December 12 was officially established by the United Nations as the International Day of Universal Health Coverage (UHC) in 2012. In 2015, this watchword was included in Goal (SDG) 3 of the 2030 Agenda for Sustainable Development, specifically in your target 3.8.
The expression “universal health coverage” (UHC) has several meanings in a global context, which, not infrequently, has generated controversy and heated public debates.
The UHC was conceived to help promote the “human right to health” taken more broadly, based on widely accepted international agreements or documents, such as the Universal Declaration of Human Rights and the International Declaration of Persons with Deficiency.
“No country can claim to have achieved universal health coverage if it has not adequately and equally addressed the needs of people with rare diseases.”
Helen Clark, United Nations for the Development Program (UNDP), 2016
In Brazil, the expression is more frequently addressed in Public Health and Nursing articles and more critically in that field of knowledge. It is because it sounds incomplete to the Brazilian reality and is seen by some as an attempt to slice up the provision of health services in such a way as to only “guarantee a minimum package” in policies of a neoliberal nature and a minimal State.
However, the WHO clarifies that it is not about that but also about ensuring the progressive expansion of health services coverage and citizens’ financial protection as more resources are made available. But the debate continues.
SDG 3
Ensure healthy lives and promote well-being for all at all ages
Target 3.8
Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
For WHO, UHC means “that all individuals and communities receive the health services they need, without being exposed to financial hardship.” Ir includes the full range of essential and quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. As far as Brazil is concerned, this definition is limited since the country considers health a constitutional right for all and a duty of the State.
In the spirit of the WHO resolution, the UHC would enable “all people to have access to services that address the most significant causes of illness and death, ensuring that the quality of these services is good enough to improve the health of the people who receive them.”
To understand this ‘generalist’ character of the WHO’s definition of UHC, we must remember that it is an international organization dealing with the difficulties of the entire planet in the most varied degrees of extension.
Let us consider for a moment the scale of the problem facing the WHO as an international body.
According to WHO, half of the world’s population does not have coverage and access to services considered essential to health, including the more than 100 million people who live in extreme poverty (less than 1.90 dollars a day) because they have to pay for health services. Also, according to the WHO, 800 million people (12% of the world’s population) spend at least 10% of their household budgets on health care (data up to 2019).
But even if the WHO arguments are convincing in terms of clarifying the meaning of UHC, it can be assumed that, as this “does not mean free coverage of all possible clinical interventions, regardless of costs,” some selectivity should exist in the health services to be offered, based on this watchword (UHC). In Brazil, health is financed by taxes paid by taxpayers, which does not make it “free.” Do you understand the polyphony of this watchword?
Let us consider for a moment the scale of the problem facing the WHO as an international body.
As the public health professional Paulo Buss observes, “Since this concept implies some selective level of care to be received, it could be considered a systematic factor that generates iniquities, in the case of patients with rare diseases or even more basic conditions, which governments could randomly exclude.”
In this way, it is necessary to emphasize, as Buss does, that, despite Brazil adding efforts to the struggle for Universal Health Coverage, the initiative is not seen here as sufficient for fulfilling the constitutional duties of the State in dealing with its fellow citizens.
Buss observes that, in Brazil, a whole generation of sanitarians and other health and social development professionals has based their activities on the broader definition of “universal health,” “always considering the conjuncture, commitments, and opportunities to advance in the struggle for the full right to health,” which “includes other services that determine health and are fundamental to social equity, such as community services for water, sanitation, waste collection, healthy food and others related to development based on the inclusion and social cohesion. “
UHC and rare diseases: a tense field?
Aldous Huxley, the author of the classic Brave New World, once said, “Sometimes it is necessary to state the obvious.”
Following your advice, I state a truism: Universal means “for ALL.” If it is not valid for everyone, but for some, it is not universal.
And here is a curious fact: the number of people affected by chronic non-communicable diseases (NCDs) on the planet is almost identical to the number of people living with rare diseases. However, there is an evident planetary inattention to the needs of rare patients, except for some exceptions that confirm the rule.
Perhaps, for no other reason, the entity Rare Diseases International claimed in 2019 to the World Health Organization the possibility of being recognized as the “forgotten pillar” of all UHC discussions.
But how can we propose universal coverage if public health systems privilege utilitarianism and economic efficiency? Utilitarianism with its maxim of the greatest possible good for the greatest number of people tends to leave some people aside.
Rare diseases strain the UHC field, given the high costs of high-complexity healthcare and orphan drugs. Here, the not rare ones will always be able to claim that their mush should come first.
Nevertheless, according to the United Nations, something needs to be done to mitigate the problems faced by one of the most vulnerable parts of the planet. Solutions exist. You have to have the political will. The new democratic air announced for the country can shorten these winding paths of dignity and citizenship.
