oxford degree that runs Britain
- America’s Humanitarian Architect
- The Second Night Of The Democratic Debate Was Really, Really Intense
- Full text of the 2019 Spending Review - what Sajid Javid just announced
- 2020 Daily Trail Markers: Trump's impeachment trial likely to bench Senators running for president
Getting to universal health coverage: the importance of deep politics have 963 words, post on globalhealth.thelancet.com at April 14, 2016. This is cached page on Talk Vietnam. If you want remove this page, please contact us.