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Universal Health Coverage: the Strange Romance of the Lancet, MEDICC, and Cuba

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Universal Health Coverage: the Strange Romance of the Lancet, MEDICC, and Cuba THEMES AND DEBATES Universal health coverage: The strange romance of The Lancet, MEDICC, and Cuba Howard Waitzkin, MD, PhD. Abstract have not been confirmed empirically. The editors of As a key supporter of universal health coverage The Lancet and MEDICC Review should explain (UHC), The Lancet recently partnered with Medical more fully the decisions to translate the UHC series Education Cooperation with Cuba (MEDICC), a and to launch the translation in Havana, and they non-governmental organization based in the United should provide “equal time” for critiques of UHC States, to produce a Spanish-language translation of and presentations of endeavors to achieve HCA. The Lancet’s series on UHC in Latin America. This translation was launched as part of CubaSalud 2015, Introduction an international health conference held during April The Lancet has emerged as a key supporter of 2015 in Havana, Cuba. Despite its often ambiguous universal health coverage (UHC).1 Recently The definition, UHC usually refers to a financial reform Lancet partnered with Medical Education Coopera- extending insurance coverage in varying degrees to tion with Cuba (MEDICC), a non-governmental a larger part of a country’s population. UHC does organization based in the United States, to produce not mean “healthcare for all” (HCA) – a healthcare a Spanish-language translation of The Lancet’s delivery system that provides equal services for the series on UHC in Latin America. Editors of The entire population regardless of an individual’s or Lancet and of MEDICC Review, a journal pub- family’s financial resources. lished by MEDICC, launched the Spanish transla- UHC has received wide criticism because it does tion on April 22, 2015, in Havana, Cuba. The not necessarily create a unified, accessible system; launch took place as part of CubaSalud 2015, a because it usually encourages a role for private, for- large international health conference, and included profit insurance corporations; and because it in- Cuban participants as well as officials of the World volves tiered benefits packages with differing bene- Health Organization (WHO), Pan American Health fits for the poor and non-poor. Although the UHC Organization (PAHO), and World Bank. Funding orientation has become “hegemonic” in global for the publication came from the Rockefeller health policy circles, its ideological assumptions Foundation, WHO/PAHO, and the Economic Commission for Latin America and the Caribbean Howard Waitzkin, MD, PhD (ECLAC/-CEPAL, a regional commission of the Title: Distinguished Professor Emeritus United Nations). Affiliation: University of New Mexico Email: [email protected] What is UHC? Accepted: 7/25/2015 Although its definition often remains imprecisely Conflict of interest: I have written and reviewed articles stated, UHC usually refers to a financial reform occasionally for The Lancet and have served on the edito- extending insurance coverage in varying degrees to rial board of MEDICC Review. I have not received fund- a larger part of a country’s population. UHC does ing from organizations either supporting or opposing not mean “healthcare for all” (HCA) – a healthcare UHC. delivery system that provides equal services for the Peer-reviewed: No entire population regardless of an individual’s or family’s financial resources. Social Medicine (www.socialmedicine.info) - 93 - Volume 9, Number 2, October 2015 UHC has received wide criticism from progres- UHC almost always involves tiered benefits sive organizations and individuals such as the Asso- packages, with differing benefits for the poor and ciation of Latin American Social Medicine non-poor. A national reform provides a minimum (ALAMES), the globally-based People’s Health package of benefits that experts view as essential. Movement (PHM), Global Health Watch (GHW), The poor and previously uninsured receive basic and various researchers including myself. Only one insurance with little or no out of pocket copayments. article in The Lancet’s series (representing The non-poor or their employers can purchase addi- ALAMES) conveys criticism of the UHC approach tional benefits. and favors a unified, public sector approach to Under minimum packages, for instance, all HCA.2 women would be entitled to periodic pap smear On the surface, UHC conveys the symbolism of screening for cervical cancer. But treatment of cer- universal access to health services. UHC proposals vical cancer if revealed by pap smear screening usually describe ways to extend services to popula- would not necessarily be covered under the benefits tions that face barriers to access, particularly poor packages, leaving women vulnerable to variability people, ethnic/racial minorities, and otherwise mar- in local government funding and policies. In Mexi- ginalized groups. The use of the term “universal” co’s UHC program (Seguro Popular) benefits avail- conveys concern about the severe access barriers able for treatment of cervical cancer for poor wom- affecting people around the world. en with positive pap smears have varied according However, the UHC approach does not necessari- to the financial resources and policies of different ly entail a unified, accessible healthcare delivery Mexican states.4,8 [and unpublished data] Surely system. In fact, most UHC proposals actually disfa- there must be something terribly wrong with a sys- vor such unified systems. Instead, the proposals tem that offers cervical cancer screening to all argue for a multifaceted financing reform that would women and then selectively denies treatment to extend some services, but not necessarily all needed those who are poor. services, to those who currently lack health insur- As the ALAMES authors point out, the concept ance. of UHC has become “hegemonic” in global health In such proposals, the public sector enters into a policy circles.2 Its promotion involves several ideo- competitive relationship with an expanded private logical assumptions:4,9 sector, in which private, usually for-profit insurance • Efficiency increases if financing is separated corporations play an increasingly important role. from service delivery, and if competition is gen- Through UHC, these insurance corporations gain eralized among all subsectors (state, social secu- access to public trust funds dedicated to health and rity, and private). social security benefits. Corporations are then paid from these funds for providing “managed care” ser- • The market in health is the best regulator of vices on a prepaid, capitated basis. As shown in costs. prior research, corporations use much of the capita- • Demand rather than supply is to be subsidized. tion payments for investment in the global financial • Private administration is more efficient and less marketplace.3,4 corrupt than public administration. A reduced role for the state and privatization of • Deregulation of health and social security trust public services therefore make UHC consistent with funds allows the user freedom of choice and an other neoliberal policies. Under UHC schemes im- ability to opt for the best administrator of his or plemented in countries such as Colombia and Mexi- her funds. co, the state gathers funds through a combination of • Quality is assured by fostering the client's satis- mandatory taxes and premiums and disburses the faction through competition of providers in the funds to corporations that contract for delivering marketplace. services to insured individuals and families.5,6 In There are only a limited number of data-driven addition, the state directly delivers services for the studies of UHC outcomes. These studies, in coun- remaining uninsured poor through public sector tries like Colombia, Chile, and Mexico – based on hospitals and clinics, which become increasingly evidence – have not confirmed the above assump- stressed due to budgetary cutbacks.4,7 tions regarding managed care, competition in mar- kets, efficiency, cost reduction, or quality. Under Social Medicine (www.socialmedicine.info) - 94 - Volume 9, Number 2, October 2015 UHC, access barriers remain or worsen as costs pects” may have orchestrated this momentous event, increase and corporate profit making expands.4,7,10,11 mainly by financing the original Lancet series, the In many countries, regressive taxes structures im- translation, and the launch. Rockefeller, ECLAC/- pede the expansion of insurance coverage, and pri- CEPAL, WHO/PAHO, and the World Bank (which, oritization of clinical services under UHC can im- along with the Gates Foundation, provides substan- pede the achievement of broader public health tial funding for WHO) have acted collaboratively to goals.12,13 foster UHC in Latin America. Now, with a detente emerging between Cuba and the United States, has the Cuban health system become a target for trans- What is HCA? formation in the direction of UHC? HCA sees heathcare as a human right, provided In this context, it is worthwhile remembering in a national system where access does not differ WHO’s World Health Report 2000, which ranked according to income, wealth, occupation, gender, the world’s health systems with a conceptual orien- racial/ethnic characteristics, age, or other criteria. tation and methodology that received scathing criti- Usually the vision of HCA involves a single public cism worldwide.14,15 Briefly, “choice” was a major system that provides outpatient, inpatient, and pre- criterion in evaluating health system performance. ventive services; that is the model of Cuba. In some From this perspective, unified public health systems countries
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