Momotaro and the Quest of Equitable Financing for UHC

By James Sale, Health & Finance Policy Adviser, Save the Children UK

PHC Pathways
Crossing the Divide
4 min readDec 18, 2017


Momotaro is a popular hero of Japanese folklore. To grossly paraphrase, the story of Momotaro begins with an elderly couple finding a boy inside a peach floating down a river. Now this may sound a little irrelevant for the UHC Forum I am attending in Tokyo this week, but the story of what Momotaro did next might just be.

Key principles of UHC financing

Universal Health Coverage (UHC) is arguably the most ambitious of the sustainable development goals (SDGs) and certainly one of the most important, the greatest of quests. UHC has only been achieved in a small number of high-income countries (HICs) and a few middle-income countries (MICs). For nearly all low-income countries (LICs) the provision of UHC is far off, in some cases possibly far beyond the 2030 target. But it’s not all doom and gloom. There are trailblazing countries demonstrating that by applying the core principals of health financing for UHC, backed by genuine political will, progress toward providing health for all can be made.

When Momotaro was a little older he started out on a quest to overcome… well let’s just say financial barriers to health for all. The odds were against Momotaro but he was helped on his quest by three allies: a spotted dog (inu), a monkey (saru) and a pheasant (kiji). Let’s imagine these as adequate revenue, pooled resources and strategic purchasing, for it was only with the help of all of these with that Momotaro was successful.

Although by no means the only reform required to move towards UHC, financing underpins many elements of health systems. There are three core financing elements for UHC:

  • Revenue must be predominantly from public sources, preferably through progressive mechanisms such as general taxation or compulsory contributions to a social health insurance scheme with subsidisation for those who cannot afford payments. In order to make significant progress toward UHC governments must spend at least 5% of GDP on health.
  • Pooling of resources to create cross-subsidisation from the rich and healthy to the poor and sick.
  • Purchasing of goods and services made through evidence-based decision making that increases efficiency, meets the health needs of the population and prioritises the poorest and most vulnerable, this is strategic purchasing.

Equitable pathways to UHC

Like most quests there is no set pathway to UHC, and the road ahead is not always clear. Whilst adhering to the financing principles outlined above, each health system will have a unique approach, reflecting their population’s needs and priorities. However, progressive, pro-poor pathways towards UHC — or “progressive universalism” — must be at the core of these efforts. For Save the Children this means:

  • When making trade-offs, decision-makers need to be aware of the social, economic and political implications, and not focus solely on cost-effectiveness or coverage that can be detrimental to other health goals.
  • A deep understanding of barriers to UHC and reform. Whether effective coverage is achieved depends on the interaction of the complex array of interrelated factors that affect access and determine the ‘fit’ between supply and demand with a lack of ‘fit’ contributing to inequity in access for the poorest and most vulnerable.
  • Understanding and planning for the effect of UHC and financing policies on vulnerable groups within the whole population.

Courage and commitment

The political environment is a critical determinant in making progress towards UHC. Ultimately UHC is a political decision, with governments needing to first commit to providing healthcare for all and then support this with action — starting with adequate resources and financial structural reforms.

In the more conventional Momotaro story he and his allies sailed a boat, breached a castle, and defeated some ogres who promised never to do wicked things again. The dog, monkey and pheasant and their collaborative efforts were an indispensable part of his success, just as the adequate revenue, pooling and strategic purchasing are for UHC. Added to these technical essentials, political leaders must show Momotaro’s courage and commitment and plot their financial pathway to UHC.

This blog is part of a series by the UHC Financing Advocacy Collaborative, a network of 50+ members which brings together multi-stakeholder representatives from civil society and development partners who support country and global level health financing priorities relating to universal health coverage. #Finance4UHC

This blog was cross-posted from the UHC Coalition:



PHC Pathways
Crossing the Divide

Working to increase the recognition and support for Primary Health Care (PHC) in the global arena.