In the extraordinary political battles in the UK and US in recent months, the issue of access to healthcare has been wielded to great effect. In the run-up to the UK’s 2015 general election, the Conservative government suddenly found £8 billion to inject into the nation’s beloved NHS. According to pro-Brexit campaigners, a year later, this would be dwarfed by the £350 million per week they claimed would be spent on the NHS were Britain to leave the EU. Meanwhile in the US, Senator Bernie Sanders’s extended campaign in the primaries was sustained by his commitment to bring healthcare to all Americans.
What he and most political leaders in high-income countries recognize is that universal health coverage (UHC – everybody having access to health services and financial protection from the costs of services) is popular. So extending health coverage to more people can bring substantial benefits to political leaders, in terms of increased popularity and therefore more votes. Conversely, taking health coverage away from people may have dire political consequences. This perhaps explains President-elect Donald Trump’s back-peddling on his threat to immediately abolish Obamacare. In fact on numerous occasions in the past, Trump has actually promoted state-financed healthcare, so it will be fascinating to see how his health policies develop when he takes office.
Processes that take countries towards UHC are inherently political because it requires the state to compel healthy and wealthy members of society to subsidize health services for the sick and the poor. This results in a much greater role for compulsory public financing mechanisms (tax financing and social insurance) over voluntary private mechanisms (user fees and private insurance). This health financing transition tends to be very popular with people on average and low incomes who gain greater access to expensive health services. It is less welcomed by people on higher wages, who are required to pay higher taxes. However despite this political opposition, with the notable exception of the US, all high-income countries have now made this transition because their governments have responded to the demand of the majority of the population to switch to a publicly financed health system.
These transitions, which occurred in the UK in 1948, Japan in 1961, Canada in 1968 and South Korea in 1977, have taken place in most Latin American countries since the 1980s – especially once democratically elected governments replaced military dictatorships. Thailand is another example of a country where a political leader (Thaksin Shinawatra) swept to power promising to bring UHC to the masses in 2002.
With all countries now committed to reaching UHC, following a special UN resolution in 2012, where might the next UHC transition occur? Not surprisingly, attention is tending to focus on middle income countries (especially democracies) that now have the fiscal capacity to finance a health system for everyone.
Indonesia appears to be going through this process; the meteoric rise in the popularity of President Joko Widodo (Jokowi) was in no small part due to his ambitious UHC reforms in the capital when he was governor of Jakarta between 2012 and 2014. Now that he is president, will Jokowi fulfil his election promise to extend health coverage in Indonesia from around 70 per cent currently to full population coverage by 2019? The World Bank has estimated that this would require public financing equivalent to around one per cent of GDP – less than what Indonesia currently spends on energy subsidies.
India and Nigeria are large middle-income countries that have only made slow progress towards UHC to date. However in both countries, while national-level reforms have stalled, state-level politicians appear to be following the lead of Jokowi and are pioneering ambitious UHC reforms. Not only is this improving access to health services in the relevant states, it is contributing to an increase in the popularity of these leaders at the national level. For example in India, Arvind Kejriwal, the chief minister of Delhi, has launched an extensive programme of free health services provided through mohalla (neighbourhood) clinics across the city. In just over seven months these have reputedly treated over 1.5 million people in Delhi. Kejriwal’s Aam Aadmi Party is now campaigning to bring these services to states holding elections in 2017. Similarly in Nigeria, some state-level governors, such as Olusegun Mimiko of Ondo State, have rapidly extended health coverage to vulnerable populations and have been championing their successes at a national level.
Perhaps these provincial level leaders have been inspired by one of the great UHC leaders of the 20th century, Tommy Douglas in Canada. Not only did he bring universal, publicly financed healthcare to the province of Saskatchewan, he fought a long and successful campaign to bring these benefits to the entire Canadian population. In recognition of this achievement, he was voted the ‘Greatest Canadian of All Time’ in a poll run by the Canadian Broadcasting Cooperation in 2004. Successful UHC reforms can not only help politicians win elections and stay in power – they can also turn them into national heroes.
Robert Yates is an internationally recognized expert on universal health coverage (UHC) and progressive health financing. At Chatham House he is project director of the UHC Policy Forum.