Universal health coverage: the roof has been leaking for far too long

• Published in: BMJ global health Vol. 6; no. 12; p. e008152
• Main Authors: Ridde, Valéry, Hane, Fatoumata
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 01-12-2021; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Acquired immune deficiency syndrome; AIDS; Editorial; Health insurance; health systems; HIV; Human immunodeficiency virus; Humans; Life Sciences; Pandemics; Santé publique et épidémiologie; Universal Health Insurance; France; Senegal; Europe; Africa; Rwanda; health systems
• ISSN: 2059-7908; 2059-7908
• DOI: 10.1136/bmjgh-2021-008152

In Burkina Faso, the issue of access to healthcare for the indigent is not of great concern to political leaders, who are constantly calling for new studies and new workshops about criteria and targeting processes.7 In the Democratic Republic of Congo, the principle of free care and medication for PLHIV (People Living with HIV/AIDS) is not respected despite the announcements.8 The solutions drawn from New Public Management (NPM) to reform health systems have also proved ineffective: fee-for-service for physician and activity-based for hospitals, payment by performance, copayments and out-of-pocket expenses, competition between institutions, autonomy, etc.9 However, many experts from international organisations and governments, including the WHO, the World Bank and the French Development Agency (AFD), still believe in these solutions. In Rwanda, for example, almost half of health expenditures are financed by official development assistance from rich countries11 and policy makers are anchored in the neoliberal ideology of user fees.12 In Senegal, the state budget for 2020 allocated only 5% to the health sector, the same amount as for public order and security. In France, hospital care accounted for almost half of healthcare consumption in 2019 and four times more than care provided by town doctors and midwives.14 Outpatient care has been forgotten in the response to the COVID-19 pandemic almost everywhere in the world, confirming that the ambulatory shift that was intended to give it more space still remains wishful thinking.15 The systemic vision necessary to meet the needs of populations through care systems is still largely lacking. At the international level, massive funding has been mobilised for years to fight a few diseases (HIV, malaria and tuberculosis, the fund distribution of which is under debate) to the detriment of others that are less visible, less endowed with advocacy organisations and epistemic communities (eg, road accidents are the leading cause of death in the world among men aged 15–1917).