9 reasons universal healthcare will fail – if we don’t act now

The global spread of COVID-19 came at a moment when momentum for universal health coverage (UHC) was increasing. On the heels of the high-level UN declaration in late 2019, many low and middle-income countries (LMICs) had been working to translate the warm intentions of world leaders into tangible actions. With the response to COVID-19 currently consuming all the political oxygen and pushing already overburdened systems past their breaking points, progress towards achieving UHC is at a standstill.

In response, here are the big challenges we encounter every day and must overcome to expedite healthcare for all. We have a 10-year deadline to deliver the SDG commitments and unless we address these systemic challenges, I cannot see the vision becoming reality.

Although digital technology has the power to transform the health of millions, it requires mobile connectivity. Unfortunately, network coverage in many rural, lower-income areas is incredibly poor. Additionally, many residents in these areas are also unbanked, necessitating an offline, cash-based economy. Some change is occurring: DBS Bank is partnering with us at reach52 to support our expansion into underserved communities in India, a country where financial institutions are increasingly regulated to devote resources to low-income clients. In my view, this is necessary; sometimes the free market doesn’t work.

There is a concentration of medical professionals in cities, leaving rural areas grossly understaffed. In our partner communities, there can be just one doctor for 70,000 people. (For comparison, the UK has a ratio of one to 8,000 and is called a “broken system”.) This is a structural issue not solved by additional staff. Even if 50% more doctors appeared today, they aren’t going to perfectly distribute according to need but will still concentrate in cities for a higher standard of living. The only way to tackle this is through remote care and telehealth.

I always thought if we built accessible health services for rural areas it would be an easy sell for people. Unfortunately, that was incomprehensibly incorrect. If you have never had quality healthcare before, then the process of using it can be a foreign concept. Instead, praying and faith, taking herbal medicines or seeing a “quack doctor”, which tend to be in every village in places where there is often one professional doctor for 25-50 villages, are often the first resort. A huge amount of effort must be made to unpick these complex cultural norms.

As unfortunate as it is, corruption is often our first stumbling block. Government officials have asked us for thousands of dollars as a precondition before allowing us help their low-income constituents access affordable healthcare. Unfortunately, this means we sometimes walk away from many in-need communities as a result.

Corruption also occurs in more systemic ways. While many multinational pharma companies are increasingly committed to access initiatives, the social impact of these schemes can be muted by predatory middlemen or even government officials with commercial conflicts of interest. Stronger enforcement must be taken to stamp out these behaviours.

Like many other countries, e-prescriptions were banned in the Philippines until recently, with temporary allowances only allowed as part of the COVID-19 response. Diagnosis still cannot be made without a physical in-person consultation. Given the lack of human health resources in rural areas these policies necessitate rule-breaking and a complete disregard for regulations for example, most pharmacies in the Philippines will not ask for a prescription.

More pressure must be put on governments to rethink the rulebook to create flexible, realistic regulations for remote communities. Technology can enable the solution, coupled with multilateral and donor policies encouraging flexible regulations for different parts of a country with different health access issues.

Partnerships with innovative social enterprises need to be fully embraced to reach the 52% of people without access to affordable healthcare. This thinking isn’t common in the health field and legacy funding systems aren’t set up to support impact-led businesses. Too much funding is put towards rebuilding the provider-led, unintegrated health systems of yesterday, rather than reinventing health systems for tomorrow. A joined-up approach to investment and implementation is essential to change systems in the right way – and to future-proof them. Many developed health systems are struggling with siloed healthcare data and services and this trend is being repeated in the countries in which we work, setting traps for the future.

Regardless of private sector discounting, good prevention strategy or any efficiency gains in service delivery, public financing is woefully inadequate. This must be acknowledged and addressed. As healthcare needs get more complex in LMICs, more money will be needed.

A huge issue related to this is the inability to collect taxes. In my view, this is something that high-income countries should build into their development and aid strategy. Getting more cash in the bank to support people with universal health coverage is essential. I can’t believe I just endorsed the taxman, but it’s a necessary evil - sorry folks!

For all the great work on sustainability, ESG (Environmental, Social and Governance measures), impact and corporate social responsibility, too many organizations are struggling to live up to the purpose they profess. It’s difficult when targets and bonuses are often linked to profit and growth. This reinforces a focus on high-income residents, inevitably centralizing efforts in cities. Targets for impact need to be led at a board level, promoting an organizational emphasis on more than just the bottom line. I believe this change is starting to happen, meaning businesses that just take and give nothing back won’t be competitive in the future.

The “private sector” in health is often talked about at the public health conferences I attend, but the term is typically used too narrowly. As I travel to various LMICs, the prevalence of Western-style junk food and toxic living environments is staggering. The private sector’s influence over the social determinants of health, including climate and environment need to come under greater scrutiny. We must accept that the way we are living our lives and how our societies and economies are developing ultimately creates challenges to the sustainability of healthcare systems and will continue to drive spiralling costs.

In the face of such challenges, we might despair, but I remain an optimist and restless for change – one of reach52’s core values. However, to make maximum progress, we need to be open and direct about the systemic, root-cause obstacles we face and then start a multi-sectoral approach to removing the blockers. The COVID-19 pandemic has made this more urgent than ever.