Series: Research in Comparative and Global Social Policy
Series Editors: Heejung Chung, King’s College London, UK, Alexandra Kaasch, University of Bielefeld, Germany, and Stefan Kühner, Lingnan University, Hong Kong.
Published in association with the Social Policy Association.
In a world that is rapidly changing, increasingly connected and uncertain, there is a need to develop a shared applied policy analysis of welfare regimes. Through a unique combination of comparative and global social perspectives, books in this series will address broad questions around how nation states and transnational policy actors deal with globally shared challenges.
Research in Comparative and Global Social Policy
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Chapter 4 traces multiple shifts in development policies with major implications for health systems. The first shift involves the Washington Consensus, where the trade-off between efficiency and equity returned as a core proposition of development, prioritizing the former over the latter. In the context of economic crises and rising poverty rates, Structural Adjustment Programs (SAPs) and targeted programmes were informed by a minimalist basic needs approach (BNA) as opposed to the comprehensiveness of primary health care (PHC). And yet, evidence of the detrimental outcomes led to another shift – towards a new human development framework that emphasizes fulfilling the basic needs of everyone, including the poorest. This new ‘universalist’ version of the BNA did not have the broader connections it had to activist states and demands for global and national income distribution during the 1970s. Indeed, the chapter traces how the health sector transformed from a space to cut social expenditures and restructure public sectors to a complex field that combines concerns with the consequences of ill health for social and economic development with a dual function: legitimizing the expansion of markets by meeting basic needs and offering new areas of growth with investment and productive potential.
This chapter returns to the main goal of the book: explaining the significance of universal health coverage (UHC) in our thinking about health systems and concerns with social and economic development in a particular world context shaped by major shifts in capitalism. Through an exploration of UHC’s journey through interviews, reports and declarations, workshop and high-level meeting proceedings, the book identifies the key dynamics that constitute it as a significant idea, probably the most prominent idea, since the Alma Ata Declaration of 1978. In addition to typical forms of evidence, such as emerging as an SDG target or shaping the contents and framings of health reforms in many countries, this book demonstrates its uniqueness in terms of the balance of forces and movements that constitute it: UHC focuses on strengthening health systems while also supporting special vertical programmes and reducing the burden of disease from infectious diseases. It uses universalism as a powerful framing tool, while also sustaining market expansion. This book argues that UHC’s popularity can only be understood in this context, as proponents and critics of neoliberalism search for ways to reduce its harms, in very different ways and with discordant conceptions of universalism and the role of government.
This chapter identifies the key dynamics of the rise of universal health coverage (UHC) on the global health and development agendas. In this second stage, UHC becomes more clearly defined and the movements forming the specific constellation become clearer. This period is distinctive not only because of UHC’s growing salience in the global health and development debates, but also due to its contradictory components and heated discussions. UHC, as formulated in the 2010 World Health Report and as matured in the path to the Sustainable Development Goals agenda, establishes a unique balance between the state and the market, or the public and private sectors in health, in comparison to earlier formulations of health systems. The chapter explains the ways in which financialization shapes the latest transformations in capitalism, altering the purpose and tools of social policy with its emphasis on expanding demand and incorporating more areas into the market (hence, marketization). This discussion demonstrates how social policies, including health agendas like UHC, emerge as key tools in the embeddedness of this regime of capitalist accumulation, but in an expanded role that includes creating markets.
Universalism in health policy has a long history that traverses diverse societies and geographies. The chapter starts with a description of the popularity of universal health coverage (UHC) and introduces its theoretical framework, aiming to explain its significance in relation to universalism and other key debates on common good, solidarity, individual rights, justice, and equity. Seen through this historical-sociological framework, UHC, as our current reality, emerges as a unique conjoining of vertical and horizontal movements in health systems, debates on human rights and basic needs, and concerns with social and economic development in a particular world context shaped by major shifts in neoliberalism. Using another related concept that historian Fernand Braudel employs, this book argues that these conjoining movements and forces interact with the world context to form a constellation.
The adoption of the historical-sociological perspective is not limited to the particular analysis of UHC. It also informs the broader framing of this book and makes it possible to draw upon multiple disciplines and fields.
In this chapter, health financing emerges as a key area of interest, as connections between poverty and ill health, development, and health systems are acknowledged. These interests shape the development of a global health agenda that combines an emphasis on health systems performance and strengthening with the new vertical programmes, often actively involving the private sector. With the announcement of the MDGs, the link between health and development is redefined, placing the former at the heart of the latter. Many observers did not see a balance between the vertical and horizontal approaches in the mid-2000s and were increasingly concerned about the scale of fragmentation and verticalization, which facilitated the interest in health systems strengthening. In this early formulation stage, we see the key components of universal health coverage solidify, such as universal access to essential health interventions and an emphasis on financing.
Chapter 3 focuses on a period with many transformations: in the context of the Cold War, decolonization, and independence struggles, an alternative development paradigm, the New International Economic Order (NIEO), challenged the predominant models of development and shaped the formulation of key global health ideas, such as primary health care (PHC) and the Health for All (HFA) agenda. The Alma Ata Conference and the formulation of PHC represent major triumphs of horizontal thinking, which has developed a systems-based approach to integrating the curative and preventive aspects of medicine and connected them to social and political reforms, over the narrow vertical approaches in global health. Although this episode ended in the early 1980s with a sharp turn to vertical programmes and narrow basic needs approaches, PHC and HFA continue to shape the current debates on universalism and health systems.
Chapter 1 lays down the theoretical foundations of the book, mapping relevant literatures and clarifying the research approach, which is grounded in historical sociology and global social policy (GSP). After reviewing the welfare state literature and the place of health policy within this literature, the chapter discusses attempts to overcome methodological nationalism through cross-national comparisons, the GSP framework, and the perspectives developed within development studies. The historical-sociological perspective exposes the limits to analysing health systems and ideas around universalism largely based on the experiences and models of welfare states in the Global North, even when an attempt is made to apply or tailor them to understand developments in the Global South. The book argues that a unique conjoining of forces, currents, and individual movements form a constellation that explains why universal health coverage (UHC) emerged as a dominant idea in the current global health and development agendas. This implies that UHC should be studied from an historical perspective to understand whether it has any distinctive characteristics that shape current ideas about health and health systems.
Chapter 2 explores the shifting dynamics between the horizontal and vertical approaches to health systems and how these dynamics shaped the evolution of ideas on universalism and health systems, especially in relation to conceptions of development. Early signs of the North–South divide emerge in this intersection of health with development: postwar reconstruction in Western Europe was envisioned not as ‘development’ but in terms of the ‘embedded liberalism compromise’ that legitimized various social programmes, including national health insurance, to address the social adjustment costs of economic liberalization practices. For the rest of the world that was ‘developing’, the predominant view in this period was that economic development would lead to social development, which implied better living and working conditions, such as improvements in hygiene, sanitation, nutrition, and housing.
Chapter 7 explores the implications of key events, such as the SDG Declaration and UN High-Level Meetings, and balances them with an analysis of major changes and continuity. It is in this period that a major pandemic unleashed an unprecedented health crisis with serious social, economic and political implications. The stark inequalities in the experience with the pandemic, and the power dynamics between the Global North and Global South that shaped these experiences, suggest new challenges and opportunities for universal health coverage (UHC). At the same time, the terms ‘synergy’ and ‘sustainability’ emerge as key policy concerns against the backdrop of some competition with other global health agendas, such as Global Health Security or One Health. Waves of economic crises, a pandemic, and existential calamities unleashed by major ecological changes have demonstrated the limits of the globalized liberal world order and its development model. This book argues that UHC’s popularity can only be understood in this context, as proponents and critics of neoliberalism search for ways to reduce its harms, in very different ways and with discordant conceptions of universalism and the role of government.
This book traces the origins of Universal Health Coverage (UHC) in the broader context of universalism since the beginning of the 20th century.
UHC aims to improve access to essential health services, provide financial protection and overcome health care inequities.
Drawing on rich first-hand data, including expert interviews and archival research, this book adopts a historical-sociological methodology to analyse some of UHC’s key political dynamics: consensus, conflicts, negotiations and struggles. It reveals that UHC is the result of a unique conjoining of movements in health, debates on human rights and concerns with development in a particular world context across the global North and global South.
