We Should Spend at Least Three-Quarters of Our Time on Domestic Resource Mobilization if We Are Serious About Universal Health Coverage and Primary Health Care
Simon Wright, Head of Health Policy, Save the Children (London, UK)
Ariana Childs Graham, Director, Primary Health Care Initiative, PAI (Washington DC, USA)
Bruno Rivalan, Directeur France/Head of French Office, Action Santé Mondiale/Global Health Advocates (Paris, France)
Next week, on 12 December, we will mark Universal Health Coverage (UHC) Day. This is the anniversary of the UN General Assembly’s unanimous endorsement of universal health coverage, now enshrined in the Sustainable Development Goals as target 3.8. Among the hundreds of UHC Day activities around the world, there will be an important meeting in Geneva: the new International Health Partnership for UHC2030 (UHC2030), hosted by WHO and the World Bank, is bringing together multilateral agencies, governments and civil society. It will be discussing how it can help drive UHC in every country.
We are advocates based in London, Washington, and Paris calling for UHC that begins with primary health care for all. In these donor capitals, we have a responsibility to focus on the role that donors play in achieving UHC.
But we see a tendency for donor aid to dominate all discussions about UHC when it can only be one part of building UHC.
In Low-Income Countries (LICs) — such as Mali, Sierra Leone, and Niger — only 28% of total health expenditure is from outside the country. In Lower-Middle Income Countries (LMICs) like Bangladesh, India, Kenya, and Ghana, only 3% of total health expenditure is from external resources.
Total health expenditure includes money spent by governments as well as money spent by individuals. In many LICs and LMICs, the amount that governments raise to spend on health is grossly inadequate. Tax collection is very low and falls unfairly on the poor. Government health budgets may be relying too much on external aid. All of this means that the majority of total health expenditure is the cash that individuals and families spend directly on health care, out of their pockets, at the time they need it. Providing quality primary health care for all is unattainable if we allow this unfair situation to continue.
We understand the tendency for many discussions to default to discussing donors. We understand why ministry of health officials from LICs and LMICs may find it easier to discuss aid than how their country needs to reform its tax system and diversify financing.
But, if we are serious about building UHC, we need to re-balance these discussions. Aid budgets unreliable and often restricted to donor priorities, are now stagnating or reducing. We need to focus on the ways that governments can collect money fairly from their population, reduce out-of-pocket payments, and invest sustainably in health. We need to discuss how to increase public budgets, encourage fair collection of taxes, introduce fair and universal health risk-pooling, how to reduce some areas of government spending and invest in health instead and how to introduce additional taxes on unhealthy goods.
If we are to achieve UHC within the next 15 years, we need a paradigm shift towards domestic resource mobilization (DRM).
This does not mean that the richest countries do not have obligations. But their responsibility should shift towards offering support for countries to build progressive tax systems and increase public spending on health. They also need to improve trade and fiscal policies and the ethical behavior of their companies operating in foreign countries.
We call for the UHC2030 meeting and the events happening worldwide for UHC Day to dedicate at least 75% of their time and attention to national domestic resources. Only this way can we ensure we are discussing what matters. We invite others to join us in a 75:25 DRM Pledge. Without improving domestic resources for health, UHC will always be out of reach.