It is exactly three years since the COVID-19 Pandemic erupted worldwide in 2020. Shutting borders and causing economic downturns wreaking havoc in the already fragile health systems common in most developing countries. But even before populations in these countries could get COVID-19 shots in their arms, we find ourselves in a seemingly unending cycle of crises. From the Russia-Ukraine war; to global energy and cost-of-living crises; food insecurity; climate emergencies; economic stagnation; Turkey-Syria tragedy, it seems as though the 2020s have become a time of perpetual crisis – aptly termed “permacrisis” by the Collins Dictionary.

But could the 2020’s permacrisis, coupled with the COVID-19 Pandemic – the biggest health crisis in over a century – catalyse a new generation of universal health coverage (UHC) reforms in this decade? This was the focus of a talk by Rob Yates, the Executive Director of the Centre for Universal Health at Chatham House, hosted by the LSE’s Global Health Initiative in December 2022.

UHC is not about free healthcare, nor is it merely about health insurance. At its core, UHC is about ensuring that everyone, regardless of their socio-economic status or background, has access to the health services they need when they need them, without facing financial hardship.

Let’s start with the basics: What is Universal health coverage (UHC)? UHC is more than just a buzzword. It is not about free healthcare, nor is it merely about health insurance. At its core, UHC is about ensuring that everyone, regardless of their socio-economic status or background, has access to the health services they need when they need them, without facing financial hardship.

Prior to the COVID-19 outbreak, countries across the world were making progress towards UHC. However, the pandemic’s sudden emergence caused unprecedented disruptions to health service delivery, skewing efforts towards infectious diseases and health security. The devastating effects of the pandemic have left many health systems in disarray, and many are still struggling to return to pre-pandemic levels.

Permacrisis as a window of opportunity for universal health coverage reforms?

Rob notes that crises often provide a window of opportunity for universal health reforms, and ample evidence supports this ‘crisis hypothesis’. Throughout history, some of the biggest health reforms arose following crises. For example, the United Kingdom, France and Japan developed their current health systems during reconstruction efforts following World War II, while Indonesia and Thailand implemented their biggest health reforms in response to the Asian economic crisis of the late ‘90’s. Similarly, Rwanda implemented universal health reforms following the 1994 genocide. However, the question remains, will the ongoing permacrisis we find ourselves in, lead to universal health reforms and accelerate UHC on a global scale?

Throughout history, some of the biggest health reforms arose following crises. For example, the United Kingdom, France and Japan developed their current health systems during reconstruction efforts following World War II.

UHC: A Political Choice

While it is true that the permacrisis could potentially lead to universal health reforms, the reality is much more complex, and is not a simple Yes or NO answer. The process of universal health reforms is often politically complex and multi-faceted, and there is no one-size fits all approach. While crises provide a window of opportunity to push large-scale health reforms, it is important to note that crisis alone is insufficient. To achieve ambitious health reforms like UHC, we need more than just an opportunity. UHC is a hugely political undertaking, and as Rob notes, political leadership and commitment are the most critical requirements to make UHC a reality. Without strong ‘political will’ (I use this term loosely), and bold leadership, it is challenging to navigate the complexities and obstacles that stand in the way of achieving UHC. But what does bold leadership for UHC mean?

First, bold leadership for UHC means getting health financing right

To achieve greater progress towards UHC, it is crucial that countries prioritise getting health financing right, as it is the backbone of the entire health system. Without adequate resources, the health system cannot function effectively, and public financing is the key to UHC. A while back, Dr Tedros wrote on the importance of public funds, noting that ,” …no country has made significant UHC progress without relying on public money as the main source”. Bold political leadership is needed to make the shift from private voluntary financing, which is common in many developing countries, to predominantly public financing. However, this transition also depends on the fiscal context of a country, and careful consideration should be given to ensure sustainability.

UHC is a hugely political undertaking … political leadership and commitment are the most critical requirements to make UHC a reality.

Second, bold leadership for UHC means committing the finances

Making tangible progress towards UHC requires more than just words, strategies and commitments. In many contexts, including Africa, the COVID-19 pandemic exposed the fragile and under-resourced health systems, accentuated by the failure of governments to allocate adequate resources to the health sector. Despite pledging to allocate 15 percent of their annual budget to health as part of the 2001 Abuja Declaration, only a handful of African countries have met that target. However, as Rob emphasises, the decision to allocate 15 percent of a country’s annual budget or even 1 percent of a country’s GDP to health, cannot be left solely to the Ministry of Health or Finance. It is a bold decision that ultimately rests with the head of state.

Bold political leadership is needed to make the shift from private voluntary financing, which is common in many developing countries, to predominantly public financing.

And third, bold leadership for UHC means an end to neo-dependency

The COVID-19 pandemic exposed a harsh reality: the West is not coming to the rescue, and that low and middle-income countries cannot rely on them. We saw how quickly these Western countries closed their borders (literally and metaphorically), and prioritised vaccinating their own citizens, stockpiled vaccines, while millions in the Global South were left without vaccines and essential supplies needed to fight the pandemic. Moreover, aid budgets including for health, have been cut over the years in some of the largest donor countries. Such budget cuts, however, present an opportunity for countries in the Global South to take bold leadership of their countries and health systems, and end their overdependence on the Global North. The responsibility for breaking free from the neo-dependence ‘bondage’, Dr. Soji Adeyi emphasises in his book “Global Health in Practice: Investing Amidst Pandemics, Denial of Evidence, and Neo-dependency”, falls squarely on the Global South. By investing in our own systems, technology transfers, vaccine development, we can break free from this neo-dependency, and ensure that we are no longer at the mercy of the Global North. But to truly break free from neo-dependency, we need bold leadership. As President Kagame of Rwanda has suggested in the past, we need to look within and increase domestic financing for health to provide basic health services, rather than waiting for aid budgets to provide healthcare for the population.

The COVID-19 pandemic exposed a harsh reality: the West is not coming to the rescue, and that low and middle-income countries cannot rely on them.

To achieve UHC, bold and sustained political leadership and commitment are essential. While some countries have made significant progress towards UHC following crises, it is important to acknowledge that a crisis alone is not sufficient. Indeed, many countries have made great progress towards made UHC, not following crises, but due to strong and consistent political leadership, at the highest levels. This sustained political commitment and bold leadership is what countries need, as they figure out how to best achieve UHC in their different contexts.

This blog is a review of the insightful Global Health Lecture delivered by Robert Yates, Executive Director of the Centre for Universal Health at Chatham House. Watch the recording here