The global movement around universal health coverage (UHC) has gathered momentum at blistering speed. Within a few years it has transformed the focus of healthcare in many low and middle income countries from single disease strategies towards a vision of comprehensive, affordable and acceptable care for all.
This ambition has energized many governments to put forward bold strategies and big investments to make it happen. Amidst the infinite choices of who, what and how to cover their citizens, a wide variety of UHC models are being developed: Zambia and Egypt are both pursuing Social Health Insurance schemes that will start with the formally employed, while India’s newly announced National Health Protection Mission, will concentrate on enrolling the poorest half of the population. South Africa’s proposed reforms would likely lead to a much greater role for the State, while several Gulf nations see private payers and providers as central to their blueprint for UHC.
Despite having one of the quintessential reference models for universal coverage, the UK government has not generally been at the forefront of this global movement. A leader in so many fields of global health, we have left other countries to fill the gap when it comes to developing the models that will best deliver UHC by 2030. Japan, South Korea and Singapore’s governments in particular have been active and vocal proponents of the benefits of their systems, providing their own consulting teams, conferences, grants and loans to their UHC-aspiring neighbors and beyond.
The world wants to learn from the NHS
Perhaps it is the UK’s (justifiable) concern to not repeat mistakes of the past by imposing our models and systems on others that lies behind our place in the stalls rather than the stage of the UHC movement. In this instance, it is unnecessary. My experience of working with dozens of governments designing and implementing their UHC models is that there is huge demand to learn from how the NHS works, and more often than not a nuanced appreciation of the strengths and weaknesses of its model against those of others.
Not only are the policy makers I work with able to appreciate the benefits of the UK NHS as a model for UHC – in particular its universality, social solidarity, transparency and progressive financing – they are actively inspired and motivated by it. The pride with which the British people hold the NHS is well known, and the political benefits of such a model have not escaped those national leaders seeking to generate similar goodwill with their electorates.
Yet there is also an understanding that the NHS cannot be ‘cut and pasted’ elsewhere, with three barriers to this particularly common in my work.
First, the public provider systems in some low and middle income countries are nowhere near ready to take on whole population coverage. In India, for example, the private sector accounts for fifty percent of hospital capacity and over seventy percent of outpatient visits. Few countries have the patience to wait for weak public systems to improve, and so a mixed provider model is often adopted – much like the modern NHS but with the public-private balance often reversed.
Second, the progressive tax financing model of the NHS, while preferable, is challenging in countries that have little formal tax base to draw from. Sin taxes, VAT, tourist levies, natural resource deposits, governments are being endlessly creative to find the money, but a purely public purse approach for all essential products and services is difficult for some to achieve all at once.
Third, there are important cultural differences in the relationship between citizens and their healthcare systems that need to be taken into account – some countries wish for greater local democratic accountability than the traditional NHS model allows. Others, having previously paid out of pocket for care, have got used to a high degree of patient centricity and therefore will not accept rules that limit direct access to specialist, for example.
The NHS can learn as well
Sustainable financing, provider mix, patient centricity: these questions aren’t just those of low and middle income policy makers looking to the NHS, they are those of British ones too. While the UK is starting from a very different place, the challenges the NHS faces and the solutions available are increasingly similar to those systems just beginning their journey to UHC. In that sense, we have a great deal to gain from more active engagement in helping to shape UHC models around the world.
Partnership, not imperialism should be the launch pad of the UK’s more active role as a global UHC leader. The aim is not so much to encourage others to follow, but to walk alongside.
“Follow or borrow: Is the NHS really the best model for UHC the world has seen?” will feature as a session of the Tropical Health and Education Trust’s 2018 Annual Conference in London on 27th September. The meeting will be chaired by Jonty Roland, with contributions from Deborah Kobewka, Managing Director, Healthcare UK and Godwin Kabalika, Country Director Tanzania, THET.