Introduction
Ten years ago, Professor Lawrence Gostin concluded his Global Health Law treatise by imagining global health with justice — what it should look like and what was required to achieve it. Universal health coverage (UHC), public health services, and the socioeconomic determinants of health all featured prominently in his vision as essential conditions to “give everyone a fairer opportunity for good health.”Reference Gostin1 Gostin’s focus on these conditions was timely and foreshadowed the 2030 Agenda for Sustainable Development, which United Nations (UN) Member States adopted in 2015. In realizing its seventeen sustainable development goals (SDGs), this 2030 agenda included health and poverty eradication, along with specific UHC and social protection targets (targets 3.8 and 1.3 respectively).2 This was a significant turning point for the UHC agenda, as it not only attracted the highest level of political attention, but also created an opportunity to address interrelated sustainable development concerns, like social protection, which had previously been discussed in isolation from UHC. However, as the SDGs’ 2030 target date draws closer, several SDG goals and targets, including those related to UHC and social protection, are “severely off-track.”3 Against this sobering backdrop, this article traces the history of UHC and social (health) protection, focusing on their development over the past ten years including the expansion of actors in this space, the persistent challenge of financial sustainability, and the impact of the COVID-19 pandemic. The article concludes by reflecting on what the future of UHC and social (health) protection should look like and what is needed to fully realize their potential to meaningfully contribute to the betterment of our planet and its people, with particular emphasis being placed on human rights, One Health and legal and financial considerations.
UHC and Social Protection: Separate but Interlinked Concepts
UHC, as defined by the World Health Organization (WHO), requires that “all people have access to the full range of quality health services they need, without facing financial hardship.”4 Importantly, “[i]t covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.”5 In meeting the SDGs, the two UHC indicators adopted by the UN Statistical Commission in March 2017 are:
3.8.1 Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, noncommunicable diseases, and service capacity and access, among the general and the most disadvantaged population); and
3.8.2 Proportion of population with large household expenditures on health as a share of total household expenditure or income.6
The International Labor Organization (ILO) defines social protection as a “set of policies and programs designed to reduce and prevent poverty, vulnerability and social exclusion throughout the life cycle.”7 SDG 1.3 on universal social protection systems is closely connected with and complementary to SDG 3.8 on UHC. Social health protection is an integral part of social protection systems, as “weak social protection systems make people less resilient to health shocks, less able to seek care when needed, less able to follow preventive advice and more prone to economic hardship related to healthcare use (especially long hospitalization), disability (including long sequelae) and quarantine.”Reference Behrendt, Bierbaum and Schmitt8 ILO’s social health protection policy therefore seeks to assure access to all to basic health services and in this context sees UHC as forming part of the “social protection floor.”9
Globally, progress toward UHC and social protection remains a challenge, with trends in financial protection worsening.10 Each year, 100 million people fall into poverty as a result of health care spending, and 800 million spend at least 10% of their household budget on health care, with the poorest disproportionately affected.11 More broadly, inequities persist even within countries that have made relatively good progress overall, highlighting the need for urgent change if the most vulnerable in society, the principal intended beneficiaries of both efforts to achieve UHC and social protection, are not to be even further marginalized.12
The Historical Evolution of UHC and Social Protection
Historically, the social protection of health emerged out of (working) citizens’ growing expectations about government’s role in the organization, financing, and provision of healthcare.Reference Tulchinsky13 These roles eventually became embedded in domestic law, which served as the earliest legal norms for the social protection of health.Reference Bump14 Drawing from these domestic protections, the origins of UHC in global health law can be traced to the WHO 1978 Declaration of Alma-Ata.15 This Declaration reaffirmed health as a human right, and framed primary health care to include both health care and determinants of health across sectors.Reference Gostin, Meier, Gostin and Meier16 Several years later, the Ottawa Charter for Health Promotion, signed in 1986 in the specific context of industrialized countries’ health needs, built on the Declaration of Alma-Ata by recognizing underlying “prerequisites for health,” including peace, shelter, food, income, sustainable resources, and social justice and equity.17 With this acknowledgement of the role of underlying determinants to health came an implicit emergent obligation for states to develop health policies in a manner cognizant of these determinants and to ensure universal primary health care.Reference Pūras18 Primary healthcare, as enshrined in these instruments, has since been recognized as a significant first step toward UHC.19 Figure 1 highlights the key milestones in the development of UHC under global health law.
Figure 1. UHC Timeline.
The early consensus on universal health care was soon challenged by political and economic developments in the decades that followed, when as a result of structural adjustment policies introduced by the World Bank and IMF, the expansive goal of primary health care for all came to be narrowed to low-cost interventions — referred to as “selective primary health care” — for vertical prevention of the main diseases in low-income countries.Reference Desierto, Patterson, Gostin and Meier20 Turning away primary health care, the 1993 World Development Report published by the World Bank, and the 2001 Report of the WHO Commission on Macroeconomics and Health, emphasized the provision of a small package of essential services, financed by the state and provided through a combination of public and private healthcare providers.21 The Millennium Development Goals (MDG), adopted in 2001, made no mention of UHC or primary health care, although three of the MDGs related to specific aspects of health — to reduce child mortality (MDG 4), to improve maternal health (MDG 5), and to combat HIV/AIDS, malaria, and other diseases (MDG 6).22 While the MDGs played a key role in mobilizing international resources toward improving health outcomes, progress was hindered by several shortcomings, notably an inadequate focus on strengthening health systems and resolving health inequities.Reference Vega23
In 2005, the World Health Assembly (WHA), building upon efforts in the previous decades, endorsed universal coverage in Resolution WHA58.33, urging Member States to “plan the transition to universal coverage of their citizens so as to contribute to meeting the needs of the population for health care … and to achieving health for all.”24 The emphasis within this resolution was on financing of and access to quality health care services i.e primarily treatment considerations. It was followed by another WHA resolution in 2011 on universal coverage which explicitly referenced the right to health enshrined in the Universal Declaration of Human Rights, thereby reflecting a slight change in understanding of universal health care as also including prevention (through addressing the social determinants of health).25 Both WHA resolutions were subsequently endorsed by the UN General Assembly in a 2012 Resolution on Global Health and Foreign Policy, recognizing the crucial importance of universal coverage in ensuring the right to health.Reference Lougarre26
Bringing Together UHC and Social Protection (2015–2024)
Political commitments toward achieving UHC further solidified with the 2015 adoption of the SDGs, which include UHC as one of the principal health targets.27 The explicit recognition of UHC within the SDGs was a significant turning point, as it mobilized the highest level of political attention and provided a framework to address UHC and social protection — as well as other sustainable development concerns — in an integrated manner.
This period saw action toward UHC expand beyond just State actors, WHO, and the World Bank, including other international organizations and non-state actors. A notable example is the International Health Partnership for UHC 2030 (UHC2030), a multi-stakeholder platform, which includes not only States but also international organizations, global health public-private partnerships, development banks, local and transnational NGOs, and other organizations.28 The platform has developed an action agenda for UHC, setting out priority actions and milestones for 2025.29 This expansion of actors reflected increasing awareness of the need for a whole-of-society approach to the issue of UHC.
During this period, UHC action also grappled with new challenges of securing global health security through the development of resilient health systems. The world’s experience with the COVID-19 pandemic reinforced that much remains to be done to ensure a robust, equitable, and effective global response to the next pandemic. UHC’s emphasis on equity and inclusiveness is key here, as it supports more effective responses to health crises such as pandemics by securing access to services and products to those most in need. This also highlights the need to expand UHC’s traditional narrow focus on treatment to also emphasize its broad scope, which includes issues of prevention and promotion (including R&D and surveillance).Reference Jain and Alam30
The COVID-19 pandemic, coupled with other overlapping crises such as climate change and conflicts, have also vividly demonstrated the fragility of some previous efforts to achieve UHC. For example, 92% of WHO Member States experienced disrupted essential health services at the height of the pandemic in 2021, with 84% of those Member States still experiencing disruptions in 2022.31 The COVID-19 pandemic also highlighted the significance of social protection to health. Individuals and families already living in situations of vulnerability were placed at further risk during the pandemic because of their lack of economic security and access to social benefits to take sick leave. Once illness from exposure in poor work and living conditions set in, some nearly 2 billion people who were already experiencing financial hardship from out-of-pocket spending on health were made even worse off.32
Drawing from the COVID-19 experience, international organizations such as the ILO, UN, and World Bank have highlighted that social protection measures such as social insurance, social assistance, and protection services such as cash transfers and in-kind support are critical to progress in attaining UHC. In this regard, UHC and social protection must be seen as two sides of the same coin if access to health services is to be truly equitable.Reference Yokobori33 Nevertheless, social protection should not be viewed as a panacea, as it has its own financing challenges along with serious gaps in the coverage and uptake of social protection programs, notably among individuals and families who are in the most vulnerable settings.34
Looking Ahead: The Future of UHC and Social Protection
Given these shortcomings, the following priority areas for action will be necessary if meaningful progress is to be made in achieving UHC and social protection: a comprehensive human rights-based approach,35 One-Health, legal preparedness, and sustainable financing.
Human Rights-Based Approach
As a former UN Special Rapporteur on the Right to Health noted, “[u]niversal health coverage cannot be achieved without meeting the core requirements of availability, accessibility, acceptability and quality under the right to health.”Reference Pūras36 In upholding this human rights-based approach, UHC must be operationalized to extend beyond mere biomedical interventions to address the determinants of health.37 Indeed, “[a]ddressing UHC as a human rights imperative — with human rights norms and principles providing explicit and non-negotiable parameters for moving forward — will help energize, support, and speed up the journey ahead, as well as ensure that it is inclusive and transformative.”Reference Nygren-Krug38 Importantly, such an approach to global health law offers a way to address the inequities that continue to plague UHC and social protection implementation by, inter alia, focusing on disaggregated data that allow the needs of individuals and groups in marginalized and vulnerable settings to be addressed. It should also be complemented by holistic monitoring which recognizes the interconnectedness and interdependence of human rights and their respective linkages to various SDGs.39
One Health
One Health, “an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems,”40 is another critical strategy for realizing UHC and social protection by reducing exposure to risks that have the potential to increase vulnerabilities.41 The 2019 UN Political Declaration of the High-level Meeting on Universal Health Coverage already started to connect “One Health”Reference Res42 and UHC, and One Health also featured in the negotiations for the revision of the International Health Regulations and the ongoing pandemic agreement negotiations. Fully integrating One Health into global health law would support the realization of both UHC and social protection by helping to address the upstream determinants of health, such as sanitation and the environment.
Legal Preparedness
Adopting a rights-based and One Health approach to realizing UHC and social protection will require legal preparedness. Law is a key tool for addressing both healthcare coverage and the broader determinants of health and therefore emphasis must be placed on national capacity-building to develop domestic legal frameworks to support operationalizing UHC and social protection.Reference Perehudoff, Alexandrov and Hogerzeil43 Law’s pivotal role in this process has been recognized by international organizations such as ILO, which has noted that “[m]onitoring of legal coverage of social health protection is an urgent imperative globally as coverage gaps help us highlight persistent social-economic inequalities.”44 Experience has also shown the need for “a legal framework and constitutional guarantee to acknowledge and legally recognize social protection as a policy and programmatic option that can help to achieve UHC as a right of all citizens.”Reference Sivanu and Sengupta45
Sustainable Financing
Financing woes have long plagued advances in global health. The 2015 Addis Ababa Action Agenda (AAAA) was intended to address this problem by mobilizing domestic and international sources of funding, thereby providing a sound financing foundation for the SDGs, including those related to UHC and social protection. Realization of AAAA’s commitments, however, remains a real challenge, with the most recent report of the Inter-Agency Task Force on Financing for Development cautioning that financing challenges remain at the heart of the current sustainable development crisis.46 As retaining the diversity and sustainability of financing options remains key, it may be necessary to create a new “Global Fund” for UHC, modelled along the lines of the Global Fund to Fight AIDS, Tuberculosis and Malaria.Reference Dagron47
Conclusion
UHC has evolved significantly since its early beginnings in the 1978 Declaration of Alma-Ata and has come to be interlinked with efforts to recognize the importance of social protection. However, achieving both UHC and social protection require a more sustained and systemic approach that goes beyond focusing on access to health care and social security — addressing the conditions which cause vulnerability. Ultimately, the future of UHC and social protection will require a new brand of political leadership that involves the pursuit of a whole-of-society, rights-based, and One Health approach, fully supported by legal and financial mechanisms. If, like Professor Gostin did in 2014, we are to reimagine UHC and social protection — what it should look like and what is required to achieve it — human rights, One Health, legal preparedness, and sustainable financing must feature prominently.
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