The one good thing to come from the Ebola outbreak in west Africa is a fresh debate on the urgency of improving access to basic healthcare and, in turn, the need for moves towards universal heathcare coverage.

Years of neglect of prevention and treatment help explain why the lethal infection claimed thousands of lives in Sierra Leone, Liberia and Guinea, whereas it was effectively contained in Europe and North America.

To some, the events have underlined the broader benefits of investment in health as a way not only to cut illness and death but also to support broader development. Given the poor response, Ebola has sharply set back economies in the region.

“Ebola revealed health systems so weak they are a threat to national and global security,” says Tim Evans, senior director for the health, nutrition and population global practice at the World Bank. “We are failing to invest to provide that secure foundation for healthy economic development.”

Despite global growth since the turn of the millennium — which has lifted many lower-income countries to middle-income status and eased absolute poverty — more than 1bn people still lack access to basic healthcare.

Many more, from those on modest incomes in the poorest nations to those in the richest who have substantial savings but are underinsured, risk financial ruin when they fall ill and are required to pay “out of pocket” for their care.

In September 2012, world leaders voted unanimously at the UN general assembly to move towards universal coverage. They will gather again in New York this September to take stock at a time when the 2000 Millennium Development Goals come to a close, with the objective of tackling ill health far from complete.

A first issue is how to quantify the extent of the problem of inadequate health coverage. Data remain patchy, and the World Bank, with the World Health Organisation and the Rockefeller Foundation, are finalising an analysis of the use and coverage of essential services, which is due to be released in May.

A second element is how best to respond. That requires defining the most suitable services and ensuring that they are delivered efficiently and effectively. More than 20 countries now share their experiences as part of a recent initiative, the Joint Learning Network.

A report on Universal Health Coverage led by David Nicholson, the former chief executive of the UK’s National Health Service, released at the World Innovation Summit for Health in Qatar this week, suggested it is better to provide an affordable basic package of care to a high proportion of the population than a broader but costlier package to a smaller group.

The authors contrasted the progress made by countries including Thailand, Sri Lanka and Brazil with more unequal advances in Vietnam, the Philippines, Nigeria and Ghana. They also urged policy makers to avoid the mistakes of industrialised countries, in which improved outcomes have been accompanied by sharply rising expenditures.

They cautioned: “Universal health coverage can only be achieved through publicly governed, mandatory financing mechanisms (general taxation and social health insurance contributions) that compel wealthier and healthier members of society to subsidise the poor and the vulnerable.”

There is little doubt that improved health is an increasing focus for politicians, including the opposing sides in the UK’s pending general election and China’s calls for equitable health cover as a factor for social harmony. President Joko Widodo’s election in Indonesia last year was in part attributed to his progressive pledges on health.

Even so, as the struggles to pass and preserve “Obamacare” in the US have shown, the battles are far from easy or complete anywhere. The human trade-offs and the financial commitments are considerable. For now, universal health remains more aspiration than reality.

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