Healthcare for all: every country can do it—an essay by Tedros Adhanom GhebreyesusBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6790 (Published 12 December 2019) Cite this as: BMJ 2019;367:l6790
I was raised in Eritrea and Ethiopia. The first time I had health insurance was as a student in Copenhagen in 1988. Even though I was only there for four months, they gave me insurance for a year. After that I was fortunate to receive a World Health Organization scholarship to undertake my master’s degree at the London School of Hygiene and Tropical Medicine, in 1991. Throughout my time as a student in the UK I was able to access the NHS, and all my medical needs were covered.
At the time I was especially struck that the NHS was created after the second world war, when the UK’s economy was in a terrible state. It was an inspirational moment to realise that universal health coverage (UHC) is not a luxury for wealthy countries: it’s the foundation of development and it is possible in every country.
When I came back to Ethiopia it was as a malaria expert, but I also had a growing passion for primary healthcare and UHC. Having seen what can be achieved in a country irrespective of wealth or economic stability, I was convinced that we could achieve this in Ethiopia. I moved back to my home state of Tigray in the north to head its health department, before eventually becoming Minister of Health for the country.
To transform a health system, the focus has to be on building strong, quality primary healthcare. Ethiopia at that time was facing significant challenges, including lack of access to health services.
To bolster the health system and move towards UHC we expanded the number of health facilities. We trained more women as health workers to help women who were prevented from seeking healthcare from male providers for cultural reasons.
We overhauled the pharmaceutical financing and supply system to improve access to drugs. We also added more medical schools, resulting in increased annual enrolment of doctors from 300 to 3000 in a matter of years. All these initiatives resulted in dramatic improvements to Ethiopia’s health system.1
I was humbled to be in a position in which I had the opportunity to create real change. The secret behind it was strong political commitment, which enabled a whole government approach to improving health, led by the late prime minister Meles Zenawi. That laid the foundation for a comprehensive transformation of the health system, including service delivery, workforce, governance, financing, information, and access to drugs.
That’s why I say healthcare is a political choice—it starts with strong commitment from the top.
On a global level, this moment in history is fraught with major threats to human health, from the increasing burden of non-communicable diseases to global health emergencies such as the current Ebola outbreak in the Democratic Republic of the Congo, and newer threats like antimicrobial resistance and the health impacts of climate change.
We should, of course, pay close attention to each global health problem, and work to save lives wherever we can. But working on improving primary healthcare and achieving UHC has benefits for every part of global health. Strong, quality health systems are more resilient and more able to cope with the consequences of outbreaks and other emergencies.
And the benefits go beyond health. When people can access the health services they need without facing financial hardship, the result is healthier, more productive societies. When countries invest in health, it has flow-on effects for productivity and economic growth. UHC is not only a human right, it is a smart economic choice.
Achieving UHC is a global movement, and the UN high level meeting this September was a major milestone along its path.2 The political declaration approved at the United Nations General Assembly in September is so important. For the first time, all 193 UN member states have unified around a common and comprehensive vision for universal health coverage,2 and 12 multilateral health agencies, including WHO, launched the Global Action Plan for Health and Well Being for All.3 But unless the declaration is implemented it will just remain a piece of paper.
In October, at the Inter-Parliamentary Union Assembly in Belgrade, Serbia, legislators from 140 countries adopted a comprehensive resolution on UHC, committing to leverage the power of parliaments to translate political commitment into laws, policies, programmes, and results.4
This level of partnership and cooperation is essential, and it’s what the world is asking for.
When you are building a house, you can’t start to construct the walls before you have laid the foundations. Ensuring that everyone can access affordable healthcare, right in the heart of their communities, is the foundation for everything else we are trying to achieve in WHO. Seeing the increase in political commitment to UHC as a result of WHO’s shift in focus has been immensely rewarding. WHO supports countries through strategic policy dialogue, reliable evidence based advice, assistance in navigating digital health, and guidance on investing in more skilled health workers where they are needed most.
All countries at all income levels can make progress with the resources they already have. We also need to help countries see that health spending is not a cost, it’s an investment.
Every country has a different path to UHC, which depends on many factors, from the state of the health system to the political, economic, social, and cultural context. Some countries are just starting down that path and others already have high performing health systems. WHO’s role is to help countries find the path that’s right for them and develop and implement UHC plans. Health systems in all countries have room to grow and change, and these systems should be developed to evolve along with emerging disease trends, emergencies, and changing health challenges.
But the one thing I believe should be the same in every country is that primary healthcare must be the bedrock of UHC, with an emphasis on promoting health and preventing disease. Giving people the tools they need to stay healthy and get well quickly when they have small health problems keeps them out of hospitals and reduces the strain on the health system.
Good quality primary care has been linked to increased access to services, better recognition of problems and accurate diagnosis, a reduction in avoidable hospitalisation, better health outcomes, reduced inequalities, lower suicide rates, and higher life expectancy.5
But many countries have not designed their health systems in a way that supports and prioritises primary healthcare. In addition, disease prevention and health promotion are often under-resourced compared with curative care.6
Seeing the benefits of UHC around the world over the years and then working to reinvent Ethiopia’s health system fuelled my passion for achieving health for all. Having an opportunity not only to spread the health for all message, but also to help all countries to make that goal a reality, is humbling and inspiring.
I am optimistic. One of the fundamental truths of global health is that health is a political choice. There are so many highly skilled, hard working health workers around the world, and so many policy makers with their hearts in the right place. But without political will at the highest level, UHC will remain just a goal for many countries.
Conflict of interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.