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The universal health coverage campaign and the medicalisation of global health By focusing almost exclusively on individual access to medical care as the solution, UHC ignores the social determinants of health and the need for political action to realise it, says Jocalyn Clark. UNIVERSAL health coverage (UHC) - universal access to needed health services without financial hardship in paying for them1 - has become the rallying cry for many in the global health community as the end of the Millennium Development Goals (MDG) programme approaches and a new agenda is being fashioned for 2015 and beyond. In the post-2015 'fervour',2 UHC has emerged as the leading recommended overarching health goal, and has the support and endorsement of major institutions and organisations like the World Health Organisation (WHO), World Bank, the Foreign Policy and Global Health group, and the Rockefeller Foundation, among others, and a multitude of mostly supportive articles and editorials have been published in major medical journals, where UHC has been described by one leading journal as 'an insuppressible right'.3 Concerned about rising and catastrophic healthcare costs, especially in low- and middle-income countries (LMICs), more than 90 countries in December 2012 endorsed a United Nations resolution on UHC,4 which ensures its consideration in the broader development discussions. Others have projected that UHC - described as no less than a 'third global health transition'5 and an 'epic transition'6 - will not only improve access to healthcare but 'could have a transformative effect in the battle against poverty, hunger, and disease'.7 While it is indeed still an 'aspirational slogan',8 it is also difficult to argue with a concept that offers the promise of health services for everyone in the world who needs them. But in the zeal to embrace 'the UHC mantra',9 the conceptualisation and consequences of UHC - not as a normative good but as the singular priority in global health - have inspired relatively little critical examination. Among the few published critiques, some have raised concerns about the imprecision attached to calls for UHC where, for example, the range, quality and equity of services are inconsistently included and articulated in definitions,8-11 and this imprecision is said to threaten consensus and appropriate policy responses.8 Most reports and resolutions, in fact, fail to specify or make commitments to ensuring actual use, acceptability, quality or the necessity or appropriateness of health services, all of which are necessary for UHC to be effective.8, 11 Others highlight the not inconsiderable challenges of implementing UHC at the country level, where the necessary financial, legal and policy ingredients to support an effective health system and requisite human resources are often missing or inadequate.10, 12 Insights from the tradition of medicalisation analyses, which have roots in sociology and social constructionist approaches, enrich these critiques and allow for an examination of the UHC campaign and its framing of this singular global health priority. A medicalisation lens can be useful for critically examining the contemporary global health agenda, including what and how issues and problems get prioritised and framed, and what solutions are advanced (see box on p.19). Unlike the cases of the medicalisation of global health that I examine elsewhere - the global mental health movement13 and the non-communicable diseases agenda14 - where a health condition is promoted, defined and 'treated' in medicalised ways, here the interest is in how the UHC campaign positions access to healthcare as a core global health problem. Viewed through a medicalisation lens, it appears that the UHC campaign is currently defined and framed in narrow terms, elevating the role of healthcare, individualising health by focusing on access to personal health services, and creating opportunities for commodification; together this reductionism risks medicalising a key and high-profile component of the current global health agenda. I trace three features. Conflating healthcare with health First, too often in the current UHC discourse there is conflation of healthcare with health, an important and misleading conversion. A recent call to action in The Lancet, for example, interchangeably uses health and healthcare, asserting that UHC addresses existing constraints to 'scaling up access to health' and that the hope is to ensure 'all of the world's people will have access to health at an affordable cost'.7 Even the WHO Director-General's comments conflate health with healthcare services when declaring UHC, in 2012, to be 'the single most powerful concept that public health has to offer'.15 In fact, public health's main contribution and worldview are to deemphasise the role of healthcare services and instead highlight the multiple influences that act on health, in particular, the social and political determinants.16 Positioning healthcare as equivalent to health in these development debates massively elevates the role of healthcare in alleviating global health problems that in reality are so centrally linked to poverty, power and inequity. In turn, by positioning the primary solution as healthcare - of which biomedicine is the dominant, modern practice - the UHC campaign medicalises the agenda. As has been argued in other medicalisation analyses where healthcare is offered as the solution to public health problems, the tendency is to focus strategies on increasing access to personal health services, often financial access. Policy responses then become about improving access to healthcare, displacing the more salient goal of improving health, and ignoring the socio-economic conditions that created the vulnerability in the first place.17 Similarly, when it comes to redressing disparities, a medicalised view conflates health status disparities with health access disparities, overvaluing and overemphasising healthcare access,17 or, as Clift argues about UHC,9 assigning 'undue importance to the delivery of healthcare services as a determinant of health outcomes and downgrading the importance of the [needed] economic, social, and environmental changes'. As decades of reports and commitments by WHO and others have stressed, there are a multitude of factors affecting health, and healthcare is only one of them.9, 18 Access to care is a necessary but not a sufficient determinant of health. Indeed, as O'Connell and colleagues point out, the definition of health present in the UN resolution on UHC is much broader than could be achieved through provision of basic or essential health services.8 And although Marmot was referring specifically to primary healthcare in relation to UHC, his caution applies more widely: improvement of access to care 'is a worthy and necessary goal but, by itself, will not revolutionise global health, nor reduce large health inequalities'.19 This focus of the UHC campaign is of particular concern because the evidence suggests that healthcare on its own does not directly improve health outcomes. Historically, improvements in health and life expectancy were not the result of biomedicine but rather living standards, especially nutrition,20 and more contemporarily, even with substantial modern medical and technological advances, estimates range from 10%16, 21 to 43%22 of health being a consequence of healthcare. Broader social and economic improvements are more likely to produce health gains, and furthermore healthcare can cause harm, be wasteful and be costly; Benatar stresses that the increasing medicalisation of health generates unsustainable costs for societies.23 In relation to the UHC agenda, in particular, Clift argues 'even if we achieve UHC as defined, . this would not necessarily produce the best outcomes',9 and Victora18 warns that 'it is possible to have UHC while still having poor and declining population health'. Moreno-Serra and Smith, in a comprehensive review, show the mixed and patchy evidence base to support the contention that UHC leads to better population health outcomes, reporting that the relationship depends a great deal on the setting and its quality of governance and institutions, the characteristics of the system, the specific health indicators measured, methodological limits and the availability of data; they also highlight the importance of targeting care to those who need it.24 While they conclude, optimistically, that policy-makers should feel secure that steps towards universal coverage are an important strategy for population health, especially among poor people, this seems over-optimistic: it is clear that there is a scarce evidence base to support causal claims.12 Indeed the 2013 World Health Report's central thesis is the strong need for more evidence on UHC.25 Reductionism in the UHC campaign Second, the UHC goal risks medicalising health because it is reductionistic. Even in its broadest definition that might include preventative, rehabilitative and palliative care in addition to treatment, UHC clearly excludes the social and political determinants of health.19 As the 1978 Alma Ata Declaration first committed to26 and the 2008 Commission on Social Determinants of Health affirmed,27 action on the social determinants of health is essential to alleviate the gross inequalities in health that exist around the world. In fact, several inputs to the post-2015 health and development agendas, including the Rio+20 declaration28 and the inclusive World We Want consultation,29 emphasise the need for health goals that address these broader determinants, including environmental and living conditions, nutrition, income, education, gender and race. Others broaden the frame30, 31 to highlight the political determinants of health, arguing that the concentration of power in health agenda-setting, neoliberal ideologies and other dimensions of politics can have an enormous impact on the health and inequalities of societies, and as such the political context must be accounted for. In contrast, UHC, however essential, 'reflects preventive and curative actions delivered at [the] individual level'.18 In fact, positioning UHC with its individualistic approach as the preeminent health goal would appear to contradict previous global health commitments and resolutions that emphasise action on the social determinants of health and the need for political action and a long-term view. Without such a view, short-term thinking 'incentivises a focus on interventions, physical entities (vaccines, medicines, devices, equipment) that one can buy, distribute, and count the effects of quickly'.32 UHC has been described as a 'silver bullet solution' to healthcare needs in LMICs12 and, when focused on expanding networks of healthcare professionals and institutions, can produce a medicalised vision of health that simply makes more medical treatments available to more people.23 Like other target and priority settings in global health, silver- or magic-bullet solutions are often favoured because they are seen as being easier to monitor, implement and measure; able to produce immediate results and quick wins; and aligned with the existing agendas of national or international institutions.33, 34 But emphasis on the individual level deflects attention from the political context and from population-level interventions such as taxation of harmful products; legislation of nutritional content of foods; and policy reforms to promote physical activity, fund preschool education, improve housing quality or ensure water and sanitation infrastructure, among others, that can improve communities' health.18, 19 Ignoring the social and political context means that the UHC goal can overlook the action needed outside the health sector, including the economic and social sectors enshrined in Alma Ata as of 'basic importance to the fullest attainment of health for all'.26 While some proponents claim that UHC is rooted in the human right to health,35 others argue it ignores international agreements on health and human rights:11, 36 Ooms and colleagues assert that UHC on its own is not enough to ensure the right to health without policy commitments to also ensure underlying determinants of health, and more robust civil society participation and collaboration with the communities whose health is at stake.2 Financing eclipses service delivery The third issue fuelling the medicalisation of health is the priority given in the UHC campaign to financing rather than service delivery. Such framing - where the promise is said to lie in pooled financing not pooled provision12 - and in particular its lack of explicit support for public health systems strengthening, provides wide opportunities for profit-making and risks commodifying healthcare. As Sengupta argues,12 the predominant definition of UHC is 'a health financing system based on pooling of funds to provide health coverage for a country's entire population, often in the form of a "basic package" of services made available through health insurance and provided by a growing private sector'. Most reports fail to emphasise the importance of public health services, instead focusing on cost-effectiveness and efficiency,12 which are values of medicalisation.37 In the leading model of UHC, the state's role is to manage, regulate and possibly purchase services, but the health services themselves are conceived as marketable commodities and they create an entry path for private insurance companies, private healthcare providers and managed care organisations.12 Thus, UHC can contribute to new and broader healthcare enterprises by transforming the healthcare needs of a population into specific commodities, defined by (mostly medical) experts, for economic markets.38 As with the growing commodification of aging,38 this is a form of medicalisation. Such a model ignores the implications for equity, whereby private systems may avoid providing care to the poor, aged, chronically ill or other patients who have conditions requiring costly or long-term care. In turn, this risks diverting attention and investment away from strengthening or rebuilding public health systems to provide UHC. Or, as Sengupta argues, this represents a 'private sellout of health systems via UHC'.12 The focus in the current UHC campaign and this framing also represents a turn away from Alma Ata commitments and the thrust of most campaigns for health systems strengthening that seek integrated, equitable and community-driven systems. Freedman and colleagues have proposed a conceptualisation of the health system as a core social institution that functions at the interface between individuals and wider structures of power,39, 40 which is thus capable of setting and reinforcing social norms. A context in which healthcare is bought and sold like a traded commodity risks the social legitimisation of the exclusion of those without the ability to pay. Indeed, even strong proponents of UHC suggest there is no guarantee that it can ensure that healthcare remains a collective good,7 and critics call instead for a strengthening of the underfinanced public sector.12, 41 How can the UHC campaign avoid medicalisation? There appear to be several ways that the UHC campaign can broaden the discourse to avoid contributing to or fuelling the medicalisation of global health. First, it would seem essential to cease confounding health and healthcare, which is misleading and inaccurate. Irrespective of one's view of the relative contribution of health services or the health system to health, it is wrong to conflate in debates on UHC the terms 'healthcare' (or 'health services') with 'health'. This serves to erroneously promote the idea that health is achieved by healthcare alone, and elevates the position and role of biomedicine in solutions, policy responses and investment, distorting the broader determinants of health and threatening the success of proposed interventions. Prioritising a goal that emphasises the importance of access to healthcare takes attention away from the social and political determinants of health, which, as a second recommendation, clearly must be better incorporated into the UHC campaign and goals. To galvanise support for this broadened campaign and goal, Marmot says, the global health community can take action on the social determinants through 'changes in clinical practice, partnership working, advocacy, education and training, and employment conditions of health-sector workers'.19 Health workers can also lobby for a much-broadened goal that avoids medicalisation, perhaps along the lines of a recent Go4Health report that advocates for a broad goal of realising the right to health for everyone, supported by two secondary goals of UHC anchored in the right to health and in healthy social and physical environments.42 Further, Navarro and others argue that no consideration of the determinants of health is complete without examining the politics and power relations of the system in which priorities emerge,30, 34 and thus more attention to how the global political economy enables or obstructs achievement of UHC is needed. Third, equity would seem a particularly important dimension to tackle further within UHC efforts as it appears to invoke a difference of opinion.25, 31, 43, 44 Whilst the early positioning of UHC would suggest that universalism and removing financial hardship equate with equity, some commentators argue that simply providing coverage of the status quo (more of the same) will reproduce present inequities.8, 31 Furthermore, health inequities can increase when, for example, only wage earners or those working in formal sectors access available health services, excluding the poor.43 In O'Connell and colleagues' analysis,8 the assumption that equity is a natural consequence of UHC contrasts with the evidence showing that improved equity is 'conditional on how UHC terms and policies are defined, designed, implemented, and sequenced'. Consequently, an explicit equity focus will need 'hard-wired' measurement and independent accountability, which has been highlighted in critical analyses of the MDG targets and implementation;31, 33 otherwise, the UHC campaigns risks worsening inequities. As Waage and colleagues33 argue more generally but relevantly for extending coverage of universal healthcare, 'issues of equity arise because many goals target attainment of a specific minimum standard . [but] to bring people above this threshold might mean a focus on those for whom least effort is required, neglecting groups that, for geographical, ethnic, or other reasons, are more difficult to reach, thereby increasing inequity'. Fourth, debates about the value and implementation of UHC must further incorporate discussions and analyses of the political dimensions (as mentioned earlier), and must specify the roles and appropriate contributions of both the public and private sectors, recognising the power of vested interests. The normative analytical frameworks of global health research (biostatistics, epidemiology, health economics) concern themselves with more proximate indicators of health, excluding due attention to the root causes and to the politics in public health, a scenario that Navarro describes as disinclining researchers to tackle the 'dirty issues' that may disrupt the neutral agendas of public funders.30, 45 But more analysis of the political dimensions and the global political economy is very much needed, and would widen the discourse beyond its current framing as a largely technical and financing issue; indeed, as Stuckler and colleagues have argued, adopting UHC and how it is implemented are primarily political choices.10 Since medicalising health props up an apolitical position with regard to UHC, it stands to reason that challenging medicalisation could be served by introducing the importance of political processes to the realisation of UHC. This then requires political debates and commitments to equity, quality and collective responsibility that could fulfil the expectations of UHC to provide a significant global health transition and 'transform poverty, hunger, and disease'. Furthermore, determining what individuals or communities want from healthcare coverage is not a technical issue either, but one of social value.8 Finally, more evidence is clearly needed on the outcomes and implications of UHC in practice, particularly in regard to health goals that aim for equitable and quality care. Jocalyn Clark is executive editor and scientific writing specialist at icddr,b (a global health research organisation in Dhaka, Bangladesh). She is also Adjunct Assistant Professor of Medicine at the University of Toronto in Canada. This article is reproduced from Global Health Action (Vol. 7, 2014, www.globalhealthaction.net/index.php/gha/article/view/24004) under a Creative Commons licence. Endnotes 1. WHO (2010). The World Health Report - Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organisation. 2. Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L, et al. Universal health coverage anchored in the right to health. Bull World Health Organ 2013; 91: 2-2A. DOI: 10.2471/BLT.12.115808. 3. The Lancet. The struggle for universal health coverage. [editorial]. Lancet 2012; 380: 859. 4. United Nations General Assembly. Agenda item 123. Global health and foreign policy, A/67/L36. 67th United Nations General Assembly; New York, 6 December 2012. 5. Rodin J, de Ferranti D. Universal health coverage: the third global health transition? Lancet 2012; 380: 861-2. 6. Frenk J, de Ferranti D. Universal health coverage: good health, good economics. Lancet 2012; 380: 862-4. 7. Vega J. Universal health coverage: the post-2015 agenda. Lancet 2012; 381: 179-80. 8. O'Connell T, Rasanathan K, Chopra M. What does universal health coverage mean? Lancet 2013; 383: 277-9. 9. Clift C. Is universal health coverage good for health? Universal health coverage and the post-2015 development agenda. 11 January 2013. Submission to www.worldwewant.org. Available from: http://www.worldwewant2015.org/node/299641#_ftn3 [cited 4 January 2014]. 10. Stuckler D, Feigl AB, Basu S, McKee M. The political economy of universal health coverage. Background paper for the Global Symposium on Health Systems Research, Montreux, Switzerland, 16-19 November 2010. Available from: http://www.pacifichealthsu mmit.org/downloads/UHC/the political economy of uhc.PDF [cited 4 January 2014]. 11. Carvalho de Noronha J. Universal health coverage: how to mix concepts, confuse objectives, and abandon principles. Cad Saude Publica 2013; 29: 847-9. 12. Sengupta A. Universal health coverage: beyond rhetoric. Municipal Services Project Occasional Paper No. 20, November 2013. Available from: http://www.municipalservicesproj ect.org/publication/universal-health-coverage-beyond-rhetoric [cited 4 January 2014]. 13. Clark J. Medicalization of global health 2: the medicalization of global mental health. Glob Health Action 2014; 7: 24000. 14. Clark J. Medicalization of global health 3: the medicalization of the non-communicable diseases (NCD) agenda. Glob Health Action 2014; 7: 24002. 15. Chan M. Universal coverage is the ultimate expression of fairness. Acceptance speech at the Sixty-fifth World Health Assembly, 23 May 2012. Available from: http://www.who.int/dg/speeches/2012/wha_20120523/en/index.html [cited 4 January 2014]. 16. Birn AE. Addressing the societal determinants of health: the key global health ethics imperative of our times. In: Benatar S, Brock G, eds. Global Health and Global Health Ethics. Cambridge: Cambridge University Press; 2011, pp. 37-52. 17. Lantz PM, Lichtenstein RL, Pollack HA. Health policy approaches to population health: the limits of medicalization. Health Aff 2007; 26: 1253-7. 18. Victora C, Buffler P, Ebrahim S, Mandil A, Olsen N, Pearce N, et al. Health in the post-2015 development agenda call for papers: a position paper by the International Epidemiological Association, December 2012. Available from: http://www.worldwewant2015.org/node/292903 [cited 4 January 2014]. 19. Marmot M. Universal health coverage and social determinants of health. Lancet 2013; 382: 1227-8. 20. McKeown T. The Role of Medicine: Drama, Mirage, or Nemesis? Oxford: Blackwell; 1979. 21. McGinnis JM, Williams-Russo P, Knickman JA. The case for more active policy attention to health promotion. Health Aff 2002; 21: 78-93. 22. Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care. Milbank Q 1994; 72: 225-58. 23. Benatar S. Global health: where to now? Glob Health Gov 2008/2009; 11. Available from: http://www.ghgj.org/benatar2.2whereno w.htm [cited 4 January 2014]. 24. Moreno-Serra R, Smith PC. Does progress toward universal health coverage improve population health? Lancet 2012; 380: 917-33. 25. WHO (2013). World Health Report - Research for Universal Health Coverage. Geneva: World Health Organisation. 26. WHO (1978). Declaration of Alma Ata. International Conference on Primary Health Care. Alma Ata, USSR. Available from: http://www.who.int/publications/almaata_declaration_en.pdf [cited 4 January 2014]. 27. CSDH (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organisation. 28. UN (2012). The future we want. A/66/L.56. New York: United Nations. 29. UN (2012). Realizing the future we want for all: United Nations task team report to the secretary-general. New York: United Nations. 30. Navarro V. What do we mean by social determinants of health? Glob Health Promot 2009; 16: 5-16. 31. D'Ambruso L. Global health post-2015: the case for universal health equity. Glob Health Action 2013; 6: 19661. DOI: 10.3402/gha.v6i0.19661. 32. Horton R. Offline: notes from the east river. Lancet 2013; 382: 1164. 33. Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, et al. The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015: Lancet and London International Develop-ment Centre Commission. Lancet 2010; 376: 991-1023. 34. Stuckler D, Basu S, King L, Steele S, McKee M. Politics of chronic disease. In: Stuckler D, Siegel K, eds. Sick Societies: Responding to the Global Challenge of Chronic Disease. Oxford: Oxford University Press; 2011. 35. Rockefeller Foundation. Universal health coverage: a commitment to close the gap. Rockefeller Foundation 2013. Available from: http://www.rockefellerfoundation. org/blog/universal-health-coverage [cited 4 January 2014]. 36. Harutyunyan V. Health after 2015: a human right? [letter]. Lancet 2013; 382: 679. 37. Sadler JZ, Jotterand F, Lee SC, Inrigh S. Can medicalization be good? Situating medicalization within bioethics. Theor Med Bioeth 2009; 30: 411-25. 38. Estes CL, Wallace SP, Linkins KW, Binney EA. The medicalization and commodification of aging and the privatization and rationali-zation of old age policy. In: Estes CL, ed. Social Policy & Aging: A Critical Perspective. Thousand Oaks, CA: Sage; 2001. pp. 45-63. 39. Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AM, Rosenfield A. Transforming health systems to improve the lives of women and children. Lancet 2005; 365: 997-1000. 40. Freedman L. Achieving the MDGs: health systems as core social institutions. Development 2005; 48: 19-24. 41. Sachs J. Achieving universal health coverage in low-income settings. Lancet 2012; 380: 944-7. 42. Go4Health. Realizing the right to health for everyone: the health goal for humanity. Available from: http://www.go4health.eu/wp-content/uploads/Go4Health-interim-report-September-2013.pdf [cited 4 January 2014]. 43. Carrin G, Mathauer I, Xu K, Evans DB. Universal coverage of health services: tailoring its implementation. Bull World Health Organ 2008; 86: 857-63. 44. Sankoh O, AbouZahr C, Adami H-O, Tollman S, Byass P, Tanner M. Universal health coverage and reliable global health estimates. [letter]. Lancet 2013; 382: 26. 45. Navarro V. Politics and health: a neglected area of research. Eur J Public Health 2008; 18: 354-6.
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