Pandemic momentum for health systems financialisation: Under the cloaks of Universal Health Coverage

ABSTRACT

Although a highly ambiguous and contested idea, Universal Health Coverage (UHC) is the hegemonic concept in international debates on health system reforms. States’ difficulties to provide adequate and comprehensive response to people’s health needs arising from the COVID-19 pandemic strengthened the impetus for UHC implementation. But while featured as the way to achieve justice in health, analyses of UHC-kind reform experiences since the 1990s show that it may be comprehended rather as a new facet of neoliberalism in the health policies’ arena. Its insurance arrangements are aimed to finance packages of health goods and services for the poor, while states play mainly a role of public funds administrators, buying from public and private providers competing in the market. UHC contributes to health system fragmentation and segmentation, weakens public structures and opens new markets for corporations to capture public funds. COVID-19 pandemic subjected health systems to unforeseen stress, underscoring the crucial role that a well-funded public health system plays in people’s lives. Assessing pandemic’s challenges may be an opportunity to build more egalitarian health systems, based on dignity and not people’s money. However, the unreflecting adoption of technocratic health paradigms and solutions may, instead, ultimately pave the way for further health financialisation and injustice.

KEYWORDS:

• COVID-19
• universal health coverage
• health system reform
• health financialisation

Re-imagining public health care – rather than the private sell out of health systems via UHC – is argued to be the only way forward in building truly universal health outcomes. (Amit Sengupta, 2013)

Introduction

Universal Health Coverage (UHC) is the hegemonic concept in international debates over health system reform (Laurell, 2015; Waitzkin, 2014). In only few years, it came to dominate health system reform international debates, as the solution to urgent healthcare needs, mainly in low- and middle-income countries (Sengupta, 2013). In general terms, UHC implies that

all people have access, without discrimination, to nationally determined sets of the promotive, preventive, curative and rehabilitative basic health services needed and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship. (United Nations General Assembly [UNGA], 2012)

Promoted by the World Health Organization (WHO), international financial institutions such as the World Bank, ‘philanthrocapitalist agenda setters’ (Birn, 2014) as the Gates and Rockefeller foundations, and a great share of the academy, UHC is also included among the United Nations (UN) Sustainable Development Goals (SDG), reaching ‘an apparent crescendo of consensus as a priority for international development’ (Birn & Nervi, 2019, p. 1). In the context of the COVID 19 crisis, this growing consensus seems to be further underpinning, given the pandemic’s disastrous effects.

But, when closely examined, the policies promoted by the UHC advocates and their epistemological foundations raise doubts on embracing this particular health policy paradigm to address the unbearable social injustices in health. Although the ‘slogan de jour’, UHC meaning and content is highly disputed and contested (People's Health Movement et al. [PHM], 2017). It may acquire different connotations in diverse contexts, according to the given social, political and financial interests involved (Heredia et al., 2015). In weighing its suitability, there is a pressing need to unveil the policy agendas behind UHC, its concrete implementation consequences and the implications embedded in this trend (Birn & Nervi, 2019).

This piece aims to politically contextualise the UHC models and highlights some of its worrying features in face of the growing consensus over its convenience and its renewed appeal, given the disastrous consequences of the current pandemic. It asks for a serious and frank reflection before embracing colourful depictions of the right to health, which actually promote insurance schemes and inherently segmented and unequal societies.

Now more than ever?

SARS-CoV-2 rapid spread transformed all spheres of social interaction and subjected national health systems to unforeseen strain, leading in many countries to virtual collapse. The lack of adequate healthcare for infected people, with enough tests to detect the spread of contagion and a timely treatment for those who developed COVID-19 disease, highlighted the inequalities that the health systems go through in many countries.

These circumstances strengthened the impetus for UHC. In March 2020, the ‘UHC 2030 International Health Partnership’ chairs signalled that ‘faced by the COVID-19 crisis, it is crucial that leaders recognize the interconnectedness of UHC and health emergencies and remember their UHC commitments’ (Kickbusch & Gitahi, 2020a). In late April, they predicted that national health systems strength and the existence of a UHC approach are ‘what will make the difference to each country’s response to COVID-19’ (Kickbusch & Gitahi, 2020b).

Suddenly, the ‘now more than ever’ appeared as a catchphrase accompanying reflections on COVID-19, post-pandemic societies and health reform. From Italy, some asserted that COVID-19 evidenced the need for ‘Universal Health Coverage now more than ever’ (Armocida et al., 2020). In the same vein, others expressed that the crisis starkly showed that ‘now more than ever, the bold commitments towards UHC made by governments must be upheld’ (Cataldo, 2020). Others pointed out that ‘WHO should, now more than ever, strengthen its mission to promote health, keep the world safe and serve the vulnerable, through advocating universal health coverage among its member states’ (Takian et al., 2020).

Notwithstanding the urgent call to move forward UHC ‘more than ever’, some preliminary studies questioned whether UHC schemes have had any impact on the effectiveness of each country’s response to the pandemic. The UHC 2030 initiative itself expressed that ‘there does not seem to be a correlation between high scores in health security assessments, or on the UHC index, and an effective response to this epidemic’ (UHC, 2030, 2020, p. 2). A study assessing national health system performance together with the existence or absence of UHC schemes in those countries found similar results. The authors concluded that ‘despite its seemingly exalted benefits, Universal Health Coverage does not appear to protect against mortality in a pandemic environment such as with COVID-19’ (Dongarwar & Salihu, 2020, p. 216).

These warnings aside, the call to advance UHC is out there, insistently ringing out at every opportunity or audience willing to listen. But a critical listening is needed to think about policies and assess their strengths and implications, to grasp what the UHC hegemonic consensus consists of and to interrogate the call for its ‘now more than ever’ implementation. To open space for reflection, to weigh its actual suitability to achieve more egalitarian societies and not to deepen the current structural conditions of inequality and discrimination.

Structural reforms in health system and universal coverage

The contours of what are the current proposals for universal coverage began to take shape in early initiatives during the 1990s in Latin America, with reforms based on packaged insurance schemes, tied to the structural reforms promoted by international financial institutions, mainly the World Bank (Sengupta, 2013).

Latin American experience in health reforms cannot be understood but in the context of the structural adjustment policies throughout the subcontinent from the eighties onwards (Heredia et al., 2015). The debt crisis that unfolded in the early 1980s found dozens of countries defaulting their loans and the international financial institutions orchestrating structural adjustment reforms to reduce their fiscal deficits and meet their debt-service burdens while demanding the implementation of a series of neoliberal reorganisations. These comprised drastic cuts to social spending, removal of agricultural subsidies, lifting of labour protections, deregulation of industries and investment, trade liberalisation, privatisation of government services and state-owned assets, so as user fees for education and health services (Birn & Nervi, 2019, p. 5). In a scenario of falling raw natural resource prices and the deepening of fiscal difficulties due to the debt crisis, for many of these countries the reforms promoting a change from a public service model to one mainly administered by private actors appeared as the most viable option to overcome budgetary difficulties and the increasingly pressing needs of their impoverished population (Nuruzzaman, 2007, p. 60). The spread of these neoliberal policies and programmes through structural adjustment projects and policy-based lending affected numerous aspects of social life, such as education, social security and, certainly, health policy (García & Parker, 2019, p. 2).

Although it had already ventured into health reform and financing in the mid-1970s and 1980s (World Bank [WB], 1975, 1980, 1987), the 1993 World Development Report ‘Investing in Health’ (WB, 1993) marked World Bank's full entry into the global debate on health system reforms. Right after its publication, the report was criticised as a ‘prescription for health disaster’ (Antia, 1994) and nowadays is generally understood as crystalising ‘the neoliberal “turn” in health – economic analyzes, a baseline service package, a focus on individualism in health, and circumscribing government’s role in the sector’. With a clear focus on competition from private providers, the World Bank called for private sector involvement as ‘a cornerstone for improving health’ (Noy, 2017, pp. 53–4). The report constituted the neoliberal prescription for scaled-back public services, opening the door to private investment and advocacy for user fees in healthcare services (Birn & Nervi, 2019, p. 6). It took popular demands for increased public investment in health and transformed them into a policy prescription that encourages private investment and the creation of a new market in the health sector (Birn et al., 2016).

Like other structural adjustment programmes, the World Bank’s package of health reforms aimed at diminishing states’ control over health issues and a correspondingly increase in the role of the private sector. The adoption of a market-based health models in these countries was not a free choice, but was permeated by pressure the technical assistance from financial institutions, particularly the World Bank. World Bank’s health reform policy had four basic components: the introduction of health insurance, user fees, decentralised management and more space for private and non-governmental service providers (Nuruzzaman, 2007). Its result was the 1990s privatisations, which drastically weakened national health systems and contributed to increase social inequalities (Birn et al., 2016; Laurell & Herrera Ronquillo, 2010). During the 1990s and early 2000s, the World Bank was the ‘largest external funder of health’ (Ruger, 2005, p. 61) and operated as a consensus builder that served as a platform for the current UHC and the financing for national health systems (Sengupta, 2013). Even before the WHO adopted the today hegemonic UHC concept, the World Bank was already talking about the need for a ‘Universal Health Care Coverage’ (Kutzin, 2000). This was the backdrop for the reforms during the 1990s that would later lead to current proposals for UHC through public or private insurance schemes.

UHC proposal is not a breakthrough innovation, nor a magical solution stemmed from thin air to resolve health pressing issues all over the world. As Birn and Nervi (2019) warn, UHC has a concrete genesis. And, when analysed, it reveals that it is, actually, ‘the logical out-growth of four decades of neoliberal capitalist (health) ideology and associated policy-making’.

UCH is a much conservative approach, aligned with the neoliberal ethos in the social sphere, for which each area of social need is a business opportunity, health being no exception. In this, private healthcare providers and insurance companies may have access to and profit from money that, otherwise, would strengthen public and unified health systems for all. Rather, in UHC approaches those who can pay may access reliable and quality services, depending on their income and the insurance plan they can afford. Meanwhile, those who cannot purchase private health insurance, those expelled by the market, may have access to a basket of services provided by an underfunded public health system. For them, the state would provide ‘universal coverage’, which is expressed in some kind of inadequate and always restrictive safety net.

Insurance is no right to health nor access to healthcare

In view of the difficulties of developing countries’ health systems to guarantee equal and non-discriminatory access to comprehensive and quality healthcare, the promise of achieving a ‘universal health coverage’ is, in a way, highly attractive to governments, especially if it comes with international organisation endorsement and is included within the SDGs. However, upon closer analysis, it seems that universal coverage is far from the ideal of universal access, for all people on equal terms and without discrimination. On the contrary, it solidifies stratified systems, in which new business opportunities are opened to profit with public money for healthcare and people have coverage and access according to their ability to pay for it.

In debates over health reform, different conceptions of universality in health policies are actually confronted (Giovanella et al., 2018, p. 1764). Universal Health Systems (UHS) are aimed to ensure that all people have their health needs met without restrictions on access. These are usually financed by public funds from general tax revenues and social contributions, providing for greater solidarity, redistribution and equity. Its public nature absorbs and divides costs within society, promoting redistribution so that the richest pay for the poorest, reducing social inequity. Meanwhile, the key element in UHC is the combination of public and private funding to finance the health expenditures of the plan holders, depending on the package that each individual is able to pay, rather than their needs. In these, access is segmented according to the coverage of each plan (Giovanella et al., 2018, p. 1766).

Although universal coverage symbolically conveys the idea of universal access, the prevailing vision does not come with a unified and accessible healthcare system, but, on the contrary, discourages it (Waitzkin, 2014). It is so that, ‘notwithstanding the clever semantic flourish of incorporating the word “universal” universal health coverage brings with it the same salient proposals of neoliberalism recipes that sprouted throughout the arc of social well-being in recent decades’ (Birn & Nervi, 2019, p. 8).

UHC appears as the latest neoliberal co-optation of the global agenda of equity and justice in health policies, which is illustrative of the fate that other progressive efforts have had over the last decades. In these, a decontextualised and selective appropriation of the progressive agenda and discourse of justice in health is used by re-emerging neoliberal ideologies and actors (Birn et al., 2016, p. 2). Its two fundamental elements – the access to essential health services, for limited rather than comprehensive health needs, and the prevention of financial risk, understood as protection against bankruptcy due to out-of-pocket expenditures – reveal that, despite policy-makers’ efforts to invoke public interest and human rights, UHC is nothing more than a massive dilution of the progressive health agenda, which is stemmed and consistent with the neoliberal turn in global capitalism. UHC has been portrayed as ‘a nod to rights amid the deterioration of social conditions, but with assurance of financialization’ (Birn & Nervi, 2019, p. 6). While gaining new markets for insurance capital, UHC claims that it is the breakthrough for a better health for all, but actually contributes to a more segmented and unequal system.

International agencies came together behind UHC in response to the increasing catastrophic out-of-pocket healthcare spending, in the context of neglected public health systems and the expansion of private providers. However, these facts are neither a compelling case nor a sufficient reason to opt for the strengthening of private provision, but rather, on the contrary, should serve as a call to action to strengthen the poorly financed public sector (Sachs, 2012). But although public health system strengthening may be a path to follow, under the call for a UHC, the emphasis moved from how services should be provided to how they should be financed, whether provided by public or private actors (Sengupta, 2013).

UHC main goal is to promote financial health protection and to prevent health catastrophic expenses that may lead to families’ impoverishment. This means that everyone should be affiliated with some type of insurance, though it may not guarantee access to and the use of healthcare whenever nec­essary. These insurance approaches are intrinsically segmented, since access is tied to a concrete insurance contract of a given individual, which is in turn differentiated by social groups according to income, with differing coverage scope. Individual’s access to healthcare depends on each insurance policy, whether private or public, or their ability to pay for premium packages (Giovanella et al., 2018, pp. 1765–1766). For the marginalised population, minimum packages would be provided by the state safety nets.

Furthermore, universal coverage schemes generally involve the demarcation of benefit packages depending on income, packages for the poor and packages for the non-poor, underpinning fragmentation and unequal access to health services and goods (Waitzkin, 2014). The social aim of ensuring the realisation of people’s fundamental rights in their relationship with the health system is displaced by a purely economic and market definition. So, actually, regardless of how it is called, any policy that fragments more than it unifies, or that provides for segmented financing for various groups according to their incomes, is in contradiction with universalism in access to health, even if it calls itself universal (Birn et al., 2016, p. 14). While the ‘Health for All’ paradigm underpinning UHS promotes healthcare as a human right in which access does not differ by people income, based on gratuity, solidarity, redistribution and universality, insurance models are mainly grounded on financial criteria, according to individuals’ income and ability to pay for it. Focused on disease and care, insurance schemes reinforce segregation, segmentation and the lack of effective access for the poor (Laurell, 2017; Waitzkin, 2014). A policy of universal healthcare provision, on the other hand, ‘dictates that the government guarantees the actual provision of healthcare services to everyone, irrespective of income, status, etc.’ (Lethbridge, 2017).

Also, whereas providing only for fragmented insurance coverage and not universal access, UHC goes further and reinforces the debacle of the welfare state. It pursues market and competition in the administration of funds, the purchase of services and the provision of healthcare. Thus, public funds collected by the state for the social security of its population feed the private health market (Laurell, 2017). Role separation between funds administration, services purchase and healthcare provision, promoted by UHC, is crucial for private actors’ entry and a market-based health sector. The state mainly assumes a role of administrator and fundraiser, with which it buys goods and services that are provided by public or private actors. The provider/financier/buyer separation was a prominent feature in other public services reforms, in which this disaggregation of the tasks performed by the state led to privatisation. The disaggregation of state role in health financing and provision, ultimately, commodifies healthcare, which is freely exchangeable in the healthcare market (Laurell, 2014; Sengupta, 2013). UHC logic is based on the need to secure pooled funds for a health system organised according to market principles, in which the state is increasingly an administrator and not a provider. So, the state collects funds through general taxes or social security mandatory contributions, which are then transferred to companies that play in the healthcare market. In this, state’s role is to collect funds and then purchase and contract healthcare goods and services for their people (Birn et al., 2016; Sengupta, 2013; Waitzkin, 2014). The health sector is thus a new action field in which private companies can deploy their economic ventures. One in which the revenues they get are originated from the state public funds which, instead of strengthening public health systems, feed the private healthcare and insurance entrepreneurships.

Along with insurance schemes, UHC promotes competition between public and private providers, from which services are purchased. In these schemes, state whether withdraws from providing care to remain only as an administrator and funder of the health system or it keeps providing healthcare, but in competition with an expanded private sector, which is often for profit and fed by public funds (Birn et al., 2016, p. 13). And, while the private may provide more timely attention and personalised care, they respond to goods and services demand and not to a given population health needs. They are usually based in areas with greater socio-economic development, offering the more profitable services for the high-income individuals, furthering fragmentation and inequalities (Giovanella et al., 2018, p. 1766).

Hence, in universal coverage proposals, health is no longer a universal human right but rather a limited package of services, available to individuals and groups ‘covered’ by these policies, which are focused on the poorer people or in a situation of ‘financial risk’. Therefore, some have warned that ‘the mantra of Universal Health Coverage hides, thus, the exact opposite of its real meaning: a non-universal, non-comprehensive, non-public and non-free health program’ (Manchola Castillo et al., 2017, p. 2155). The replacement ‘Health for All’ in the spirit of Alma Ata with the much narrower goal of a universal coverage is deeply problematic because, although ‘deceptively similar’, these are ‘fundamentally different’ approaches (Sengupta & Prasad, 2011). Despite its aspirational language, universal coverage offers the possibility of penetration by large-scale private actors and the channelling of public resources towards private interests that strengthen inequitable and stratified health systems on the basis of people’s income (Birn et al., 2016, p. 14).

Semiotics transformations

It may sound rather cantankerous to question UHC, since, as Birn and Nervi (2019) ask, why would anyone contest measures taken to get more healthcare to more people. However, in the ambiguity of the term ‘coverage’ and the vagueness of its components, an approach that deviates from universal healthcare is actually masked (Birn et al., 2016, p. 12). The conceptual ambiguity provides space for different interpretations and approaches. Notwithstanding, its main features give way to a number of pro-market reform guidelines, such as the reduction of state intervention an emphasis on selective and focalised health policies, concerned on preventing catastrophic expenses rather than health needs (Giovanella et al., 2018, p. 1764).

A 2010 study on UHC literature found that there was little consensus regarding the definition of the concept, its components and features. While some referred to a comprehensive package of healthcare services, others envisaged a limited supply of goods and services, and others referred only to some kind of financial arrangement for reimbursement of medical expenses (Stuckler et al., 2010). The multiplicity of (mis)conceptions around UHC makes it difficult to understand what it actually refers to. And this also makes it difficult to distinguish the intentions and interests behind it (Laurell, 2014).

The first time the WHO explicitly referred to Universal Coverage was in its General Assembly resolution in 2005, entitled ‘Sustainable health financing, universal coverage and social health insurance’. There, WHO recognised the need to ‘guarantee access to necessary services while providing protection against financial risk’ and entrusted states to ‘ensure that health-financing systems include a method for prepayment of financial contributions for healthcare, with a view to sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care’. For this, they should take advantage ‘of opportunities that exist for collaboration between public and private providers and health-financing organizations’ (World Health Assembly, 2005).

Some has noted that this resolution meant the beginning of a ‘semiotic transformation’ through which the concept of the right to health and universal access was translated into that of ‘universal coverage’, indelibly associated with financial risk (Noronha, 2013). In this vein, states no longer aspire to guarantee universal, comprehensive and equal access to health, but are called upon to concentrate their efforts on preventing healthcare expenses from being disastrous for families. In achieving this goal, the preferred route has been through public and/or private health insurance schemes.

In its 2010 report ‘Health systems financing: the path towards universal coverage’, the WHO outlined the essential characteristics of its UHC. It presented its well-known UHC scheme in the form of a cube with three main variables: the percentage of the population with coverage (public or private insurance), the services and benefits included in it and the proportion of expenses covered (World Health Organization, 2010). In 2012, then WHO Director Margaret Chan celebrated that more than sixty countries had approached them to seek ‘technical support’ to advance universal coverage. ‘Universal health coverage is the single most powerful concept that public health has to offer’ she asserted (Chan, 2012). Although the prevention of catastrophic spending was the only clear thing about this system, the consensus was growing on universal coverage as the public health policy.

That same year, The Lancet published a series of articles with ‘arguments in favour of universal health coverage’, the conclusions of which ‘support the WHO Director-General Margaret Chan’s assertion’ (The Lancet, 2012). The special issue was financed by the Rockefeller Foundation whose president wrote one of the most commending articles together with the World Bank (1987) report author. They celebrated UHC as the ‘great third global transition in health’, only after the demographic and the epidemiological transition (Rodin & Ferranti, 2012). The special issue aim was to present these arguments to the next UN General Assembly and to end with its critics, which were described as ‘irrational protests’ (The Lancet, 2012).

The definitive political endorsement for UHC came with the UN General Assembly resolution that year, entitled ‘Global health and foreign policy’. In its conclusions, the General Assembly expressed that ‘universal health coverage implies that all people have access, without discrimination, to nationally determined sets of the promotive, preventive, curative and rehabilitative basic health services needed and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship’. For this, it was recognised the need ‘to pool risks among the population in order to avoid catastrophic health-care expenditure and impoverishment of individuals as a result of seeking the care needed’. The Assembly also recommended the study of ‘including universal health coverage in the discussions of the post-2015 development agenda in the context of global health challenges’ (UNGA, 2012).

Later on, in 2015, The Lancet issued a special series focused on UHC in Latin America. The articles voiced that ‘the argument about universal health coverage (UHC) has been won, and won remarkably quickly’, stating that the debate was no longer about why, what or when, but about how to do it. They celebrate that ‘Latin America is a laboratory to study the mechanics of implementing UHC’ (Horton & Das, 2015, p. 1).

That year, the UN General Assembly approved its ‘2030 Agenda for Sustainable Development’, which established ‘a plan of action for people, planet and prosperity’, with 17 SDGs for the next 15 years. In this, the General Assembly included as a specific goal 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’ (UNGA, 2015). UHC inclusion in the SDG, some has argued, ‘was the latest expression of the capitalist interests that sustain the MIFC’ (medical–industrial–financial complex) (Abadía- Barrero & Ardila- Sierra, 2019, p. 27), being another feature of corporate influence on the global health agenda, as a new area of exploitation is agreed for corporate healthcare providers and the insurance industry (Gopakumar, 2017). UN commitment to the UHC programme was crystallised in the SDGs and reaffirmed year after year, to the point that in 2017 it proclaimed 12 December as the International Day of UHC (UNGA, 2017). Unquestionably, universal coverage is out there as the winning concept. Woe to anyone who means to bet against the recipe in whose honour an international day has been established.

As mentioned, UHC may take various forms and content. Although at its core is the establishment of insurance schemes to reduce catastrophic financial risk, the concrete implementation may be more or less commercialised. However, in practice this model is characterised by a series of concerted efforts to promote health-financing models based on the collection of fees from users of the system, the establishment of affordable health insurance and the expansion of private health companies (Hunter & Murray, 2019, p. 13). Latin American experiences, which are deed purported as virtuous examples of the universal coverage, have been of the commodified and market-based kind, with a strong presence of private actors and high degrees of stratification and inequality.

Latin America has been an experimental setting for universal coverage health reforms, and for neoliberalism as a whole, starting with Pinochet’s US-backed 1973 military coup which implemented economic liberalisation policies and privatised public services (Birn & Nervi, 2019, p. 4). Following the health reform in Chile in the 1980s, a neoliberal health reform wave spanned in the region during the 1990s. The most celebrated case was the Colombian reform, which, until its collapse in 2009, was recommended to other countries as a model of success. Since the early 2000s, Mexican health reform, with its Popular Insurance (Seguro Popular), has taken a place on the international scene as a virtuous example of universal coverage in a middle-income country (Laurell, 2015, p. 106).

However, experiences in these countries have shown that in no case have they accomplished their explicit purpose of achieving universal coverage for their people. Even where insurance is mandatory, these schemes have not been able to cope with the exclusion of large masses of the population, and the rule has been the establishment of restricted packages of health benefits for the poor, responding to financial sustainability, rather than health needs satisfaction (Laurell & Herrera Ronquillo, 2010). In many countries, health insurance has resulted in a new dynamic of inclusion-exclusion in which, instead of counteracting the fragmentation of health systems, it has sharpened it, according to people’s income and their ability to purchase insurance for the provision of medical services (Laurell, 2010).

In the Chilean dual model, a private insurance market is open for the wealthy population to buy, with both their social mandatory contributions and out-of-pocket payments, while a public insurance remains for the rest. This private and public insurance model brought with it a ‘skimming’ process, with significant inequality and a curtailed citizenship for those unable to pay. The unemployed and less wealthy are to be cared by the public insurance, ill funded with general taxes and the lower mandatory contributions of its beneficiaries (Uthoff et al., 2012). This segmentation resulted in low-income and high-risk populations being serviced by the public sector, while high-income and low-risk populations are covered by the private sector. Those covered by the public insurance face high out-of-pocket expenditures, inequities in access to specialised care utilisation and lower quality of services (Chapman, 2016, p. 299).

Purported as the ideal model by its advocates, the Colombian UHC system established in 1993 ended in its economic bankruptcy in 2009, despite several partial reforms (Laurell, 2017). Denial of services persistence and the structural inequality of the Colombian system led to the filing of more than a million individual legal actions for the right to health. Ultimately, this led to a reform ordered by the Constitutional Court itself, which declared unconstitutional the service package differentiation between the contributory and the subsidised insurance (Yamin & Frisancho, 2015). However, these reforms were not sufficient to overcome the failures inherent to the model, which persists (Giovanella et al., 2018).

The Mexican Popular Insurance implemented in the early 2000s has been widely praised by promoters of universal coverage, including The Lancet journal which published a special series in 2006 commending these reforms (The Lancet, 2006). This insurance scheme for the poor, with a restricted package of goods, has been also broadly criticised, especially because of its commodified approach, its non-universal and packaged nature and its sharpened segregating effects between the rich and the poor (Laurell, 2007, 2015). Having failed to achieve universal coverage, with over 21 million people without insurance, Mexican system segmentation was accentuated over the years, with high out-of-pocket expenses, restricted package services and inequalities of access (Giovanella et al., 2018). When president López Obrador took office, Laurell addressed the task of transforming Popular Insurance, leading the federal Health Secretariat. On 1 January 2020, the new Institute of Health for Welfare became operational, with effusive criticism from universal coverage advocates (Agren, 2020; Frenk et al., 2019). The results are yet to be seen.

In other places, such as India and Thailand, the case studies have emphasised that the UHC led to increasing private provision and declining equity and efficiency in health systems (Sengupta, 2013, p. 20).

In view of the experience of the last decades, the rise of UHC as a global priority does not presage comprehensive and unified health systems. Rather, it is foreseeable a co-optation of such approaches in privatised or semi-privatised systems, with segmented and fragmented institutional arrangements and plenty of lucrative possibilities, only to ‘universalize partial’ and insufficient health coverage (Birn et al., 2016). Although we might expect the creation of better and more juicy businesses for some, not much social and health justice will come out of these approaches. Not much justice is possible to get from health systems, which are segmented by individual income.

Old yearnings, new clothes

The stakes are high in global debates over health system reforms. The field is intensely contested between several parties, many with interests in the final outcome of the debate. Several of these interest groups project and defend a policy narrative that seeks to print a ‘public interest logic’ to the routes and agendas they promote while keeping the vested interests that support them in the shadows (PHM et al., 2017, p. 73).

As illustrated by Giovanella et al., in the disputes over different concepts of universality in health, two confronted conceptions of citizenship are more deeply rooted. While in universal systems full citizenship takes shape in a right to health for all, universal coverage reflects a residual conception of citizenship. In the latter, state social intervention is residual and on a focalised basis. It would only take place when individuals are unable to guarantee the satisfaction of their minimum necessities in the market. In implementing this health paradigm, states ‘should subsidise insurance and guarantee a restricted package of benefits for poor groups that have “failed” to secure their basic needs in the market’ (Giovanella et al., 2018, p. 1767). Only where the market does not reach, for those displaced by market forces, the state should lay a safety net.

With a narrative of rights, the UHC paradigm advances a commodified concept of health, in which states withdraw and give market place for companies, so to profit with public funds collected through mandatory contributions. As Laurell cautioned, UHC aims, in a single movement, to solve an economic issue – that of opening health as a full field of private profit generation – and appeal to a widely shared social value – that of guaranteeing the right to health so that no one dies or becomes incapacitated due to lack of money. (Laurell, 2014, p. 60)

But to detach healthcare from the human condition and tie it to their income and ability to pay an insurance plan, is to abdicate from any possible understanding of human dignity.

UHC is not the so call ‘single most powerful concept for public health’, as it has been purported, nor the answer for the undoubted health dramas that our people suffer. Rather, it appears as a new tool to deepen the ongoing health financialisation process, to weaken public health systems and advancing the private rent extraction on public services, to the detriment of the most needed. As Birn and Nervi posed it, ‘although portrayed as an antidote to the consequences of neoliberalism for health-care access’, UHC ‘is itself shaped by, and a product of, neo-liberal ideology and policies’. It is nothing more than ‘a massive dilution of the progressive health agenda’. UHC ‘stems from, and is consistent with, the neoliberal turn in global capitalism’ (Birn & Nervi, 2019).

Thinking seriously requires reviewing the political issues and interests under the surface of the health system reform debates and, indeed, doubting the prevailing rhetoric, albeit it might be under the shadow of progressive cloaks. In this case, doubting the polysemic entelechy of UHC that presents itself as a panacea solution for indisputably real problems.

To suggest that crises are actually opportunities is, to a large extent, a fairly widespread cliché. Regarding COVID-19 and UHC, some has noted that it provides a scenario in which ‘opposition voices are weaker, and grand moves toward improving welfare, including steps toward universal health coverage, take place more easily’ (McDonnell, 2020). When faced with the scourge of a pandemic that evidenced health system shortcomings to fully respond to people’s health needs, the promise of a UHC for all, ‘leaving no one behind’, sounds especially appealing. But enthusiasm may lead to embrace health paradigms that may actually deepen existing inequities and impede progress in truly universal systems.

Crises may well be opportunities, although the hasty adoption of health paradigms and solutions that may ultimately pave the way for further injustice does not seem to be a successful crisis outcome. Assessing pandemic’s challenges gives a chance to build more egalitarian health systems, focused on people’s well-being and based on their rights and dignity, rather than on their ability to pay an insurance plan. Hopefully, it would not be wasted in a further neoliberal capture of progressive agendas.

Disclosure statement

No potential conflict of interest was reported by the author(s).