THEMES AND DEBATES

Universal coverage: The strange romance of The Lancet, MEDICC, and

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 . 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 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.

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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), 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

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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 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 as diverse of Brazil and Canada, HCA is that did not encourage choice among private provid- based on public sector funding for services provided ers ranked lower than those that did. As a result, in either the public sector or by private practitioners, Colombia (ranked 22nd in the world and 1st in Latin hospitals, and clinics; however, participation by for- America), Chile (33rd), Costa Rica (36th), and even profit corporations is either prohibited or tightly the United States (37th) ranked higher than Cuba regulated. (39th), despite Cuba’s much admired, accessible The unifying principle in HCA is that the nation- health system and outstanding health indicators. al health system should not include tiers with differ- Brazil ranked very low, 125th, again due to its at- ing benefit packages for rich and poor. For instance, tempt to achieve HCA through a unified public sec- because Canada prohibits private insurance for ser- tor health system, codified in the Brazilian constitu- vices provided in its national health program, Cana- tion of 1988. da’s wealthy must participate in the publicly fi- The co-director of WHO’s ranking project, Dr. nanced system. The presence of the entire popula- Julio Frenk, later became an architect of UHC re- tion in a unitary system assures a high quality na- form as Mexico’s minister of health. He and his tional program. The ALAMES article in The Lancet colleagues described Mexico’s reform in The Lan- series succinctly expresses the HCA vision: cet,6 an article which generated criticism for unsub- “ALAMES argues for the right to health for all citi- stantiated claims of success.4,7 Despite wide criti- zens, without distinction, with the state as the guar- cism of the WHO ranking project and of UHC in antor of finance and administration.”2 In Latin Mexico, Frenk and his coworkers became leading America, countries trying to advance the HCA mod- proponents of UHC, partly through a key article in el include Cuba and Brazil, as well as Bolivia, Ec- The Lancet’s series.16 Because they have not disa- uador, Uruguay, and Venezuela, all of which have vowed the low rank of Cuba’s health system, Frenk moved in the direction of HCA after rejecting the and colleagues may still believe that Cuba would prior neoliberal models. benefit from a reformed health system, reorganized

as UHC with private insurance corporations in com- Why Cuba for a Launch of UHC? petition with Cuba’s public sector. In light of Cuba’s unified public system embody- Is a subtext for the Havana launch a hope to pri- ing HCA, the launch of The Lancet’s UHC series vatize Cuba’s health system, or to open it up to pri- seems ominous. Does UHC figure in the future of vate insurance corporations? Although this scenario Cuban healthcare? Is HCA in Cuba entering a tra- may seem farfetched given Cuba’s accomplish- jectory of decline? How was a decision reached to ments, the Cuban government has been moving launch the UHC translation in Havana? swiftly to reduce its public sector expenditures by The editors of The Lancet and MEDICC Review eliminating jobs and expanding private sector eco- should become more transparent about the process nomic activities. Is healthcare soon to follow? This leading to UHC’s debut in Havana. “The usual sus-

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scenario should worry those who have admired and Conclusion supported Cuba’s public health endeavors. Such The translation and launch of the UHC series changes do worry Cuba’s activists in ALAMES, have generated concerns that warrant attention. whose coordinator wrote just after the Havana Clarification of the rationale and process of deci- launch of UHC: “ALAMES-Cuba supports and sion-making should occur with transparency that works in accord with the process of social and eco- resolves the mysteries discussed above. The Lancet nomic transformations that are developed in the and MEDICC Review should clarify whether they country in the consolidation of SOCIALISM, pros- support UHC or HCA, and why. Additional publica- perous and sustainable, which conceives health as a tions and translations should present a balanced human right for all, that never will be an object for picture of UHC and HCA, including critiques of the profit or commodification.”17 hegemonic principles associated with UHC.1

Where from Here? Author’s contributions The editors of The Lancet and MEDICC Review The author conceived the effort, conducted the should explain their decisions to translate the UHC literature review, wrote the article, and edited it. series and to launch the translation in Havana. Sev- eral issues in particular warrant transparency and References clarification: 1. Horton R, Das P. Universal health coverage: not why, • What role did funding agencies play and how what, or when--but how? Lancet. 2015; 385: 1156-7. were the funds used? 2. Heredia N, Laurell AC, Feo O, Noronha J, González- Guzmán R, Torres-Tovar M. The right to health: • What conflicts of interest affect the authors and what model for Latin America? Lancet. 2015; 385: editors? Particularly troubling is the lack of clear e34-7. disclosures in the translated articles about major 3. Stocker K, Waitzkin H, Iriart C. The exportation of funding from the same international financial in- managed care to Latin America. N Engl J Med. 1999; stitutions and foundations. 340: 1131-6. • Why was the editorial board of MEDICC Review 4. Waitzkin H. Medicine and public health at the end of not consulted before the decisions to translate the empire. Boulder, CO: Paradigm Publishers; 2011. UHC series and to launch it in Havana? 5. Giedion U, Uribe MV. Colombia's universal health • Do The Lancet, MEDICC, and MEDICC Review insurance system. Health Aff (Millwood). 2009; 28: support UHC or HCA? 853-63. The Lancet and MEDICC Review should provide 6. Knaul FM, González-Pier E, Gómez-Dantés O, García- “equal time” for critiques of UHC and presentations Junco D, Arreola-Ornelas H, Barraza-Lloréns M, Sandoval R, Caballero F, Hernández-Avila M, Juan of endeavors to achieve HCA. Future articles should M, Kershenobich D, Nigenda G, Ruelas E, Sepúlve- address such topics as: da J, Tapia R, Soberón G, Chertorivski S, Frenk J. • implementations of UHC and HCA The quest for universal health coverage: achieving • “hegemonic” versus “counter-hegemonic” public social protection for all in Mexico. Lancet. 2012; 380: 1259-79. health policies • “philanthro-capitalism,” including the positions 7. Laurell AC. Three decades of neoliberalism in Mexico: of key foundations (Rockefeller, Gates) and non- the destruction of society. Int J Health Serv. 2015; 45: 246-64. governmental organizations • Global Health Watch, the People’s Health 8. Waitzkin H, Jasso-Aguilar R, Iriart C. Privatization of Movement, ALAMES, and popular movements health services in less developed countries: an empir- ical response to the proposals of the World Bank and

favoring HCA Wharton School. Int J Health Serv. 2007; 37: 205-27. Financing for this effort should come from the same funders who supported the translation of The Lan- 1 After this article was accepted for publication, the edi- cet’s UHC articles, or from others if the original tors of MEDICC Review provided a brief explanation of funders do not agree. their decision making process in response to my letter to the editors that they published; this is available at http://tinyurl.com/hhzg3hd (Cited August 6, 2015).

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9. Iriart C, Merhy EE, Waitzkin H. Managed care in Latin low-income and middle-income countries. Lancet. America: the new common sense in health policy re- 2015; 386: 274–80. form. Soc Sci Med. 2001; 52: 1243-53. 13. Schmidt H, Gostin LO, Emanuel EJ. Public health, 10. Sengupta A. Universal health coverage: beyond rheto- universal health coverage, and Sustainable Develop- ric. Ottawa, Canada: International Development Re- ment Goals: can they coexist? Lancet. 2015 Aug search Centre. Occasional Paper No. 20. November 29;386(9996):928-30. 2013. Available from 14. World Health Report 2000. Health systems: improv- http://www.municipalservicesproject.org/sites/munic ing performance. Geneva: World Health Organiza- ipalservicespro- tion, 2000. Available at ject.org/files/publications/OccasionalPaper20_Sengu http://www.who.int/whr/2000/en/whr00_en.pdf?ua= pta_Universal_Health_Coverage_Beyond_Rhetoric_ 1 (Cited July 25, 2015). Nov2013_0.pdf (Cited July 25, 2015). 15. Almeida C, Braveman P, Gold MR, Szwarcwald CL, 11. Stuckler D, Feigl AB, Basu S, McKee M. The politi- Ribeiro JM, Miglionico A, Millar JS, Porto S, Costa cal economy of universal health coverage. Back- NR, Rubio VO, Segall M, Starfield B, Travassos C, ground paper for the global symposium on health Uga A, Valente J, Viacava F. Methodological con- systems research. November 16-19, 2010. Montreux, cerns and recommendations on policy consequences Switzerland: World Health Organization. Available of the World Health Report 2000. Lancet 2001; 357: from: 1692-7. http://www.pacifichealthsummit.org/downloads/UH 16. Frenk J. Leading the way towards universal health C/the%20political%20economy%20of%20uhc.PDF coverage: a call to action. Lancet 2015; 385: 1352-8. (Cited July 25, 2015). 17. Castañeda Abrascal I. Postura de ALAMES- Cuba. 12. Reeves A, Gourtsoyannis Y, Basu S, McCoy D, Re: Launch: MEDICC Review Spanish edition of McKee M, Stuckler M. Financing universal health Universal in Latin America series. Email coverage—effects of alternative tax structures on correspondence, April 22, 2015, translated and pub- public health systems: cross-national modeling in 89 lished with author’s permission.

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