JAMA Forum: Legal Solutions for Universal Health Coverage

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Among all global health initiatives—such as the Global Polio Eradication Initiative, Roll Back Malaria (the RBM Partnership to End Malaria), and the Stop TB Partnership—universal health coverage (often abbreviated as UHC) has garnered the most political attention. The “sustainable development goals” adopted by all United Nations (UN) member states in 2015, have a single health goal, to ensure healthy lives and as well as promote well-being “for all at all ages.” Its most important target is to achieve universal health coverage by 2030.

World Health Organization (WHO) Director-General Tedros Adhanom has made universal coverage WHO’s highest priority. And last October, the UN General Assembly unanimously adopted a historic political declaration, “UHC: Moving Together to Build a Healthier World.”

Strong and resilient health systems are vital for health, but how universal health coverage is defined varies widely, which is troubling. The UN, WHO, and World Bank all stress financial risk protection. The sustainable development goals limit universal health coverage solely to medical and nursing care, rather than also encompassing public health services: “access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” The World Bank’s definition also stresses health care, noting that health services support nations’ strongest asset: human capital, a foundational investment in economic growth.

Even though the WHO rarely advocates for population-based public health services as part of the package of services, the agency has a broad concept of universal health coverage as “promotive, preventive, curative, rehabilitative and palliative health services.” Importantly, the WHO and the World Bank jointly monitor universal health coverage implementation, using the WHO’s definition.

If the ultimate aim of such coverage is to achieve healthier populations, then it must go well beyond health care, encompassing public health (for example, clean air, potable water, vector control, injury prevention, tobacco control) and social determinants such as income, education, housing, gender equality. Although the sustainable development goals do not broadly define universal health coverage, they do encompass vital targets, including sanitation, food, tobacco control, and alcohol control.

Legal Determinants of Health
Whatever the definition, universal health coverage can be accomplished only through the law. At the September 2019 UN General Assembly, the WHO, United Nations Development Programme, UNAIDS, the Inter-Parliamentary Union, and the O’Neill Institute for National and Global Health Law at Georgetown University launched the Legal Solutions for UHC Network to support national law reform. There are 3 core legal determinants of health: health laws must fulfill each element of universal health coverage, health systems must be well-governed, and public officials must abide by the rule of law.

Advancing the right to health through universal health coverage requires adherence to 5 key values. Health services must be universally accessible, equitable, affordable, of high quality, and cost effective. A comprehensive national health law should ensure that everyone in the country is eligible for the full package of health services, medicines, and vaccines. No one should be excluded, regardless of their income, gender, race, legal residence, or other status. There should not be special eligibility criteria such as work requirements. In many countries, coverage of unlawful residents and migrants is most controversial, and most governments do not extend full (or even any) coverage to these groups. Yet, exclusion of migrants from full access to the health system is guaranteed to impede the sustainable development goal target of universal health coverage.

The next value of a vibrant health system is equity. Universal health coverage must not simply be universal but also fair. Many countries purport to offer universal coverage, but often the services offered in poor neighborhoods are of lower quality than what is offered in high-income communities. Every person has a right to a roughly equal set of services, with uniformly high quality. Affording certain communities fewer services or lesser quality violates the letter and spirit of universal coverage. National action plans for health equity, including disaggregated data to reveal inequities, are vital.

Both the UN and WHO emphasize the importance of affordability. Requiring user fees for health services will render services unaffordable for the poor. Furthermore, accessing services should not lead to impoverishment. In the United States, for example, surprise medical billing has become a major issue because it often pushes families into bankruptcy.

Health services should be of uniformly high quality. Laws and regulations, for example, can ensure that pharmaceuticals are safe and effective, that physicians are well qualified, that hospitals meet certification standards, and that health facilities avoid medical errors or hospital-acquired infections.

Finally, health systems must be cost effective. No country has an unlimited budget for health services, and governments must balance health services with other important national priorities, such as education, transportation, infrastructure, and social safety nets. Thus, national legislation can appropriately limit guaranteed health services, guided by evidence of what interventions are most effective and how much they cost, and consistent with robust health budgets and equity considerations. Many countries limit medical spending by negotiating drug prices or refusing to cover high-priced services that have relatively low effectiveness compared with other more cost-effective services.  

Financing Gaps
National health budgets are primarily important, but many low- and middle-income countries do not have the financial resources to ensure high-quality health services for all. The international community should help close financing gaps for universal health coverage through financial assistance for health-related development, commonly called development assistance for health, or DAH. This requires 2 transformations in DAH. First and foremost, countries must expand their budgets for this kind of assistance. Although the United States consistently provides more funding for DAH than any other country, high-income European nations have far surpassed the United States’ assistance in per capita and other expenditure measurements. Importantly, many countries, including the United States, make contributions below agreed-upon international targets for development assistance.

Even if national health laws adequately address these 5 core values, there are additional requirements for ensuring healthy populations. Health systems must be well governed. Good governance requires evidence-based targets, monitoring and measuring outcomes, transparency, honesty, and accountability. It is impossible to know if health systems are meeting population needs without carefully evaluating outcomes, based on full transparency. Public officials, health workers, and hospitals must be good stewards of health resources. Thus, active measures to combat waste and corruption are essential. And, of course, there must be systems of accountability for meeting key health system objectives.

We also need high-quality information, including subpopulation data. It is impossible to track health disparities without understanding who is being left behind. The only way to close the health equity gap is to measure health outcomes with granular data, and then act on those data.

Finally, but importantly, governments must abide by the rule of law. If people, especially the most vulnerable, are subjected to discrimination or marginalization, their health is undermined. If the political and judicial systems are poorly functioning, we cannot achieve health justice. And if civil society freedoms are suppressed, people’s health and safety will be threatened.

While many people think of universal health coverage as a purely scientific, technological pursuit, in truth, good law and governance are vital for the health and safety of populations everywhere.

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About the author:  Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. He is an elected lifetime Member of the National Academy of Medicine (formerly Institute of Medicine) of the National Academy of Sciences. His book Global Health Law (Harvard University Press) is now translated in traditional and simplified Chinese and will soon be published in Spanish and Korean.  (Image: Georgetown University Law Center)

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