All for universal health coverage.

As the USA engages in what promises to be a vibrant debate over how the world’s most costly health-care system can effi ciently and equitably provide access to quality health services to all American people, controversies about universal health coverage are brought into high relief, not only in the USA, but also worldwide. Since the mid-20th century, most nations have signed many accords, establishing that provision of health is a fundamental human right; health for all should be not only an aspirational target but also an essential framework for the United Nations system; international donor mechanisms should include support for essential health systems and health-workforce development; poor population health contributes to social and economic instability and undermines development eff orts; and specifi c targets for country achievements in health should be set, and funded, through international instruments. The world community is at a crucial juncture in implementation of all these understandings and agreements, each of which underscores the need for, and utterly depends upon, extending universal health coverage. The nearly US$25 billion yearly enterprise that is global health features a long list of bold, targeted programmes, from child vaccination eff orts to appropriate treatment of tens of millions of people now living with HIV/AIDS. Yet, the full bill for health spending in the world may already surpass $6 trillion or 10% of the global gross domestic product (GDP), and the fi nancing challenges in low-income and middle-income countries will increasingly be domestic, just as they are in high-income countries. There is increasing appreciation of the links between disease and population health and nations’ security, foreign policy, economic, and general social wellbeing. Amid the unfolding H1N1A infl uenza pandemic, political leaders everywhere are appreciating the strong link between health systems in low-income and middle-income countries, and the ability of the global scientifi c community to acquire real-time assessments of epidemic spread and clinical eff ect. And new threats to health arising from climate disruption suggest the need for vast infrastructures of adaptation to population-scale health disasters resulting from rising global carbon dioxide concentrations: catastrophic weather events, drought, heatstroke and dehydration, new infectious diseases emergence, food and malnutrition crises, and human migrations. On an immediate basis, the global campaign to provide antiretroviral drugs to people with HIV living in low-income countries, coupled with the worldwide increase in cancer, cardiovascular disease, diabetes, and other long-term management ailments, have prompted a shift in thinking about global health. For decades, global health referred mainly to prevention of infectious diseases and epidemic control. Campaigns nowadays increasingly address lifelong interventions that need permanent systems of medical assessment and treatment in addition to population approaches to health promotion. In the 20th century global health world, vaccination was a dominant approach, often administered in one-off campaigns. The 21st century exigencies for global health dawned in Durban, South Africa, at the International AIDS Conference, amid demand for universal access to antiretroviral drugs, and the lifelong disease management required to sustain the life-sparing eff ects of the drugs. As WHO Director-General Margaret Chan has correctly pointed out, “I think we can now let a long-standing and divisive debate die down. This is the debate that pits single-disease initiatives against the agenda for strengthening health systems.” Chan continued in her address in June, 2009, “As I have stated since taking offi ce, the two approaches are not mutually exclusive. They are not in confl ict. They do not represent a set of either-or options. It is the opposite. They can and should be mutually reinforcing. We need both.” Debate has emerged, pitting—we believe, incorrectly— health-systems support against targeted health campaigns. In truth, development of systems capable of delivering health, generally, or specifi cally targeted campaigns and health initiatives, all rely on the existence of health fi nancing mechanisms that off er universal access to health. The specifi c nature of such fi nancing schemes and service delivery models will vary, dependent on nations’ economic and cultural norms. To assume that universal health coverage necessarily requires a single-payer government mechanism would be a mistake, and adherents to that position doom the people of the poorest nations to generations of medical defi ciency. In classic terms, debates may be framed as the Bismarck model versus the Beveridge model, but this dichotomy is increasingly viewed as being as false as that which seeks to pit vertical schemes of health against horizontal. Whether a nation chooses a mixed economy model of coverage, single-payer mode, donor-issued voucher mechanism, or other innovative models of universal fi nancing is not the issue; provision of universal health coverage is the issue facing the entire global health construct. Sadly, for most of the world’s populations universal health coverage remains a mirage, blurred further out of focus by the present world fi nancial crisis. In the USA, for example, where spending on health topped $2·4 trillion in 2008, or 17% of GDP, an estimated 47 million citizens have no health coverage whatsoever, and another 25–45 million are covered by insurance that is so inadequate that major medical events may cause family bankruptcy (panel). Studies in the USA show that at least half of all bankruptcies fi led by American families Lancet 2009; 374: 1294–99