This paper reviews contemporary policy debates regarding priority setting for universal health coverage (UHC) in the context of instabilities in the global economy and the neoliberal program for managing those instabilities.
PHM recognises the importance of universal health coverage (UHC) although our endorsement is qualified because of the diversity of interpretations of UHC circulating, some of which, such as the World Bank’s multi-payer, stratified access, mixed delivery model, PHM does not support.
PHM endorses the need for equity and efficiency in the allocation of resources for health care and population health programmes including in the implementation of UHC. Health system design (funding and delivery configuration) is the major determinant of equity and efficiency in resource allocation and health care delivery. More specific approaches, discussed below, include: first, the use of ‘defined benefit packages’ in insurance dominated systems; and second, the methods and mechanisms through which equitable and efficient resource allocation can be promoted in tax-funded, public delivery systems.
While it is easy to define ‘benefit packages’ in terms of a list of ‘interventions’, it is a huge and costly administrative task to ensure that benefit payments are restricted to interventions that are used in accordance with clinical guidelines (assuming that clinically authoritative guidelines for that environment exist). The opportunity costs of implementing the defined benefits package strategy with integrity are particularly high in the context of private insurance and private practice.
Resource allocation in tax-funded public delivery systems can be efficient and effective; critical elements include: adequate funding, planning and budgeting at the district health system level, the role of senior clinicians in budget management and guidelines implementation at the clinical level, and community accountability with respect to both funding and administration.
The marketisation of UHC undermines the implementation of comprehensive primary health care. Reducing PHC to arbitrarily defined ‘interventions’ limits and distorts the analysis of needs and priorities; precludes effective community accountability; ignores public and community action around the social determination of health; and prevents best use of limited resources.
Contemporary policy debates around UHC are framed by macroeconomic instabilities globally and the neoliberal policies being put in place to manage those instabilities. Widening social and economic inequalities associated with neoliberal economic policies contribute to the fraying of social solidarity and consequently weaken political support for single pool single payer systems. Transnational corporations, as the principal conduits of foreign direct investment, are driving a race to the bottom with respect to tax policies (through tax competition) with increased restrictions on public funding of health care as a consequence. Neoliberal pressures to open new markets for corporate investors through health system privatisation (supported by trade in services provisions and investor protection provisions in contemporary trade agreements) contribute to the privileging of market models in health policy debate.
Not only are the policies of neoliberalism exacerbating the global economic crisis but they are driving inequity and inefficiency in health care delivery through marketisation and privatisation. Health policy makers should be fully aware of the perverse influence of the neoliberal program in debates around UHC, including around priority setting.
PHM calls upon policy makers to approach UHC with full consideration of the benefits of single payer financing and publicly managed health care delivery, including equitable resource allocation for efficient, safe and high quality care.