The possible impossibility of universal health coverage, by Richard Horton

The Lancet – Republicans eagerly assembled in the US Congress last week to formulate plans for dismantling President Barack Obama’s signature health initiative—the Patient Protection and Affordable Care Act, 2010—which has extended health-care coverage to 20 million citizens. Although “repeal and replace” has now given way to a more pragmatic “repeal and delay”, the new Republican-controlled Congress has the power to torpedo further attempts to deliver universal health coverage for Americans. But if Congress succeeds, the US Government will have struck a deadly blow against the global effort to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all” (Sustainable Development Goal 3.8). Given the commitment of nations, including (paradoxically) the US, to the SDGs and Goal 3.8, delivery of universal health coverage will be the major metric by which the global health community, and WHO and its new Director-General in particular, will be judged in coming years. But is universal health coverage truly deliverable? Putting America’s ideological proclivities to one side, are there forces overwhelming countries most in need of health care today, rendering their hope for universal health coverage a cruel illusion?

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The most important threat to universal health coverage is rarely discussed in polite global health circles. The issue is seen as politically incorrect, jeopardising human rights, potentially coercive, and, anyway, far too pessimistic. But an unvarnished review of the figures should disavow such qualms. The biggest danger facing universal health coverage is the risk of already weak health systems being unable to offer high-quality health care, free of financial risk, to their rapidly rising populations. Look at projections (from the US Population Reference Bureau) out to 2050, beginning with sub-Saharan Africa. Between 2016 and 2050, sub-Saharan African nations will add 1·2 billion people to their already strained health systems (2016 population, 974 million; 2050 estimated population, 2·13 billion). That is a 118% increase. Nigeria will add 211 million people to its struggling political and social infrastructure (2016, 187 million; 2050, 398 million; a 113% increase). The Democratic Republic of Congo will see a 168% rise in its population (2016, 80 million; 2050, 214 million). A further 19 African countries (with 2016 populations over 10 million) will see their peoples more than double between now and 2050: Benin, Burkina Faso, Cote d’Ivoire, Guinea, Mali, Niger, Senegal, Togo, Burundi, Mozambique, Somalia, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe, Angola, Cameroon, and Chad. It is very hard to see how these increases, taking place over just two generations, can possibly be sustainable.

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The population predicament for universal health coverage is not confined to sub-Saharan Africa. In South Asia, between 2016 and 2050, India will see its population grow by 379 million (or 29%) to 1·71 billion people. Pakistan, by 141 million (69%) to 344 million people. And Bangladesh, by 39 million (24%) to 202 million people. In North Africa, Egypt’s population will grow by 75 million (81%) to 169 million people. Sudan, by 63 million (149%) to 105 million people. And Algeria, by 22 million (55%) to 63 million people. The Middle East, an existing region of great political instability, is not exempted. Iraq’s population will increase by 101% (from 38 million to 77 million people). Afghanistan’s population will rise from 33 million to 62 million people (87%). Yemen’s population, from 28 million to 47 million people (71%). Resource-rich parts of the world will also see population increases, but in far more sustainable proportions. The Population Reference Bureau estimates a 5% growth in the population of more developed nations between 2016 and 2050—from 1·25 billion to 1·32 billion people. So what can be done? Some might argue that good political and economic stewardship can generate the fiscal space needed to invest in the health sector—especially if financing is targeted to sexual and reproductive health and rights—thereby avoiding a population-driven health system crisis. I am not so sure. Few of these nations give one confidence about the quality of their political leadership. To be sure, we should continue to champion the idea of universal health coverage. But we should be cautious about promising what we cannot deliver.

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