How do political considerations shape Universal Health Coverage?

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Taylor Williamson

Taylor Williamson

Taylor Williamson is a Health Systems Manager at RTI International, where he helps governments, universities, and civil society tackle health systems and policy challenges. His published work, including peer-reviewed articles, working papers, and policy briefs, explores human rights, accountability, and health systems strengthening. You can find him on Twitter at @WilliamsonRT.

How many times have you heard that there is a consensus on universal health coverage (UHC)?  How often have you been told that the global community agrees on UHC as a goal, and we just need to figure out the mechanisms?

As noted in our previous blog, advocates have historically framed UHC as a universally agreed upon policy objective and have focused on technical design and implementation questions. With this technical focus, we have intentionally de-politicized UHC in a modern version of what James Ferguson memorably called the Anti-Politics Machine, reducing challenging investment decisions to technical cost-benefit analyses. Instinctually, however, we understand that decision making is not solely a question of costs and benefits. We must start asking, and answering, tough political questions if we are to realize the promise of UHC.

Fortunately, the global community is starting to recognize the political nature of UHC. Dr. Tedros Adhonom, the Director-General of the World Health Organization, for example, acknowledged these concerns calling UHC a “political choice” that requires “vision, courage, and long-term thinking”. The truth is that UHC is still very much a political question and requires forging coalitions, convincing constituencies, and exercising political power.


Lawmakers meet during a session of Parliament in Accra, Ghana, June 16, 2006. (Photo by Jonathan Ernst)

Political elements that affect UHC

Saying that politics is important to UHC is not novel, or enough.  Advocates want guidance on which factors are important and how to navigate tricky political waters to make UHC a reality. Thanks to some forward-thinking political scientists, we are starting to learn more about the political factors that influence the adoption and design of UHC. Let’s turn, first, to one factor of critical importance in high income countries: labor groups.

According to Jesse Bump, worker shortages and political support from labor provides crucial leverage necessary to achieve UHC. In late 19th century Germany, for example, labor unions supported the Social Democratic Party (SDP) and their efforts to increase worker protections.  The conservative government did not see these demands as human rights issues, but understood that providing protections was an opportunity to promote loyalty to the state.  Otto von Bismarck, the German Chancellor at the time, noted that, “The social insecurity of the worker is the real cause of their being a peril to the state.” He understood that to remain in power and prevent social unrest, conservatives, like himself, needed to blunt the growing demands of labor by appealing to nationalism. In response to labor demands, the German government created employment-based Social Health Insurance (SHI) schemes, starting with industrial workers in 1883. SHIs, however, were not truly universal until 1981, when artists were included in the schemes.

Yet many low and middle-income countries do not have the necessary labor conditions, or the competitive party system, for labor to wield political power. Ghana is perhaps the closest  example, where in 2000 the then-opposition and nominally center-right National Patriotic Party won an election by adopting a national health insurance, which had been a pilot project under the National Democratic Congress party. Labor unions had a strong influence on the design of the insurance scheme.

In some cases, though, countries that do not have competitive politics or worker shortages have also enacted UHC reforms. How has that happened? Here researchers found that social agreement, or the “willingness of a citizenry to support expansion of the welfare state.” Gupta, for instance, identifies that Buddhism unifies Thailand, and that Thais are more likely to support social programs that benefit their fellow Buddhist Thais.   In countries with greater class, socio-economic, ethnic, or religious differences, however, he expected UHC reforms to be slower or more halting.

Fundamentally, this factor depends on the citizens’ understanding of the role of the state and willingness to “impos[e] upon its members the sacrifices of redistribution.” This question should seem familiar to anyone who closely follows politics, as political debates in many countries hinge on disagreements over the appropriate levels and structure of taxation, benefits for the poor, and pension or retirement funds. UHC imposes new costs and benefits on a countries’ citizens; yet, we, as UHC advocates, do not often acknowledge that some members of society may not be willing to share those costs, and those citizens often wield outsized political influence.

Even with social agreement to move toward UHC, a majority party must still be able to pass laws and implement UHC. Fox and Reich note that countries with fewer “veto points” embedded in legislative processes are more likely to enact transformative legislation, including UHC reforms. This factor can be defined constitutionality, for example, if a super-majority is needed to pass certain laws. Or it can be found in norms and rules that put barriers in the path of radical change, such as unanimous consent in the United States Senate.

Path dependency also becomes a problem, as previous choices create entrenched interests that lobby to preserve the status quo. The United Kingdom’s relatively fewer veto points, a consequence of the legislative majority’s greater power to change laws, is one of the many explanations for why UHC reforms were adopted there, but not in the United States after World War II.


How can we use political thinking to bring us closer to UHC?

Knowing the outlines of the political processes and decisions that lead to UHC is only half the problem.  We must be able to use that knowledge to navigate country-level challenges and help advocates support UHC. Using the elements identified above, let’s consider some questions for advocates to consider.

First, we need to know how stakeholder motivations, interests, and power, including the relative position of labor unions, affect the drive for UHC. A number of tools exist to map stakeholder power, including easy-to-download software.  Though this step may seem obvious, I’ve seen a number of health reform efforts meet resistance due to an incomplete understanding of stakeholder motivations. For example, the writers of the 2010 Kenyan constitution did not fully grasp health worker opposition to devolution in Kenya, leading to crippling ongoing strikes for the last four years.

Mapping is only the first step, however. Advocates must also ask what messages will resonate with specific constituents and how UHC reforms should be structured to appeal to those groups. While technically sound legislation is important, legislation must be informed by a deep understanding of social dynamics to succeed. How does the country’s cultural heritage affect social protection? Should messages appeal to social solidarity (e.g., Thailand)?  A sense of nationalism (e.g., Germany)?  Or try to thread a narrow ideological divide (e.g., the United States)? These are questions that cannot be answered without context-specific information on influential stakeholders, public opinion, and social fault lines.

Finally, any reform process has sticking points that are built into the legislative process.  Is a particular political party more or less supportive of UHC? Is a supermajority needed to pass legislation? Which key supporters can overcome these barriers? Are there ways to enact UHC at lower levels of government, such as in a state or province?

Countries have enacted Universal Health Coverage in very different ways. Multi-payer systems, national health insurance, and national health services are all viable models for ensuring people get health services without going bankrupt.  Yet, the politics of how UHC is designed and implemented are just as important as the structures, once in place. By paying attention to these political issues, we can improve the odds that UHC becomes a reality.