Speech by Labour’s next International Development Secretary Mary Creagh MP on Inequality and Universal Health Coverage
Thank you, Melissa for your kind invitation to address the Institute for Development Studies.
You are world leaders in your field and it is a great honour to be here.
You play a crucial part in training the next generation of development professionals.
I want also to recognise my Labour colleague Purna Sen – who gave me such a warm introduction. Thank you Purna.
As many of you know, Purna is standing to be the next Member of Parliament for Brighton Pavilion.
She is also an expert in international development.
She is the Deputy Director of the Institute of Public Affairs at the London School of Economics, and has worked on Human Rights for the Commonwealth Secretariat and at Amnesty International.
Two weeks ago, at the launch of Action 2015, Ed Miliband reaffirmed the Labour Party’s commitment to global justice and solidarity.
And I am delighted to see we have some Youth Ambassadors here from that campaign, and colleagues from the across the sector who have travelled here today.
It would be easy in the current climate of political frustration and cynicism to turn away from addressing the world’s most intractable problems.
Other parties say now is not the time for renewed global ambition, especially for international development.
Social justice and human rights are central to Labour’s values.
As Ed said, “business as usual is not acceptable”.
The world today is globalised and connected: climate change, economic crises and disease outbreaks are everyone’s concern.
Our commitment to the world’s poorest and most vulnerable is not just morally right, it is in Britain’s national interest.
I want to talk about the once-in-a generation opportunity that 2015 – the European Year of Development – gives us.
In September, in New York, the United Nations will agree the replacement to the Millennium Development Goals.
In December, in Paris, we will agree a framework to tackle climate change.
Both would be priorities for a Labour government.
As well as eradicating extreme poverty, the Sustainable Development Goals must go faster to tackle growing economic inequality.
Inequality matters. It reduces growth and hinders development.
Health, education, jobs and participation.
Each a basic human right, increasingly determined at birth.
Nearly half of the world’s wealth belongs to just one per cent of the population.
But inequality is about more than money.
Gender, caste, race, community, disability, religion, and ethnicity – far too often this is what determines your life chances.
If more is not done to protect the most vulnerable people, countries can never fully develop.
It is for this reason that I am determined the SDGs do more to tackle inequality in three areas that matter deeply to the Labour Party:
Human rights, climate change and universal health coverage.
Areas that this Government barely discuss at all – at home or abroad.
Basic human rights are integral to what it means to be free.
Women and girls must be free from the fear of violence, coercion or intimidation; and have the freedom to choose how many children they have.
We want girls to have all the same chances as boys: to enjoy their education, free from the threat of forced marriage.
I want to see DFID spearheading more approaches that change the value of education such as the successful cash transfer projects.
We want to tackle the economic conditions and supply chains that tolerate the obscenity of 168 million child workers.
There is no better route out of poverty than a job.
Workers must have access to decent work, decent pay and rest breaks, and the freedom to join a trade union.
We must not have a repeat of the terrible Rana Plaza disaster.
So a Labour government will reverse this Government’s ideological decision to stop funding the International Labour Organisation.
The private sector needs to play its role.
Labour will support good companies that pay their fair share of tax, maintain a clean supply chain and pay a fair wage.
I will say more about this in March, in Cambridge.
We also want to ensure that children affected by conflict have the psycho-social services they need and the right to go to school.
And we want LGBT communities to be free to love and marry whom they wish, the disabled to participate fully in society and protection for indigenous peoples.
The effects of climate change hit the poorest hardest.
Eradicating poverty will only be possible if we tackle climate change.
If we do not cap temperature rises below two degrees then millions will fall back into poverty.
The Prime Minister says very little about his wind turbine these days.
He is a prisoner of a divided party: split over whether climate change even exists.
For Labour, climate change will be at the centre of our foreign policy and integral to our plan to change Britain.
There is a genuine opportunity to address climate change this year.
The United States, the EU and, most importantly, China, all show a willingness to act.
A Labour government would push for global targets to reduce carbon emissions, with regular reviews towards the long-term goal of what the science now tells us is necessary.
Zero net global emissions in the latter half of this century.
Health care is the bedrock of development.
As the party of the NHS we want others to enjoy the protections that we take for granted.
Ensuring everyone in the world has access to affordable healthcare is essential to end poverty.
Because it is deeply unfair that three million people die every year from preventable illnesses.
Because last year there were 1.5 million AIDS-related deaths when we have treatments that could have kept those people alive.
Three-quarters of those living in low-income countries lack access to decent healthcare.
This government does not understand why this matters.
They will not support a goal on UHC in the Sustainable Development Goals.
Figures from the House of Commons library show this Government cut bilateral spending on health in Sierra Leone and Liberia from 26 million pounds in 2010 to 16 million pounds this year.
And while I support the help DFID has given to the Ebola crisis, the best way to protect against disease is to build a resilient, government controlled and government funded health service.
The World Health Organisation has calculated that Universal Health Coverage would stop one hundred million people a year from falling into poverty.
There is no simple, measurable solution to help those countries that want it to set up a health service.
Lasting healthcare systems are about more than the delivery of commodities like vaccines and bednets, vital though they are.
We have seen the devastation that a failure to strengthen health systems can induce.
With no treatment, and no vaccine, we have had no option but to watch health-systems in Sierra Leone, Liberia and Guinea all but collapse.
The World Health Organisation, the World Bank and countries like France and Japan are all clear that UHC is the right direction to move in.
Britain needs to catch up.
I want DFID to lead the pack not follow it.
So today, I want to set out two things that Labour will do in government to increase universal health coverage.
First, Labour will establish a Centre for Universal Health Coverage.
This will provide global partnerships, support and encouragement to countries that want to healthcare.
Labour learned a lot when we set up the NHS. We can watch the difference it made every Sunday night, on TV, on Call the Midwife.
Pre natal care. Orange juice and rosehip syrup for expectant mums. Every birth attended by a skilled midwife.
Milk tokens for the children and parenting classes to discuss the benefits of breastfeeding over formula feeding.
Prostitutes, immigrants and the middle classes all treated with care dignity and respect.
It is a long and difficult journey.
It requires vision and courage. It needs bold political commitment. Long term funding. Trained health workers. Functioning public finance systems. And much more.
None of this is easy.
A Centre for Universal Health Coverage would recognise that building a robust and equitable health system is ultimately a political decision.
It would work with enlightened political leaders in developing countries.
It would help them to generate adequate funding from their own as well as external sources and the systems needed to deliver it especially in rural areas.
Second, I want DFID to play a role in trying to reshape the global health system.
Today, the global health system is under immense strain.
It needs reform.
The last Labour Government helped found the Global Fund to fight Aids, TB and malaria.
Today, 13 million people access life-saving HIV treatment.
We set up Gavi to provide vaccines to halve the number of children who die before their fifth birthday.
To reach those Millennium Development Goals we knew we needed new ways of working together.
We need a similar step change if we are to reach the sustainable development goals.
The WHO lacks focus and struggles to reform itself.
Too many organisations are focused on specific diseases – with too few focused on strengthening health systems.
The rate of tackling TB in particular is too slow and must be addressed.
I want DFID to bring cohesion across the myriad organisations and to encourage them to work directly with governments to establish durable, country-directed solutions.
There is global will at the macro level – the UN.
And huge political commitment at the micro level of development organisations working on the ground.
I want to develop the meso level – the intermediate stage between giant global organisations and the mother in DRC or South Sudan who turns up to a clinic to find no vaccines, no healthcare workers.
The meso level is where countries are enabled to take ownership of their own development and health and can fund and deliver it themselves.
Labour will provide global leadership to bring some clarity and coordination that puts the needs of partner countries first.
I am not claiming I have all the answers.
But I do have values and ideas and political will and a desire to change the world and leave it better than I found it.
I know that you share that hope and vision for a better world.
Ours is the generation that can end extreme poverty, reduce inequality and tackle climate change.
We can move to a world beyond aid, and enable people to secure justice instead of charity.
2015 is a unique opportunity for the world to think bigger and do better – for ourselves, our children and the world’s poorest people.
That is a thrilling opportunity. We must not let them down.
By Joe Walker, Vice Chair of Policy for LCID
Originally published on LabourList
Internationalism, a movement advocating greater economic and political cooperation among nations for the benefit of all, has been a strong tradition within the Labour party from the beginning. Our values and ideals have always looked beyond our shores and have contributed to influencing and shaping Britain’s role in an increasingly interdependent world.
We have a record that we can be proud of. We supported the establishment of the League of Nations in the inter-war years. We backed Indian independence and de-colonisation around the world. We campaigned against apartheid in South Africa. The last Labour Government tripled aid, cancelled debt and rescued the global economy. The recent enshrining of 0.7% into law is something that Labour championed in government, paving the way for that commitment to be honoured after we left office.
In recent times, a lot has been written and debated about the Labour party’s international posture and perspectives since the Iraq war – and what a future government led by Ed Milliband would prioritise.
This debate will take centre stage tonight at an event hosted by the Labour Campaign for International Development, LabourList, and twenty partners from across the Labour movement, to discuss the next Labour Government’s internationalist vision.
Chaired by Mary Riddell, the panel will include Douglas Alexander MP, Mary Creagh MP, Caroline Flint MP and Ian Lucas MP. The panel will be asked: how can Britain once again become a progressive powerhouse, leading global efforts for a more equal, safer, and more prosperous world?
Shadow Foreign Secretary, Douglas Alexander has made the case for a ‘progressive internationalism.’ These words will sit easily with many on the left. But what does this mean in reality? Ed Miliband’s idea of ‘responsible capitalism’, for example, can begin to shape this progressive agenda but it can only be achieved on a global scale, broadening the way the global system is governed, focused on cooperation between countries.
Ed Miliband and Mary Creagh gave speeches this month outlying a future Labour Government’s commitment to combating extreme poverty, inequality and climate change. Miliband said: “More than ever Britain and the world need leadership on tackling poverty, inequality and climate change. This is about ensuring the next generation can do better than the last in this country and around the world.” These words reflect the ideals of a progressive internationalist agenda and will be welcomed by many campaigners and activists in this important year for tackling global poverty and combating climate change. But what will they mean in practice? How will Labour make this gear-change?
These words will also, we hope, chime on the doorstep in the year that Britain goes to the polls. We know that the British media and the public are sometimes critical of Britain’s overseas aid commitments. So it may not feel politically advantageous for Labour to commit to end poverty and inequality in the world.
But Labour must be ready to take strong and sometimes controversial positions based on the principles and the tradition of internationalism and solidarity within the party. And there are plenty of potential voters – in the diaspora, young people, students, faith groups – for whom this matters.
In his tribute at Nelson’s Mandela’s funeral in 2013, President Obama’s challenge to the world was this: “There are too many of us who happily embrace Madiba’s legacy of racial reconciliation, but passionately resist even modest reforms that would challenge chronic poverty and growing inequality.”
The Labour party should listen to these words.
On Monday night you can come and listen to the men and women who will be leading the next Labour Government’s global agenda and reshaping Britain’s role in the world, driven by collectivism, solidarity and social justice.
Numbers are limited, so please RSVP by clicking here – bit.ly/LabourWorld and follow updates on Twitter using #LabourWorld.
One Nation, One World: The Next Chapter in Labour’s Internationalist Story – RSVP to our special event
Monday 26 January 2015 | 17.15-18.45 | Lecture Hall, Methodist Central Hall
We are pleased to invite you to a special event we are organising with the Labour Campaign for International Development and over fifteen partners from across the Labour movement to discuss the next Labour Government’s internationalist vision.
- Labour’s next Foreign Secretary, Douglas Alexander MP
- Labour’s next International Development Secretary, Mary Creagh MP
- Labour’s next Climate Change Secretary Caroline Flint MP
- Labour’s our next Defence Minister Ian Lucas MP
- Chaired by Mary Riddell, columnist for The Daily Telegraph.
Internationalism is in Labour’s DNA. From Indian independence, to the anti-apartheid struggle, and the last government’s tripling of aid and rescuing of the global economy, the Labour Party has a record to be proud of. In a year that will see Britain go to the polls, a new set of Sustainable Development Goals agreed, and a global climate deal negotiated, how can that great tradition be carried forward? How can Britain once again become a progressive powerhouse, leading global efforts for a more equal, safer, and more prosperous world?
Come along to this event to find out – your only opportunity to see all of Labour’s international Shadow Cabinet team in one event before the election.
Numbers are limited, so please RSVP by clicking here – and follow updates on Twitter using #LabourWorld.
The panel will be followed by a Q&A discussion. The event will start promptly at 17.30 – registration is open from 17.15.
A drinks reception will follow the event and take place on the top floor of The Westminster Arms, next door to the event, from 18.45.
This event is being organising by the above sister organisations from across our movement and with the kind support of UNISON.
Stephen Tunstall (@SCTunstall), an LCID member, writes from Gaza about the humanitarian situation following last year’s war, urging Labour to continue pursuing justice and peace for its beleaguered inhabitants. Stephen is Programmes Manager for Palestine and Israel at Embrace the Middle East.
I am constantly enthralled by Hans Rosling’s Gapminder presentations. Development statistics are rarely more interesting and less nerdy than when they are in his hands. A common theme in his lectures is that the world is actually getting better, despite what the cynics may have us believe. Across a whole range of indicators the gap between traditionally rich and poor countries is disappearing. Essentially, development works.
Against this assumption, that things generally get better, stands Gaza. GDP per capita has decreased 33% in the twenty years since the Oslo Accords were signed. Unemployment has tripled in fifteen years, with even once-safe government jobs no longer paying salaries. Before the Israeli-imposed blockade started in 2007, around 10,000 truckloads of goods were exported annually. In the first eleven months of 2014, just 150 trucks left Gaza. Mains power is now only available for six hours a day, while the sewage system is a public health risk, especially when it floods. In 2012 the UN warned that Gaza could be unliveable by 2020. It is already unliveable for many, a fact illustrated by the recent development of Palestinians joining the ranks of Mediterranean boat people, drowning in pursuit of freedom.
No place for a child
Only ultra-wealthy city states sustain a higher population density than Gaza, which also has one of the youngest and fastest growing populations in the world. This is only too evident as one moves around the Strip; there are children everywhere. You see them playing amidst the rust and rubble of side streets, with stones deputising for marbles, running perilously between cars, or these days warming themselves around open fires in hollowed out homes. All too frequently they are also found working – driving donkey carts, hawking sundries, and in the case of Fadi, harvesting breezeblocks from bomb sites.
I found Fadi in Shujaiya, the neighbourhood flattened during the Israeli bombing and ground assault last summer. Considering that children here tell you they are about four years older than you had predicted, I assume Fadi is about thirteen. He was loading his horse cart with rough boulders that his older brother was throwing down from on top the wreckage of the Al-Wafa hospital. It’s dangerous work, as there’s a high chance of finding unexploded ordinance among the ruins. The blocks were clearly heavy, and a cloud of white dust escaped as Fadi tipped each one on to the cart. I asked him how much a full cart of rubble would be worth. About 85p, he told me.
No sign of reconstruction
Shujaiyais truly a shocking sight, but the scandal today is that I could actually recognise destroyed streets from the images I had seen shortly after the bombings.The wreckage is all in the same place; the same shaped concrete mounds formed of lopsided walls and mangled cables. The only sign of change is evidence that, amazingly, life has returned here. In amongst the bomb sites you see freshly hung washing, and people sitting in rooms with a sheet fluttering where a wall once stood.
Despite $5.4bn of aid being pledged for Gaza’s reconstruction at the Cairo conference in October, no one I’ve spoken to has seen much sign of it. Only a small proportion of these pledges have been fulfilled, and the much maligned UN supported reconstruction mechanism is yet to result in rebuilt homes. While houses stand in ruins, tens of thousands remain homeless. Multiplied by the loss of jobs and government salaries, a corresponding increase in crime and lawlessness, and shortages of medical supplies and services, these are truly bleak days. Most people are anticipating another conflict before long.
Money is not the problem, and it never has been. “We are not poor, we are made poor” Dr Bassam Abu Hamad, Assistant Professor of Public Health at Al-Quds University, told me. The solution to Gaza’s humanitarian crisis is not more aid, but a lifting of the blockade. “If you open the borders, let us trade and travel, we will be prosperous and you will see Gaza thrive.” Having seen how industrious and resilient Palestinians in Gaza are, it’s hard not to agree with him.
I have been able to hold my head a little higher since Labour drove parliament’s recognition of Palestine in October, and I look forward to a Labour government’s official recognition later this year. As Ed Miliband prepares to launch Labour’s internationalist vision, we must ensure a just peace in the Middle East is near the top of our agenda. The coming catastrophe in Gaza has political causes and political solutions. A Labour government must compel Israel to lift the siege and set a timeline for the realisation of Palestinian state, with repercussions if it fails to adhere to that timeline. While this will bring improvements in human security throughout the region and the world, the humanitarian imperative alone is sufficient. For the nearly two million people struggling to survive in Gaza, we might be the best hope they have.
By Billy Hill, LCID Membership Officer
Last week, Ed Miliband helped to launch action/2015 with a commitment that the next Labour government will seek to raise global ambitions for combating extreme poverty, inequality and climate change. Here are 5 things we learnt from his speech….
There’s no doubt about it: 2015 could be a game-changing year for international development. With the new Sustainable Development Goals, a set of 17 global goals which aim to make progress on issues surrounding health, education, and poverty being decided in September, there’s no time to lose.
With the launch of action/2015 movement last week, LCID we’re thrilled to be invited to Queen’s Park Community School to hear Ed Miliband’s speech and Q&A session on Labour’s commitment to international development. Here are five things we learnt from the Party’s leader:
2015 a huge year for Labour and international development
Straight off the back, Ed couldn’t be clearer. Labour will raise global ambitions for combating extreme poverty, inequality and climate change. With the G7 happening in June, the Sustainable Development goals being announced in September, a global climate summit happening in December, the UK can play a huge role.
Ending extreme poverty (people living on less than 80p a day) is a top priority
Having been asked by one of the young members of the audience on what Ed’s priority goal was, he answered ending extreme poverty by 2030. Over the last twenty years, we’ve seen a huge drop in the number of people living on less than a 80p a day, around 50%. The last Labour government helped lift 3 million people out of poverty each year, so we’ve got a legacy to live up to.
We will demand a global goal for tackling climate change
Photograph: Twitter, @marianeo77
As the former Secretary of State for Energy and Climate Change, Ed knows these issues like the back of his hand. He outlined his desire to see a separate Sustainable Development goal on the issue of climate change and the ambitious goal of zero net carbon emissions by 2050 with the UK leading the way by decarbonising electricity supply by 2030.
The UK can be a leader in ending global inequality
A key priority for Ed and especially Mary Creagh, Labour’s Shadow Secretary of State for International Development, is making progress on inequality. Mary outlined her commitment to human rights and universal health coverage. We just need the right leadership.
Campaigners are at the heart of these issues
Politicians hold the keys to change, but it’s campaign groups, like LCID, that build the pressure and shape the agenda. Ed showed his great support for the action/2015 movement and highlighted why campaigners will be at the heart of this incredible year
Ed Miliband: the next Labour government will seek to raise global ambitions for combating extreme poverty, inequality and climate change.
Ed Miliband will today help launch action/2015 with a commitment that the next Labour government will seek to raise global ambitions for combating extreme poverty, inequality and climate change.
Speaking to an audience of young people including at Queen’s Park Community School, London later this morning, he will declare that 2015 is the biggest year for global action in half a century with a series of summits and conferences that can shape our future.
These include the New York summit in September to renew the Millennium Development Goals on tackling poverty and inequality – and the Climate Change conference in December where, at last, there is a chance to achieve a binding agreement on the greatest threat to our planet.
Mr Miliband will acknowledge that these great causes may not be as fashionable as they were a few years back but, emphasising that they go to the heart of his beliefs, he will say they are more important than ever.
He will commit the next Labour government to use these talks to fighting for
– An end to extreme global poverty (people living on $1.25 a day) by 2030
– Tackling inequality must remain at the heart of the post-2015 development agenda, with a focus on securing equal access to healthcare and protecting the rights of women, children and workers.
– A separate development goal on climate change and a binding international agreement on climate change leading to zero net carbon emissions by 2050 with the UK leading the way by decarbonising electricity supply by 2030
Ed Miliband is expected to say:
“More than ever Britain and the world need leadership on tackling poverty, inequality and climate change.
With the right Sustainable Development Goals, ours is the generation that can wipe out extreme poverty, reduce inequality and tackle climate change.
Today marks the launch of action/2015. It is a campaign to make sure that governments and political parties listen to peoples’ hopes and dreams – to ensure our political ambition matches the scale of the challenge.
In 2015, after the General Election here, the countries of the world will come together to agree two plans.
The first plan aims to eradicate poverty over the next fifteen years. And the second will tackle climate change.
These two plans affect all of us: everyone in this room, everyone across the world, and especially, everyone in your generation because they will help determine the world you will live in.
They matter. And what the British government does at these conferences – what it does in your name – matters too.
I know tackling climate change, global poverty and inequality are not as fashionable as they once were. But I also know they are more important than ever.
For me, they are not luxury items in our programme for change. They are not part of a branding exercise. They go to the heart of my beliefs and the reason why I entered politics.
“This is about ensuring the next generation can do better than the last in this country and around the world.”
“The last two decades have been the most successful in history in the fight against poverty: the share of people living in extreme poverty has been cut in half worldwide. But it is unacceptable that more than one billion people still live on less than USD$1.25 a day – just 80 pence.
Our challenge must be to bring this number to zero by 2030.”
“Inequality threatens to undo much of the progress of the past 20 years in making sure millions more people have food on the table, a decent education and health care. It is as unfair as it is uneven. So while the wealth of a powerful minority grows greater, the poorest get left behind.
A Labour government would fight for equal access to healthcare, and protect the rights of women, children and workers.”
“The progress of the last 15 years in the tackling poverty, improving health, on food security and access to sanitation could all be eroded if global temperatures are allowed to soar. I believe tackling climate change is the most important thing I can do in politics for my children’s generation. It demands leadership and resolve.
So in Paris next year, a Labour government would be pushing for global targets for reducing carbon emissions that rise every five years with regular reviews towards the long-term goal of what the science now tells us is necessary – zero net global emissions in the latter half of this century.”
Originally uploaded to The Guardian 6th January, by Amartya Sen
Twenty-five hundred years ago, the young Gautama Buddha left his princely home, in the foothills of the Himalayas, in a state of agitation and agony. What was he so distressed about? We learn from his biography that he was moved in particular by seeing the penalties of ill health – by the sight of mortality (a dead body being taken to cremation), morbidity (a person severely afflicted by illness), and disability (a person reduced and ravaged by unaided old age). Health has been a primary concern of human beings throughout history. It should, therefore, come as no surprise that healthcare for all – “universal healthcare” (UHC) – has been a highly appealing social objective in most countries in the world, even in those that have not got very far in actually providing it.
The usual reason given for not attempting to provide universal healthcare in a country is poverty. The United States, which can certainly afford to provide healthcare at quite a high level for all Americans, is exceptional in terms of the popularity of the view that any kind of public establishment of universal healthcare must somehow involve unacceptable intrusions into private life. There is considerable political complexity in the resistance to UHC in the US, often led by medical business and fed by ideologues who want “the government to be out of our lives”, and also in the systematic cultivation of a deep suspicion of any kind of national health service, as is standard in Europe (“socialised medicine” is now a term of horror in the US).
One of the oddities in the contemporary world is our astonishing failure to make adequate use of policy lessons that can be drawn from the diversity of experiences that the heterogeneous world already provides. There is much evidence of the big contributions that UHC can make in advancing the lives of people, and also (and this is very important) in enhancing economic and social opportunities – including facilitating the possibility of sustained economic growth (as has been firmly demonstrated in the experience of south-east Asian countries, such as Japan, South Korea, Taiwan, Singapore and, more recently, China).
Further, a number of poor countries have shown, through their pioneering public policies, that basic healthcare for all can be provided at a remarkably good level at very low cost if the society, including the political and intellectual leadership, can get its act together. There are many examples of such success across the world. None of these individual examples are flawless and each country can learn from the experiences of others. Nevertheless, the lessons that can be derived from these pioneering departures provide a solid basis for the presumption that, in general, the provision of universal healthcare is an achievable goal even in the poorer countries. An Uncertain Glory: India and its Contradictions, my book written jointly with Jean Drèze, discusses how the country’s predominantly messy healthcare system can be vastly improved by learning lessons from high-performing nations abroad, and also from the contrasting performances of different states within India that have pursued different health policies.
Over the last three decades various studies have investigated the experiences of countries where effective healthcare is provided at low cost to the bulk of the population. The places that first received detailed attention included China, Sri Lanka, Costa Rica, Cuba and the Indian state of Kerala. Since then examples of successful UHC – or something close to that – have expanded, and have been critically scrutinised by health experts and empirical economists. Good results of universal care without bankrupting the economy – in fact quite the opposite – can be seen in the experience of many other countries. This includes the remarkable achievements of Thailand, which has had for the last decade and a half a powerful political commitment to providing inexpensive, reliable healthcare for all.
Thailand’s experience in universal healthcare is exemplary, both in advancing health achievements across the board and in reducing inequalities between classes and regions. Prior to the introduction of UHC in 2001, there was reasonably good insurance coverage for about a quarter of the population. This privileged group included well-placed government servants, who qualified for a civil service medical benefit scheme, and employees in the privately owned organised sector, which had a mandatory social security scheme from 1990 onwards, and received some government subsidy. In the 1990s some further schemes of government subsidy did emerge, however they proved woefully inadequate. The bulk of the population had to continue to rely largely on out-of-pocket payments for medical care. However, in 2001 the government introduced a “30 baht universal coverage programme” that, for the first time, covered all the population, with a guarantee that a patient would not have to pay more than 30 baht (about 60p) per visit for medical care (there is exemption for all charges for the poorer sections – about a quarter – of the population).
The result of universal health coverage in Thailand has been a significant fall in mortality (particularly infant and child mortality, with infant mortality as low as 11 per 1,000) and a remarkable rise in life expectancy, which is now more than 74 years at birth – major achievements for a poor country. There has also been an astonishing removal of historic disparities in infant mortality between the poorer and richer regions of Thailand; so much so that Thailand’s low infant mortality rate is now shared by the poorer and richer parts of the country.
There are also powerful lessons to learn from what has been achieved in Rwanda, where health gains from universal coverage have been astonishingly rapid. Devastated by genocide in 1994, the country has rebuilt itself and established an inclusive health system for all with equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality has fallen sharply and life expectancy has actually doubled since the mid-1990s. Following pilot experiments in three districts with community-based health insurance and performance-based financing systems, the health coverage was scaled up to cover the whole nation in 2004 and 2005. As the Rwandan minister of health Agnes Binagwaho, the US medical anthropologist Paul Farmer and their co-authors discuss in Rwanda 20 Years on: Investing in Life, a paper published in the Lancet in July 2014: “Investing in health has stimulated shared economic growth as citizens live longer and with greater capacity to pursue the lives they value.”
The experiences of many other countries also offer good lessons, from Brazil and Mexico (which have recently implemented UHC with reasonable success) to Bangladesh and the Indian states of Himachal Pradesh and Tamil Nadu (with progress towards the universal coverage that has already been achieved by Kerala). Bangladesh’s progress, which has been rapid, makes clear the effectiveness of giving a significant role to women in the delivery of healthcare and education, combined with the part played by women employees in spreading knowledge about effective family planning (Bangladesh’s fertility rate has fallen sharply from being well above five children per couple to 2.2 – quite close to the replacement level of 2.1). To separate out another empirically observed influence, Tamil Nadu shows the rewards of having efficiently run public services for all, even when the services on offer may be relatively meagre. The population of Tamil Nadu has greatly benefited, for example, from its splendidly run mid-day meal service in schools and from its extensive system of nutrition and healthcare of pre-school children.
The message that striking rewards can be reaped from serious attempts at instituting – or even moving towards – universal healthcare is hard to miss. The critical ingredients of success that have emerged from these studies appear to include a firm political commitment to the provision of universal healthcare, running workable elementary healthcare and preventive services covering as much of the population as possible, paying serious attention to good administration in healthcare and ancillary public services and arranging effective school education for all. Perhaps most importantly, it means involving women in the delivery of health and education in a much larger way than is usual in the developing world.
The question can, however, be asked: how does universal healthcare become affordable in poor countries? Indeed, how has UHC been afforded in those countries or states that have run against the widespread and entrenched belief that a poor country must first grow rich before it is able to meet the costs of healthcare for all? The alleged common-sense argument that if a country is poor it cannot provide UHC is, however, based on crude and faulty economic reasoning.
The first – and perhaps the most important – factor overlooked by the naysayers is the fact that at a basic level healthcare is a very labour-intensive activity, and in a poor country wages are low. A poor country may have less money to spend on healthcare, but it also needs to spend less to provide the same labour-intensive services (far less than what a richer – and higher-wage – economy would have to pay). Not to take into account the implications of large wage differences is a gross oversight that distorts the discussion of the affordability of labour-intensive activities such as healthcare and education in low-wage economies.
Second, how much healthcare can be provided to all may well depend on the country’s economic means, but whatever is affordable within a country’s means can still be more effectively and more equitably provided through universal coverage. Given the hugely unequal distribution of incomes in many economies, there can be serious inefficiency as well as unfairness in leaving the distribution of healthcare entirely to people’s respective abilities to buy medical services. UHC can bring about not only greater equity, but also much larger overall health achievement for the nation, since the remedying of many of the most easily curable diseases and the prevention of readily avoidable ailments get left out under the out-of-pocket system, because of the inability of the poor to afford even very elementary healthcare and medical attention.
It is also worth noting here, as European examples richly illustrate, that providing UHC is compatible with allowing the purchase of extra services for the especially affluent (or those with extra health insurance), and the demands of UHC must be distinguished from the ethics of aiming at complete equality. This is not to deny that remedying inequality as much as possible is an important value – a subject on which I have written over many decades. Reduction of economic and social inequality also has instrumental relevance for good health. Definitive evidence of this is provided in the work of Michael Marmot, Richard Wilkinson and others on the “social determinants of health”, showing that gross inequalities harm the health of the underdogs of society, both by undermining their lifestyles and by making them prone to harmful behaviour patterns, such as smoking and excessive drinking. Nevertheless, the ethics of universal health coverage have to be distinguished from the value of eliminating inequalities in general, which would demand much more radical economic and social changes than UHC requires. Healthcare for all can be implemented with comparative ease, and it would be a shame to delay its achievement until such time as it can be combined with the more complex and difficult objective of eliminating all inequality.
Third, many medical and health services are shared, rather than being exclusively used by each individual separately. For example, an epidemiological intervention reaches many people who live in the same neighbourhood, rather than only one person at a time. Healthcare, thus, has strong components of what in economics is called a “collective good,” which typically is very inefficiently allocated by the pure market system, as has been extensively discussed by economists such asPaul Samuelson. Covering more people together can sometimes cost less than covering a smaller number individually.
Fourth, many diseases are infectious. Universal coverage prevents their spread and cuts costs through better epidemiological care. This point, as applied to individual regions, has been recognised for a very long time. The conquest of epidemics has, in fact, been achieved by not leaving anyone untreated in regions where the spread of infection is being tackled. The transmission of disease from region to region – and of course from country to country – has broadened the force of this argument in recent years.
Right now, the pandemic of Ebola is causing alarm even in parts of the world far away from its place of origin in west Africa. For example, the US has taken many expensive steps to prevent the spread of Ebola within its own borders. Had there been effective UHC in the countries of origin of the disease, this problem could have been mitigated or even eliminated. In addition, therefore, to the local benefits of having UHC in a country, there are global ones as well. The calculation of the ultimate economic costs and benefits of healthcare can be a far more complex process than the universality-deniers would have us believe.
In the absence of a reasonably well-organised system of public healthcare for all, many people are afflicted by overpriced and inefficient private healthcare. As has been analysed by many economists, most notably Kenneth Arrow, there cannot be a well-informed competitive market equilibrium in the field of medical attention, because of what economists call “asymmetric information”. Patients do not typically know what treatment they need for their ailments, or what medicine would work, or even what exactly the doctor is giving to them as a remedy. Unlike in the market for many commodities, such as shirts or umbrellas, the buyer of medical treatment knows far less than what the seller – the doctor – does, and this vitiates the efficiency of market competition. This applies to the market for health insurance as well, since insurance companies cannot fully know what patients’ health conditions are. This makes markets for private health insurance inescapably inefficient, even in terms of the narrow logic of market allocation. And there is, in addition, the much bigger problem that private insurance companies, if unrestrained by regulations, have a strong financial interest in excluding patients who are taken to be “high-risk”. So one way or another, the government has to play an active part in making UHC work.
The problem of asymmetric information applies to the delivery of medical services itself. It makes the possibility of exploitation of the relatively ignorant a likely result even when there is plentiful market competition. And when medical personnel are scarce, so that there is not much competition either, it can make the predicament of the buyer of medical treatment even worse. Furthermore, when the provider of healthcare is not himself trained (as is often the case in many countries with deficient health systems), the situation becomes worse still. As a result, in the absence of a well-organised public health system covering all, many patients, denied any alternative, remain vulnerable to exploitation by unscrupulous individuals who robustly combine crookery and quackery.
While such lamentable conditions are seen in a number of countries, there are other countries (or states within countries) that, as has already been discussed, demonstrate the rewards of having a functioning universal public healthcare system – with better health achievements and also larger development of human capabilities. In some countries – for example India – we see both systems operating side by side in different states within the country. A state such as Kerala provides fairly reliable basic healthcare for all through public services – Kerala pioneered UHC in India several decades ago, through extensive public health services. As the population of Kerala has grown richer – partly as a result of universal healthcare and near-universal literacy – many people now choose to pay more and have additional private healthcare. But since these private services have to compete with what the state provides, and have to do even better to justify their charges in a region with widespread medical knowledge and medical opportunity, the quality of private medical services tends also to be better there than where there is no competition from public services and a low level of public education. In contrast, states such as Madhya Pradesh or Uttar Pradesh give plentiful examples of exploitative and inefficient healthcare for the bulk of the population. Not surprisingly, people who live in Kerala live much longer and have a much lower incidence of preventable illnesses than do people from states such as Madhya Pradesh or Uttar Pradesh.
A system of universal healthcare also has the advantage that it can focus on vitally needed – but often ignored – primary medical attention, and on relatively inexpensive outpatient care when a disease receives early attention. In the absence of systematic care for all, diseases are often allowed to develop, which makes it much more expensive to treat them, often involving inpatient treatment, such as surgery. Thailand’s experience clearly shows how the need for more expensive procedures may go down sharply with fuller coverage of preventive care and early intervention. Good healthcare demands systematic and comprehensive attention, and in the absence of affordable healthcare for all, illnesses become much harder and much more expensive to treat. If the advancement of equity is one of the rewards of well-organised universal healthcare, enhancement of efficiency in medical attention is surely another.
The case for UHC is often underestimated because of inadequate appreciation of what well-organised and affordable healthcare for all can do to enrich and enhance human lives. It is one thing to accept that the world may not have the resources and the dexterity at this moment to provide the finest of medical care to all, but that is not a reason for eliminating our search for ways of proceeding towards just that, nor a ground for refusing to provide whatever can be easily provided right now for all. In this context it is also necessary to bear in mind an important reminder contained in Paul Farmer’s book Pathologies of Power:Health, Human Rights and the New War on the Poor: “Claims that we live in an era of limited resources fail to mention that these resources happen to be less limited now than ever before in human history.”
In addition, we have to take note of the dual role of healthcare in directly making our lives better – reducing our impoverishment in ways that matter to all human beings – as well as helping to remove poverty, assessed even in purely economic terms. Reduction of economic poverty occurs partly as a result of the greater productivity of a healthy and educated population, leading to higher wages and larger rewards from more effective work, but also because UHC makes it less likely that vulnerable, uninsured people would be made destitute by medical expenses far beyond their means. Here again, Thailand’s experience shows how penury caused by medical costs can fall rapidly once UHC is established.
The mutual support that healthcare and economic development can provide has been brought out very extensively by the results of UHC-oriented policies in south-east Asia, from Japan to Singapore. The complementary nature of health advancement and economic progress is also illustrated in the comparative experiences of different states within India. I remember being admonished 40 years ago, when I spoke in support of Kerala’s efforts to have state-supported healthcare for all. I was firmly told that this strategy could not possibly work, since Kerala was, then, one of the poorest states in India. The thesis of unaffordability was, however, wrongly argued for reasons already discussed. Despite its poverty, Kerala did manage to run an effective UHC programme that contributed greatly to its having, by some margin, the longest life expectancy in India and the lowest rates of infant and child mortality, among its other health accomplishments. But in addition to these so-called “social achievements”, it was possible to argue even in those early days – despite scorn from those who were opposed to UHC – that with the help of a more educated and healthier workforce, Kerala would also be able to grow faster in purely economic terms. After all, there are no influences as strong in raising the productivity of labour as health, education and skill formation – a foundational connection to which Adam Smith gave much attention.
This has actually happened. In fact, the previously poor state of Kerala, with its universal healthcare and universal schooling, now has the highest per capita income among all the states in India. Tamil Nadu and Himachal Pradesh, both of which have made substantial moves towards the provision of education and basic healthcare for all, have both progressed admirably and now belong solidly among the richer Indian states.
There is, thus, plenty of evidence that not only does universal healthcare powerfully enhance the health of people, its rewards go well beyond health. There is, indeed, a strong relationship between health and economic performance, and we have every reason to base public policy on a proper understanding of the nature and reach of what is clearly a positive interdependence. There is no mystery in all this given the centrality of health for better lives and for enhancing human capabilities