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What matters in health (care) universes:
delusions, dilutions, and ways towards
universal health justice
Anne-Emanuelle Birn
1*†
and Laura Nervi
2†
From The Political Origins of Health Inequities and Universal Health Coverage
Oslo, Norway. 01-02 November 2018
Abstract
The presumed global consensus on achieving Universal Health Coverage (UHC) masks crucial issues regarding
the principles and politics of what constitutes “universality”and what matters, past and present, in the struggle
for health (care) justice. This article focuses on three dimensions of the problematic: 1) we unpack the rhetoric of
UHC in terms of each of its three components: universal, health, and coverage; 2) paying special attention to Latin
America, we revisit the neoliberal coup d’état against past and contemporary struggles for health justice, and we
consider how the current neoliberal phase of capitalism has sought to arrest these struggles, co-opt their language,
and narrow their vision; and 3) we re-imagine the contemporary challenges/dilemmas concerning health justice,
transcending the false technocratic consensus around UHC and re-infusing the profoundly political nature of this
struggle. In sum, as with the universe writ large, a range of matters matter: socio-political contexts at national and
international levels, agenda-setting power, the battle over language, real policy effects, conceptual narratives, and
people’s struggles for justice.
Keywords: Universal health systems, Universal health coverage, Universal health justice, Neoliberalism, Latin
America, Global health agendas, Co-optation
Background
UHC is everywhere: agendas matter
Since (re)appearing on the global health agenda in 2005
through a timid World Health Assembly resolution on
sustainable health financing, universal coverage, and
social health insurance [1], and then vigorously bolstered
circa 2010, Universal Health Coverage (UHC) now seems
to be everywhere. From the World Health Organization
(WHO) to the World Bank, the Sustainable Development
Goals (SDGs), the G-20, the Rockefeller Foundation and
other philanthropies, as well as global, national, and re-
gional health policy meetings and statements, and more,
advocacy for UHC has reached an apparent crescendo of
consensus as a priority for international development [2].
For instance, the G20 meeting in June 2019 made
headlines worldwide when member nations “confirmed
the importance of stronger ties to secure the necessary
financial resources for UHC”[3].
A superficial reading of the voluminous production of
reports, statements, and resolutions by key actors and
agencies might lead policy-makers, activists, and aca-
demics alike to believe that health is (at last!) being rec-
ognized and pursued as a human right, and that the
persistent calls to strengthen healthcare systems have fi-
nally become imbued in at least the discourse of these
agencies (without necessarily translating into concrete
changes in most international/donor aid patterns).
Today UHC is portrayed as the one and only way to im-
prove access to health care for the half of the world’s
population that lacks even minimal (not to mention com-
prehensive) access. Further, the 2018 Astana Declaration
marking the 40th anniversary of the Alma-Ata Declaration
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* Correspondence: ae.birn@utoronto.ca
†
Anne-Emanuelle Birn and Laura Nervi contributed equally to this work.
1
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
Full list of author information is available at the end of the article
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0
https://doi.org/10.1186/s12992-019-0521-7
appears to indicate that there is global agreement on a
renewed commitment to primary health care as the strat-
egy that will enable the goal of UHC to be reached. UHC
has visibly arisen as the key idea for the present global
health era, as a slogan and as a vision.
What does all of this mean for “real people,”those
who are actually the targets of UHC [4]? Do we really
know what UHC denotes and promotes for them?
1
The
omnipresence of the concept suggests that it is seen as
the primary vehicle for contemporary global health, one
that can address the shortcomings of the global disease
initiatives of recent decades, which have shunted aside
the fundamental role of healthcare systems. But what is
UHC, where did it come from, and what does it por-
tend? Ultimately, what matters for people’s health in our
universe—or at least on our planet?
While it may seem cantankerous to question UHC
(after all, how can measures to get more health care to
more people be contested?), and although much ink has
already been spilled on the topic, some crucial points
warrant further exploration. Here we seek to unpack the
drive for UHC, revisiting lively debates of recent years
and paying special attention to a set of matters that
merit deeper consideration in the current atmosphere of
UHC verbal and policy ubiquity.
Yet…everything is nothing: language matters
The word universality is expansively defined as “pertain-
ing to the whole of something specified; occurring every-
where”[5]. In the area of mechanics, universality means
“allowing free movement in any direction”(as per the
1670s term “universal joint”). This connotation implies
that what is universal need not be impeded by con-
straints, be they ethical principles, values of accountabil-
ity, or other factors.
Moreover, the term coverage is problematic in its very
origins. Etymologically traceable to a “charge for a booth
at a fair”[5], its more recent use stems from the early
twentieth-century US insurance industry, referring to
the “amount of protection given by a policy.”However,
coverage of what, for whom, how, and so on has
remained vague.
Clearly, parsing of the expression UHC is both illu-
minating and troubling. Since its resurgence, observers
have been citing the ambiguous meaning(s) of the term
UHC and its component parts: despite its “apparent mo-
mentum…the goals of UHC’s proponents are unknown
except in broad senses”[6]. Especially in the United
States, UHC appeals to the idea of health insurance for
everyone. UHC is also viewed by some as a principle/
guarantee of healthcare services for all (gratis or at low
cost), or to welfare-state-like national health systems and
services.
Such equivocation has prompted “an impassioned de-
bate among today’s global health community about how
UHC should be operationalized in low- and middle-
income countries,”particularly in Latin America [7].
Critical analysts have underscored how these ambiguities
have both led to diverse governmental and civil society
interpretations and policy approaches and enabled co-
optation by powerful forces of the long-time progressive
agenda for public sector-based comprehensive, equitable,
and accessible healthcare systems [8–11].
Beyond the definitional predicaments surrounding
“universal”and “coverage,”there is a (not so) surprising
silence: among mainstream UHC champions, the matter
of what comprises/constitutes health is largely side-
stepped. Does “health”solely signify “health care”—or
does health writ large figure into this issue, as per con-
tentious discussions around the “right to health”versus
the “right to health care”? Amid such questions, a wide-
ranging debate is sorely needed.
Further, although the most critical analysts have advo-
cated for broadly addressing (not just rhetorically invok-
ing) the political, commercial, and other societal
determinants of health [12,13] instead of the exclusive
emphasis on UHC [14], the terms of the debate remain
framed by a reductionist healthcare-centered vision. This
stance (i.e. that health derives from health care), ad-
vanced by the dominant players around UHC (WHO,
the World Bank, the Rockefeller Foundation, etc.),
means that almost all of the focus has been around the
language of universal and coverage, with little attention
paid to health per se. This mainstream take on UHC
turns societal and social concerns into narrowly medical
ones and subjects them to individualized, technical, and
de-politicized interventions.
In taking deliberations around UHC to the next,
stratospheric, level, we propose, and will circle back to,
the need to revive a broad understanding of health (not
solely as healthcare access, even as this remains a critical
component) while recognizing the deeply political and
politicized nature of the struggles inherent to advancing
universal health justice as the core of the global health
agenda.
Main text
How did we get here? An emerging and re-emerging
concern: historical context matters
The call for UHC is not new. To be sure, while the
particular configuration of this term is recent, the
concept and pursuit of UHC date back to at least the
nineteenth century, traceable to militant workers’move-
ments and fiery policy debates. This activism spanned
1
Here we use “them”in an “othering”sense, as UHC policies and
schemes are rarely relevant or applicable to decision-makers, aca-
demics, and international agency experts.
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 2 of 12
workers’mutual aid societies (cooperative, non-profit
insurance arrangements for particular ethnic groups,
occupational clusters, and geographic localities) across
Europe and Southern Cone countries, as well as bot-
tom–up and top–down governmental efforts (social
movement-based and more cynical repressive gestures)
aimed at extending the reach of—and rights to—pub-
licly-funded (and -delivered) healthcare services, first for
urban industrial workers and civil servants, and then for
greater and greater swathes of the population, eventually
including family members of these groups, rural agricul-
tural workers, the elderly, informal sector workers, and
others [15].
The resulting arrangement of healthcare services, and
rights/access to them, depended both on timing and
context. For example, in the 1880s, the universal, non-
profit private health insurance arrangement in Bismarck’s
Germany offered a carrot to laborites, while reining in
their activism [16]. Great Britain saw multiple efforts,
building upon mutual aid societies starting in 1911 but
only gradually expanding upon who and what was eligible
until the sacrifices and sense of unity during World War
II enabled a post-war Labour government to push through
a public national health service (although—unlike Cana-
da’s subsequent, if now battered, attempts—never fully
abolishing a private sector). In the 1920s, the Soviet
Union’s post-revolutionary, centrally administered social-
ist health system integrated healthcare services, research,
pharmaceutical production, and public health, and came
to serve as a model for socialist states.
As early as the 1920s most Latin American countries,
including then-industrializing Argentina, Chile, and
Mexico—each undergoing a flurry of state-building ef-
forts—witnessed the beginnings of healthcare systems
within social security expansion. However, almost all of
these systems remain/ed. highly segmented, with distinct
schemes and services for different industrial sectors and
population groups (including informal and agricultural
workers), plus persistent, all but untouchable, private
healthcare arrangements for elites.
2
Both Chile and
Costa Rica sought to rationalize this segmentation in the
mid-twentieth century; and after its 1960s–1980s dicta-
torship, Brazil responded to a wide social mobilization,
creating a unified public healthcare system (albeit retain-
ing a powerful private sector). Only post-revolutionary
Cuba achieved a socialist healthcare system capable of
resolving the inevitable inequities engendered by separ-
ate, or what are sometimes referred to euphemistically
as “pluralistic,”systems [20,21].
Depression-era New Zealand and Sweden managed to
harness worker solidarity into among the most far-
reaching national health services in the context of bur-
geoning welfare states. Sidelined from these developments
were many former colonies across Africa, the Caribbean,
and Asia, virtually all of them financially strapped given
the terms and cost of decolonization, with only a few (like
Barbados and Sri Lanka) managing to channel liberation
struggles into public population-wide healthcare systems.
Elsewhere, civil servants and (some) industrial workers
were among the few groups to enjoy healthcare entitle-
ments. Similarly, in the USA’s private insurance-driven
(though paradoxically majority publicly-financed) health-
care market, only seniors, persons with long-term
disabilities, and veterans attained (mostly) publicly-funded
health coverage. Additionally, certain low-income groups
and Native Americans have come under nominally
publicly-funded and -delivered arrangements, but with
much lower access and quality. Throughout these differ-
ent eras, the International Labour Organization (ILO) and
other multilateral agencies have advocated for countries to
extend social security insurance [22].
Yet even in those countries that putatively achieved
“universal”public-sector healthcare rights and access,
especially in the post World War II era, universality
(has) remained an aspiration rather than a reality.
Whether particular types of care are not, or are inad-
equately, covered—for example, LGBTQ health needs,
therapies for rare diseases, public health, expensive care
(e.g. for treating cancer), reproductive health services
(birth control and abortion)—or some populations are
left out, such as temporary/new residents, refugees, and
migrant workers, or Indigenous populations, whose heal-
ing traditions have long been marginalized and excluded,
no system or country should have the hubris to declare
that it has achieved “universality.”In many settings,
segmenting the population is a legacy of sector-by-sector
labor struggles—or an intentional effort to divide
populations, as in the USA, with means-tested, decentra-
lized, limited, and underfunded services for the indigent
under Medicaid, as opposed to Medicare’s better-funded
(although premiums, deductibles, coinsurance, and
exclusions can still result in exorbitant out-of-pocket
expenses), more comprehensive coverage for seniors and
people with long-term disabilities.
Across Europe, the Americas, and parts of Asia in the
late 19th and into the 20th centuries—and for Africa,
the Caribbean, South Asia/some of East Asia in the de-
colonizing post-Cold War era—these precursors to con-
temporary UHC efforts marked an arc of struggle for
2
The extreme segmentation of healthcare systems in Latin America is
not a question of policy design: it is the product of structural
economic heterogeneity. Within most countries in the region, there
are vast differences in productivity levels and labor-market features by
economic sector, resulting in enormous inequalities in remuneration,
benefits, and, ultimately, relations among state, market, and population
[17]. Although inequality has at times decreased (as during the first
decade of this millennium), Latin America—with its historical and
structural inequalities—remains the most unequal region of the world,
followed by sub-Saharan Africa [18,19].
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 3 of 12
social rights, public healthcare systems, and welfare
states. Cold War tensions between capitalist and com-
munist blocs sometimes spilled over into debates around
social security vs. socialism, often serving to advance
healthcare rights. Notwithstanding the shortcomings of
these efforts, many did, as per Martin Luther King’s dic-
tum, begin to bend towards equity in the context of pub-
lic, comprehensive, population-wide healthcare systems.
Especially in Scandinavia and in socialist countries, pub-
lic and seemingly universal benefits grew expansively,
consistent with the general trend of redistributive,
socialist, and social democratic states having better
population health indicators than other societies [23].
Nonetheless even in Sweden, for example—whose uni-
versal healthcare system has long been considered one
of the most egalitarian in the world—sexist, racist, and
classist health policies and institutions remain. This is
witnessed by delays in care and second-class care re-
ported by immigrants [24] and by market-oriented pri-
mary healthcare reforms that privilege access to care for
the affluent and healthy [25]. All told, universality, even
if invoked as such, has never been reached, because of
who and what are left out of policy design and policy
outputs/outcomes. Universality remains an elusive if ad-
mirable goal.
Even so, and despite the exclusions and stratification
characteristic of much of the Third World and parts of
the First (especially the USA), efforts at creating
publicly-financed and operated healthcare systems made
undeniable gains until the 1970s. Marking the apex of
these struggles at the international level, and their turn-
ing point (with dashed hopes), was the International
Conference on Primary Health Care held in Alma-Ata,
Kazakhstan (former USSR), in 1978 and the movement
surrounding it [26]. The effort to move from disease
control to the broader right to health, from top–down to
community-based approaches to health—all in the con-
text of a New International Economic Order, upending
existing power asymmetries between First World and
Third, between capital and labor, etc.—might have be-
come revolutionary indeed.
But the decreasing profitability of capital against the
mounting gains of crisscrossing people’s movements—
for the rights of women, Indigenous groups, LGBTQ,
the environment, workers—amid ever-more inclusive
and robust welfare states in high-income countries
(HICs), as well as in a growing number of low- and
middle-income countries (LMICs), led capitalist elites
and their political allies to engage in a frontal attack.
Starting in the late 1970s and heightening in the 1980s,
enabled by the waning threat of the Soviet model, the
world order was re-oriented toward business interests—
a process of neoliberal globalization aimed at making
capital profitable again. Initially led by neoconservative
governments in the UK and USA, this transformation to
a neoliberal phase of capitalism [27] (neoliberalism for
short) has involved infusing “free”market ideology
throughout the world through a series of steps, from
currency liberalization and debt crises, to rapacious
forced loans and debt servicing (bailing out the HIC pri-
vate banking sector), and financialization (the process
through which the financial sector increases in size and
influence in relation to the overall economy)—each gen-
erating untold social misery, including massive effects on
health and the marketization of health care.
As succinctly put by Wendy Brown:
Neoliberalism—the ideas, the institutions, the policies,
the political rationality—has, along with its spawn,
financialization, likely shaped recent world history as
profoundly as any other nameable phenomenon in the
same period, even if scholars continue to debate
precisely what both are. …Neoliberalism is most
commonly associated with a bundle of policies
privatizing ownership and services, radically reducing
the social state, leashing labor, deregulating capital,
and producing a tax-and-tariff-friendly climate to
direct foreign investors [28].
There is a substantial body of evidence that connects
deteriorating health outcomes to neoliberalism, due to
the associated rise in economic inequality, insecurity,
and poverty [29] and mediated by the worsening living
and working conditions produced by neoliberal policies,
including the effects of labor precarity and austerity
policies on physical, mental, and behavioral health. Fur-
ther, as we shall see, UHC—although portrayed as an
antidote to the consequences of neoliberalism for health-
care access—is itself shaped by, and a product of, neo-
liberal ideology and policies.
Painfully illustrating the real effects of this onslaught in
LMICs, Latin America became a laboratory for
neoliberalism. This started with Augusto Pinochet’sUS-
backed 1973 military coup and decades-long dictatorship
in Chile, which piloted economic liberalization and
privatization of public services. By the 1980s, a regionwide
(soon to be LMIC-wide) debt crisis generated a “lost
decade.”Interest-rate hikes by major banks led to a doub-
ling of Latin America’s debt burden in just three years. Be-
ginning with Mexico in 1982, dozens of countries within
and beyond Latin America defaulted on private loans in
rapid succession [30,31]. The International Monetary
Fund and World Bank orchestrated structural adjustment
loans to “help”debtor countries reduce deficits and meet
debt-servicing burdens by forcing a series of neoliberal re-
forms. These obligatory economic reforms (quid pro quo
loan “conditionalities”)weredesignedtofuellow-cost
exports and open domestic economies to foreign direct
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 4 of 12
investment (FDI). Measures comprised: drastic cuts to
social spending (including to the already-underfunded
health sector); removal of agricultural subsidies; ratch-
eting back of labor protections; deregulation of min-
ing and other industries; lifting of restrictions on
foreign investment and banking; trade liberalization;
currency devaluation; privatization of government ser-
vices and state-owned assets; and imposition of user
fees for school attendance and health services [15].
These much-reviled reforms damaged health, not only
through corroded quality and huge declines in access to
care, but also through deterioration in education, wages,
neighborhood conditions, worker safety, and a host of
other societal protections. Exacerbating pre-existing
inequities and problems of fragmentation, neoliberal re-
forms—under the advisement of international financial
institutions (IFIs)—sparked a wave of social-security and
health-system reforms in Latin America and across the
Third World [32].
The specific and often enduring effects on the health-
care sector have been wide-ranging, as illustrated by the
Latin American experience. On one level, increased
entry of financial capital stimulated greater private
health insurance coverage for the healthy and wealthy
(entrenching the long-standing practice of excluding
“high-risk”individuals); by the 1990s there was soaring
FDI in social security systems (feeding on health insur-
ance and pension “markets”) serving middle class and
formal sector workers. Simultaneously, Big Pharma
increasingly displaced domestic generic and public drug
manufacturers and distributors. On another level, state
health systems became privatized “from within”—with
public funds used to contract private hospitals and
providers, outsourcing of management and human re-
sources, and subcontracting to private entities of profit-
able services, including laboratories and pharmacies, as
well as food services, cleaning, and patient transporta-
tion. On yet another level, policy-makers turned to user
fees in order to increase revenue and reduce demand for
state-funded health services and institutions. While “The
proponents of these measures touted their efficiency and
transparency, …they have produced opposite effects:
waste, unnecessary expenses, growing inequities and cor-
ruption”[10].
Such ruthless policies spurred persistent and wide-
spread resistance worldwide, perhaps nowhere more
than in Latin America, by the early 2000s reaching ballot
boxes across the region in an upsurge for change. The
much-touted Pink Tide of socialist-leaning or social
democratic movements, political parties, and elected
governments used sizeable commodity-boom earnings to
invest in a host of policies aimed at improving living and
working conditions (thereby improving health)—from
living wages to the enforcement of labor laws, and
including greater access (and in some cases rights) to
healthcare services. Concerted progressive policies
ranged from anti-poverty programs such as noncondi-
tional cash transfers
3
(Uruguay), to integrated nutrition,
primary health care, and cash-transfer programs (Brazil),
progressive tax reforms and a unified public health in-
surance financing pool (Uruguay), neighborhood-based
primary-care clinics (Venezuela), intercultural healthcare
services (Bolivia), and increased access to an integrated
network of health services and effective intersectoral ac-
tions for health (El Salvador) [33].
In some cases, progressive health reforms predated the
arrival of left-leaning governments to power, as with
Brazil’s investing in a unified public healthcare system.
In others, neoliberalism was embodied in contrary health
reforms through UHC-style “structured pluralism”ap-
proaches (Colombia, Mexico, Peru), continuing (albeit
expanding) highly inequitable segmented and stratified
healthcare arrangements [34,35].
Although measurably bettering health and social con-
ditions, Pink Tide efforts did not fundamentally upend
the capitalist basis of these societies because most of the
social investments came not from redistribution or tax-
code reforms, but from commodity earnings (even in
Venezuela, Barrio Adentro was never integrated with the
public system, and the capitalist economy has remained
in place). Moreover, persistent asymmetries of power en-
abled a shockingly rapid retrogression of these reforms
in the wake of the commodity bust, with a return to
conservative rule in recent years (which, as this article
was going to press, was being contested by the election
of anti-neoliberal governments in Mexico and Argentina
and by massive popular demonstrations and mobiliza-
tions against neoliberal policies in Ecuador, Chile, and
elsewhere).
Even before the Pink Tide, the suffering under neo-
liberal globalization had not gone unnoticed by IFIs;
however, their remedies typically reinforced the very pol-
icies they purported to address. The World Bank sought
to give a “human face”to its loan remedies, creating an
alphabet soup of partial debt forgiveness programs—
without de-attaching conditionalities, leaving countries
tethered to the same economic precepts that were stran-
gling them. The WHO’s 2000–2002 Commission on
Macro-Economics and Health underscored the issue of
ill health in instrumental terms—as draining productivity
and causing impoverishment—but failed to grasp the
role of poverty in generating ill health in the first place
[36].
3
It is essential to distinguish between nonconditional transfers going to
all those who meet poverty criteria, and conditional cash transfers
based on a mandatory and paternalistic quid pro quo, such as proof of
school and health clinic attendance, regardless of the quality and
accessibility of these services.
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 5 of 12
Emblematic of the neoliberal response by international
agencies, UHC in many ways arose out of the preoccu-
pations raised by this Commission. Meanwhile, the
2003–2008 WHO Commission on Social Determinants
of Health (SDOH) sought to recapture the agenda by
focusing on social injustice, unequal distribution of
power and resources, and the need to improve the day-
to-day living conditions of “the other half”of the world’s
population who had seen their circumstances devastated
under neoliberal ascendance. But the push for SDOH
remained at a largely technocratic level and was soon
overshadowed by philanthrocapitalist encouraged top–
down (vertical) disease initiatives [37].
Fast forward another decade and these mixed aims—a
nod to rights amid the deterioration of social conditions,
but with assurance of financialization—are now fully
inscribed in the SDGs of the 2030 Agenda for Sustainable
Development, adopted at a UN Summit in September
2015. Goal 3, Target 3.8 puts UHC among the global
priorities for development: “Achieve universal health
coverage, including financial risk protection, access to
quality essential health care services and access to
safe, effective, quality and affordable essential medi-
cines and vaccines for all”[38].
In this short definition, and in the monitoring indica-
tors defined a year later, the two fundamental elements
of UHC are highlighted: access to essential health ser-
vices (“essential”: a limited rather than comprehensive
package of provisions); and financial risk protection,
understood as the proportion of the total income of each
household spent on health care—aimed at preventing
/limiting medical bankruptcy/impoverishment, while en-
suring new markets for insurance capital.
In sum, UHC’s genealogy—despite policy-makers’ef-
forts to invoke public, rights-based healthcare systems as
forerunners—reveals a massive dilution of the progres-
sive health agenda: UHC stems from, and is consistent
with, the neoliberal turn in global capitalism.
Unveiling the co-optation and perils of UHC beyond
discourses: policy matters
The war of words is important: as noted by Foucault
and many others, power is evidenced and manifests in
discourse, which in turn profoundly shapes (and is
shaped by) how people’s preoccupations are defined,
political priorities are set, and policy-makers establish
guiding agendas.
And yet, deliberation is not enough. When the debates
(and debaters) are exhausted and even once a discourse
of (healthcare) rights and (healthcare) justice takes hold,
as it seems to have, the realities of governing and policy
become the crucial space for attention—and struggles
(see below).
Delving into how and why UHC is not equivalent to
public and universal healthcare systems necessitates far
more than rhetorical unpacking. Instead, as made clear
in the scholarly literature, it requires an unveiling of the
concrete policy agendas, implementation consequences,
and further implications embedded in this trend. Here
we review a selection of critical analyses showing why
UHC is a problematic approach and what assumptions
undergird the policies and practices it spawns.
Building on the ambiguities cited above, Lethbridge
emphasizes that WHO and the World Bank Group’s
promotion of universal health coverage—as opposed to
provision—“involves the creation of health insurance
schemes which allow people to access health care facil-
ities run by public, private and not-for-profit sectors”
[39] and adds that universal healthcare provision (or
universal health systems [UHS]: publicly financed and
delivered, single-payer healthcare systems), on the other
hand, “dictates that the government guarantees the ac-
tual provision of health care services to everyone, irre-
spective of income, status, etc., rather than offering what
is in effect hypothetical ‘access.’” The “hypothetical”ac-
cess offered by the UHC model is another way of saying
that coverage only ensures nominal, not necessarily ef-
fective or realizable, access to health care.
Moreover, despite the assertion that public sector
provision is included in the UHC mix, what it heralds in
terms of actual policy is the extension of insurance to
those not currently covered through partial financial pro-
tection via (circumscribed) packages of “essential”services,
often purveyed in the for-profit sector. This harks back to
the 1993 World Bank’s World Development Report’s
“Investing in Health”neoliberal prescription for scaled-
back public services, opening the door to private invest-
ment, and advocacy for out-of-pocket payment (user fees)
for healthcare services.
Amplifying the critical analysis, Giovanella and col-
leagues [40] compare and contrast UHC-based and
UHS-based models, identifying a range of divergent fea-
tures. What follows is a non-exhaustive summary of
what these authors argue based on their comprehensive
review of the literature
4
:
–The UHC approach conceives of health as a
commodity; UHS recognize health as a human right.
–In UHC, the role of the state is minimized,
restricted to the regulation of the healthcare system,
with explicit separation of financing/purchasing and
service functions. UHS, by contrast, are based on
principles of social welfare, wherein the state is
4
There is a vast literature analyzing the equity, efficiency, fairness, and
health outcomes of for-profit versus non-profit healthcare delivery in
the United States, including these two classic reviews [41,42].
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 6 of 12
responsible for the funding, management, and
delivery of health services.
–As to funding, UHC is based on the pooling of
public and private funds (insurance premiums, social
contributions, philanthropy, taxes); UHS are based
on public funding via tax revenues (general taxes
and social insurance contributions).
–Regarding the underlying rationale for each reform,
UHC subsidizes/incentivizes demand for health
insurance purchase via delimited packages of
services and targeting of (some of) the poorest; UHS
subsidize supply to guarantee equitable access to the
entire population.
–Concerning eligibility/entitlement, UHC systems
create segmented access based on enrollment within
particular insurance schemes (private or public);
UHS pursue universal access as a condition of
citizenship or residency.
–In terms of efficiency, the UHC approach raises
operational and administrative costs, leading to
higher total expenditures on health; UHS maintain
lower administrative and operational costs, reduced
unit costs due to economies of scale, and lower (or
at least more equitably distributed) total expenses
due to greater regulation of supply.
–UHC arrangements are fragmented, providing only
selective packages of primary healthcare services;
UHS are organized through networks of
territorially-based, comprehensive primary health
care.
–UHC is focused on individual care and biomedical
services and is separated from collective care; UHS
seek to integrate individual care and public health
actions, as well as integrating health promotion,
prevention, and curative care.
–Lastly, UHC marginalizes the SDOH approach; UHS
incorporate societal determinants of health and call
for intersectoral action.
These differences are not simply abstract policy mat-
ters but translate into real pocketbook and access issues.
Insurance arrangements that involve premiums, co-
insurance and co-payments, and often sky-high deduct-
ibles may ostensibly increase UHC, while impeding
actual access—both because the costs themselves may be
prohibitive, with household health resources spent on
payments rather than services, and because the modus
operandi of UHC-based systems is to minimize health-
services use through barriers to care. Paradoxically, as
we will see, opposing pressures for increased use of cer-
tain products and services are also a factor.
In the end, as seen in Latin America and beyond, the
results of the expansion of UHC-based health arrange-
ments (as opposed to UHS) have been grim, negating
the touted gains of these reforms. Far from being a
major accomplishment for global health and equity,
UHC represents a continuation (wrapped in emperor’s
clothes) of (more) business as (than) usual since the rise
of the neoliberal phase of capitalism and the assault on
the long struggles for health and healthcare justice.
To contend otherwise would be a delusion.
In a prior analysis, we argued that UHC represents
one of the most cynical and effective contemporary in-
stances of co-optation of the global health equity agenda
[10]. Despite having recommitted itself to the Alma-Ata
principles in 2008, WHO fully endorsed UHC two years
later, amid the Great Recession and in a context of rising
healthcare costs and continued LMIC healthcare system
disarray “following decades of neglect and downsizing.”
We cited well-grounded studies showing that “through
UHC, insurance corporations gain access to public rev-
enue streams (social security contributions and taxes)
that finance contracts to provide a set of services to the
previously uninsured,”and noted with dismay that those
newly covered under UHC schemes are “overwhelmingly
economically precarious”yet are often legally required
to spend large proportions of their earnings to pay a
range of user fees and new taxes regardless of their pre-
carity, and that those even more vulnerable—informal
sector workers—may be excluded from “universality”
altogether [10].
Acknowledging the menaces of UHC policies, some
agencies have sought to preserve the message of com-
prehensive, equitable approaches. The Pan American
Health Organization’s (PAHO’s) “Strategy for Universal
Access to Health and Universal Health Coverage,”
adopted in October 2014, recognizes that these princi-
ples “imply that all people and communities have access,
without any kind of discrimination, to comprehensive,
appropriate, and timely, quality health services deter-
mined at the national level…as well as access to safe, af-
fordable, effective, quality medicines…” [43]. Taking up
the term “universal health”to overcome the dilemmas
over coverage, PAHO endorses a “multisector approach
to address the social determinants of health and pro-
mote a society-wide commitment to further health and
well-being”[43].
Nevertheless, in refraining from discussing the roots of
social and health injustices, or the power relations that
impede the fundamental changes needed to address
these injustices, PAHO enshrines a functionalist UHC
approach. Incorporating a discourse of health justice
without actions to remedy injustice is insufficient. In-
equities are not genetic: they are produced by societies
in which a small and powerful elite garners massive ad-
vantages, excluding most of the population.
While functionalist approaches can enable the identifi-
cation of inequities, they draw attention to the existence
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 7 of 12
of inequities without actually addressing them. Ultim-
ately, such approaches attribute inequities to unavoid-
able societal malfunctions, not to a system designed to
perpetuate asymmetries of power and maintain struc-
tures that benefit elites to the detriment of the majority.
As such, even PAHO’s aspirational language is unable to
circumvent the deep flaws of UHC.
To reiterate, a critical mass of research findings has in-
dicated the inadequacies of UHC in terms of equity, fair-
ness, social justice, and health itself [39,40]. It is
essential to consider UHC not as an innovation that has
magically appeared to address/resolve the woes of in-
accessible and inequitable health care (not to mention
health) of unspecified genesis, but as the logical out-
growth of four decades of neoliberal capitalist (health)
ideology and associated policy-making. Notwithstanding
the clever semantic flourish of incorporating the word
“universal,”UHC effectively reproduces the features of
neoliberalism that have plagued healthcare systems,
health, and overall societal well-being over recent de-
cades: proliferating user fees, privatization and outsour-
cing, public subsidies to the for-profit sector,
subcontracting of public roles and jobs to private inter-
ests, greater precarity and loss of union protection for
health workers, increased market entry for profiteering
corporate interests (e.g., insurance companies and phar-
maceuticals), carte blanche to FDI with a bare minimum
of regulation/oversight—and more.
In sum, UHC represents not a break with the past, but
rather the fruition of a long assault on public healthcare
systems and welfare states, and, therefore, on health. It
is only the de-contextualized and de-historicized por-
trayal of UHC that makes it seem revolutionary instead
of just one more brick in the mansion of neoliberalism.
Unfortunately, many health advocates and activists,
pleased at what they envision as a step towards universal
and public healthcare systems, have not fully recognized
the nefarious underbelly of UHC.
Transcending the debates and dilemmas around UHC
versus UHS is an additional element little discussed in
health-policy circles. It is critical to take into account
that, in conjunction with the rise of neoliberal
globalization in the 1980s, US (later global) biomedicine
began to be “transformed from the inside out through
old and new social arrangements that implement bio-
medical, computer, and information sciences and tech-
nologies to intervene in health, illness, healing, the
organization of medical care, and how we think about
and live ‘life itself’” [44].
Biomedicalization generates an internalized “self-con-
trol and [health] surveillance”regime, whereby healthy
individuals are encouraged to undergo health “enhance-
ments”through unnecessary and often dangerous proce-
dures and products, such as vitamin supplements and
cosmetic surgery. As Iriart and Mehry argue, biomedica-
lization involves not only “defining, detecting and treat-
ing”illness processes, but also “being informed and alert
to potential risks and conditions that could lead to
disease”[45]. This frequently takes the form of disease-
mongering—direct or indirect marketing or preying on
subject populations, be they youth and young parents on
social media, or older groups affected by more trad-
itional channels. Examples of how this process affects
real people include the assignment of “at-risk”or
“sick”labels to otherwise healthy individuals when the
thresholdvaluesofwhatisdeemedtoconstitute
hypertension, high cholesterol, hyperactivity, anxiety,
depression, or overweight/obesity are arbitrarily low-
ered, prompting the ordering/prescription/consump-
tion of tests and drugs “of dubious efficacy and in
many cases iatrogenic”[45].
These processes are driven by corporate profiteering,
and abetted by WHO and other international agencies
propagating a noncommunicable disease crisis [46]:
disease-mongering and global agenda-setting combine
with internalized subjectivity to “pre-disease,”creating
huge marketing possibilities. As a result, healthcare
systems around the world are beleaguered by soaring
costs due to over-diagnosis, over-prescribing, and over-
treatment, with severe consequences for the well-being
of populations and the financial sustainability of health-
care systems. Meanwhile, the production and distribu-
tion of ultra-processed food and beverages directly
related to the worsening of key health indicators remain
largely unregulated.
Ironically, but not unexpectedly, biomedicalization has
also provoked deep suspicions, often wrongheaded and
uninformed, about the safety and purview of the main-
stream biomedical establishment, resulting in the bur-
geoning appeal of “alternative”medicine in both HICs
and LMICs where traditional healing cultures have long
been disappearing.
Moreover, the realm of biomedicalization reveals a
profound and under-discussed paradox relating to UHC.
If, as per the above, it is in the interest of the private
insurance sector to minimize people’s access to health-
care services in order to maximize profits, the reverse is
true for industrial (medical) capital (Big Pharma, Big
Diagnostics, Big Devices, etc.): increasing access to ser-
vices and products is both necessary and desirable, re-
gardless of the funding stream [45]. Such paradoxes
between the different segments of capital, even as at
times they also join forces, make the analytic task and
points of resistance extremely complex.
Although debates around UHC have centered on
healthcare services and systems, the larger environment
of biomedical hegemony and of capitalist extraction ex-
ists both inside and outside the boundaries of what are
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 8 of 12
typically understood as healthcare systems. Thus, it be-
hooves us to recognize the struggles ahead as occurring
both within the health sector and well beyond it.
Conclusions
Deconstructing is not enough: politics, power relations,
and struggles matter
If “being insured does not mean guaranteed access to
health services”(let alone a comprehensive array of ser-
vices) and if “the UHC model increases segmentation
and crystallizes social stratification and inequities in ac-
cess to health and health conditions”[40], how can the
large majority of activists, communities, health workers,
and scholars committed to health equity and social just-
ice escape the dilutions and delusions of UHC? How can
the terms of the debate be recast to—together with the
necessary struggles and actions—put us all on the road
towards universal health justice?
Our invocation of the term “universal health justice”
rests on the conviction that each and every individual/
community/population, regardless of who they are or
where they come from, deserves equal rights and equit-
able outcomes, including the right to health (and health
care), and the power to exercise those rights. Drawing
on the work of countless social justice-oriented activists,
policy-makers, academics, investigative journalists, and
others [14], we hold that the path towards universal
health justice requires: an understanding of how the
structural determinants and determination of health [47]
operate within each context and globally; identification
of what policies and social forces reinforce the associated
asymmetries of power; organizing to remove structural
impediments to health (explicitly including racism, sex-
ism, xenophobia, poverty, hetero-normativism, classism,
denialism of climate change, among others); defining
specific local and global strategies to create equitable
and fair living and working conditions within and across
societies; and building equitable and participatory
healthcare systems for all.
Beyond UHC mania
Of central importance is not getting lost in the techno-
cratic battles created by those who frame the debate [48,
49]. We join the chorus of actors from LMICs/Global
South and allies who call for the political to be extracted
from the technocratic. Even an aspirational understand-
ing of UHC is far more than a matter of extending the
right “model.”This is a fundamentally political issue
about how resources are harnessed and distributed and
affect people’s lives and does not just involve the balance
sheets of decision-makers or international bureaucrats.
Here, the questions concern the political spaces afforded
governments seeking to be accountable to people’s
needs—be it governments heavily reliant on foreign
donors, or those with putatively more “sovereignty”but
having virtually no possibilities of implementing the pro-
gressive platforms on which they are elected because of
the constraints (financial, political, and more) of the
neoliberal capitalist global order. For these peoples and
societies, it is politics that matters, at the local and glo-
bal levels, far more than the war of words.
Adiós a la nostalgia
Above all, it is crucial that progressive-minded critics
of UHC not wield a superficial nostalgia for welfare
states of yore—we should not retreat to a defensive
stance or wear blinders to the multifarious and deep
limitations of even the most expansive welfare states
of the past. This is undoubtedly a complicated task,
given how many rights, services, and protections have
been clawed back in recent decades in both LMICs
and HICs. Building anew will require aspirations and
values that strive to overcome the constraints and
limits of what have often been welfare states designed
largely by and for (mostly) men, civil servants, settler-
colonialist groups, those of dominant ethnicity, and
the industrial working class [50].
UHS, as outlined above (comprehensive healthcare ac-
cess as a right, with unified, integrated, and publicly fi-
nanced and delivered healthcare services) are worth
fighting for—but they will have to be envisioned and
structured anew, to break with embedded forms of op-
pression and inequities from the past.
Among the knowable requisites for paving the long
road to UHS oriented to universal health justice are: as-
surance of political and financial viability (with global
cooperation, if necessary); bona fide representation and
participation of the people and of healthcare workers
5
in
decisions and management; constitutional and tax-code
reforms, and reforms to prevent illicit financial flows
that drain domestic coffers; addressing the geographic,
social, and system-level barriers to health care (inequit-
able quantity, distribution, and networks of health ser-
vices, institutional and societal racism, xenophobia,
sexism, aporophobia, queerphobia, inadequate or un-
affordable transportation, etc.); multisectoral planning
and coordination; ensuring, as a matter of human rights,
women’s full access to reproductive health services, in-
cluding abortion; critical evaluation, monitoring, and
forestalling of the negative effects of corporatization and
5
A crucial, if oft-ignored, dimension of UHC and even many UHS con-
cerns the role of healthcare workers, who play a central role in any
healthcare system, but are increasingly subject to authoritarian man-
agement, ever-deteriorating labor relations and work conditions, and
precarious employment, particularly in LMICs. Despite this ongoing
dehumanization of health workers, “attempts to incorporate social par-
ticipation into health systems almost always bypass health workers”
[51].
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 9 of 12
biomedicalization on population health and health sys-
tems (and inclusion of non-biomedically-based health
models, within a perspective of interculturality); global
(health) agencies and policies that respond to articulated
and contextualized needs and priorities from below, in-
stead of health-policy agendas crafted on the interests of
corporations and their political partners; and addressing
gender and social inequities within the healthcare
workforce.
Continue building counter-hegemonic epistemological and
policy paradigms
We recognize the ongoing role of evolving worldviews
and policy frames that articulate health as the product of
the conditions of life, work, the environmental viability
of the planet, and the intersectionality of class, gender,
and race/ethnicity. Part and parcel of this effort is
understanding the power dynamics that underscore the
ways in which economic and political resources and
power are themselves appropriated by and concentrated
among elites and dominant structures, including via a
hegemonic biomedical model. Nowhere is this more
evident than in the contemporary resurgence of authori-
tarian governments as a “therapeutic”response to wide-
spread deterioration in social conditions, employment
prospects and security, social protections and rights,
health and life expectancy, and morale—whether in the
USA, Brazil, Hungary, or India. Gramsci reminds us that
day-to-day struggles reside not only at the level of ma-
terial circumstances, but also in the ideological battle-
fields around what constitutes a desirable, ethical, and
fair society amid a “contradictory consciousness”that
pervades thought processes and influences people, often
against their own objective interests. It is in this context
that the combined interests of capital and right-wing
hate-mongers in many societies have revived the attract-
iveness of fascist parties and beliefs, often goaded on by
conservative evangelical religious forces, in which mem-
bers of the working class (mostly men) rally their resent-
ment against all possible “others”—especially, but not
exclusively, immigrants, women, people of “non-domin-
ant”race/ethnicity, LGBTQ, Indigenous groups, and
low-income populations—while never addressing the
true perpetrators of declining quality/conditions of life:
ever-greedy capitalist interests [52].
Translated to the global health arena, counter-
hegemonic paradigms must include analysis of the em-
bedded assumptions in the many global policies that
may be characterized as “Grand Plans from Above”
(UHC, as well as GH2035, etc.), in which (indisputably
growing and persistent) health inequities between coun-
tries, social classes, and groups are cited—but then nor-
malized, naturalized, depoliticized, and ultimately
discarded. Not only do these Grand Plans from Above
fail to recognize or address the roots of these inequities,
they also blame the public for their own “poor choices,”
viewing social and health injustices (particularly in
LMICs) as inherent to their own contextual realities. Oft
mentioned are the role of corruption (which also affects
the USA and other HICs) and the influence of elite/cor-
porate interests on policy-making (legalized in the USA
through political lobbying), with no acknowledgement of
the role of colonialism/imperialism in the making of
abysmal inequities in the first place, and in the contin-
ued extraction of profits and resources, or of the con-
centration of power in the hands of global and local
elites.
In whose universe? Towards transforming the global
political order: real people, real actions, and real
movements matter
We have raised a few points, admittedly incomplete,
aimed at taking back the (terms of the) debate over what
we call “universal health justice.”However, we recognize
that the real political challenge lies in achieving the
transformation of the global political and economic
order.
In examining and engaging in the “hows”of achieving
this transformation from our political vantage point in
the global health arena, it is important to bear in mind
that struggles for health justice, social justice, and eco-
nomic justice go together—that struggles for just (fair)
health policies at the level of healthcare systems are part
of larger struggles for equitable social and economic pol-
icies. Striving for socially just economic/financial and so-
cial policies writ large is central to any effort towards
universal health justice.
If anything has been learned from the neoliberal period
of global capitalism of the past four decades in Latin
America and the conservative resurrection in the last few
years (following the Pink Tide), it is that “even the most
profound health and social justice achievements may be
reversible”[10]. This is a poignant reminder that historic
gains are and will remain provisional as long as the con-
struction of democratic societies continues to rest solely
on the idea of a clean electoral system—without address-
ing and fundamentally transforming the role of real people
in the construction of power within and across societies
on an ongoing basis. Social participation must not be a
checklist or an afterthought that tinkers at the margins
while continuing to reproduce power asymmetries: with-
out true social accountability of government actions and
international (financial and governance) rules and ar-
rangements, in all their dimensions, there can be little real
or lasting change.
The necessary transformations will require sustained, in-
defatigable, and relentless commitment and mobilization
that continuously recognizes and addresses the injustices
Birn and Nervi Globalization and Health 2019, 15(Suppl 1):0 Page 10 of 12
highlighted above, drawing on a deep conceptual under-
standing, and enabling the development of real, feasible, if
ambitious, actions to confront these injustices. It is crucial
to learn from and practice solidarity with the many inspir-
ing and persevering movements, especially in the Global
South, that struggle for justice—including decent-work
movements, youth movements, women’s movements, In-
digenous rights movements, anti-racism movements, anti-
imperial and anti-militarism movements, environmental
justice movements, tax and banking/financial system just-
ice movements, trade justice efforts, movements to com-
bat resource extraction and climate change, and so many
others. The struggle for universal health justice should not
be separate from these movements: a universal vision for
health justice demands universal actions.
Abbreviations
FDI: Foreign Direct Investment; HICs: High-Income Countries;
IFIs: International Financial Institutions; ILO: International Labour Organization;
LGBTQ: Lesbian, Gay, Bisexual, Transgender, and Queer; LMICs: Low-and
Middle-Income Countries; PAHO: Pan American Health Organization;
SDGs: Sustainable Development Goals; SDOH: Social Determinants of Health;
UHC: Universal Health Coverage; UHJ: Universal Health Justice; UHS: Universal
Health Systems; UK: United Kingdom; UN: United Nations; USA: United States
of America; USSR: Union of Soviet Socialist Republics; WHO: World Health
Organization
Acknowledgements
We are grateful to the reviewers for their helpful feedback.
Dedication
This article is dedicated to the memory of David Sanders, whose lifelong
commitment to universal health justice and social equity was matched by
his deep sense of camaraderie, solidarity, and an ever-present wit, helping
those around him to persevere through challenging political struggles.
About this supplement
This article has been published as part of Globalization and Health, Volume 15
Supplement 1, 2019: Proceedings from the Conference on Political Determinants
of Health Inequities and Universal Health Coverage. The full contents of the
supplement are available online at https://globalizationandhealth.
biomedcentral.com/articles/supplements/volume-15-supplement-1.
Authors’contributions
AEB and LN contributed equally to this work. AEB and LN read and
approved the final manuscript.
Funding
No funding was received for the research or writing of this article.
Publication costs were covered by the Independent Panel on Global
Governance for Health, an initiative funded by the University of Oslo.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
2
College of Population Health, University of New Mexico, Albuquerque, USA.
Published: 28 November 2019
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