World Health Day 2023: Universal Health Care and the Challenge of Fragmentation 

By Anna Thabuis

This 7th April, we are celebrating World Health Day and the World Health Organization (WHO)’s 75th anniversary. This year, the topic chosen is Universal Health Care Coverage (UHC), a goal the WHO is hoping to achieve by 2030. For the occasion, the WHO invites all to reflect on the 75 years of work and the challenges ahead of us in the quest to achieve health for all. An obstacle to reaching UHC is the fragmentation of Global Health financing and donor dependency. 

Lead Picture from the WHO World Health Day 2023 campaign

The challenge of increasing donor dependency

Although the WHO has set to achieve UHC by 2030, Covid-19 has revealed itself as a significant obstacle to achieving the goal. Besides Covid-19, overlapping challenges are emerging, from health emergencies, humanitarian and climate crises, to economic hardships and conflicts, which have shed light on the inequitable financing, and sustainability of care underlining the necessity of achieving UHC. 

Sustainable health financing is a requirement for reaching UHC because it supports the healthcare system as well as ensures proper research and investment in diseases. According to the WHO’s latest report, over the last two decades, health financing in low-income countries (LICs) fell upon the people and donors; with out-of-pocket spending and external aid representing, respectively, 44% and 29% of health expenditures.  On top of that, this dependency is only increasing: in 2019, low- and middle-income countries (LMICs) saw their dependency on donor funding grow while the share of government health expenditures declined.

What is Universal Health Coverage (UHC)?
UHC is a key component to providing health for all as it guarantees that all have efficient and timely access to the complete spectrum of quality healthcare services they require, without facing financial hardship throughout their lives. These services must be provided by healthcare workers who are evenly distributed throughout the health system and are adequately supported. 

Shifted priorities through donor interest

External funding plays an important role in the financing of care globally, as it helps address and fill the gaps in government funding, yet, this external funding comes with ties. External funding in research and care does not reflect the burden of disease, but rather the passions of the donors. This misalignment in priorities is probably best illustrated by external non-communicable disease (NCD) financing. Although NCDs, such as cardiovascular diseases, diabetes, and cancers represent 74% of global deaths; 77% of which are in LMICs, NCDs only receive 1-2% of international aid. Assumptions about NCDs, such as them being only a high-income country (HIC) problem, that they are a result of personal choices, or an inevitable consequence of aging populations, make investments seem cost-inefficient, deterring external funding in the prevention and care of these diseases. In turn, these assumptions shape national health strategies, pushing the NCD agenda even further back in the list of priorities. 

Covid-19 is another example of the power of biases in donor funding, as the pandemic diverted attention and resources away from other diseases as well as achieving UHC. Throughout the pandemic, many donors shifted their financial support to help develop the Covid-19 vaccine and mitigate the effects of the pandemic. In March 2020, the Global Fund, a private-public partnership funding organization aimed at fighting HIV, TB, and Malaria, issued a statement of guidance for Covid-19 responses. Here, the Global Fund advised countries to re-allocate existing grants to help mitigate the effects of Covid-19 by allowing the time-bound reprogramming of up to 5% of savings under existing grants, utilizing underused funds, and deploying resources, particularly infrastructures, acquired under existing grants. In turn, this weakens the responses to HIV, TB, and Malaria, uses up already scarce resources and assumes that Covid-19 is the biggest health threat in the partner countries.

The biases also influence local health financing plans as significant cash inflows into LMICs produce a power imbalance. Those with the financial capital get to set the agenda in the approach to care, which often ignores the voices of those marginalized by neoliberal and neocolonial systems. The resources allocated through these systems do not represent the needs of those alienated by the systems. In Australia, the National Aboriginal Community Controlled Health Organisation found a 4.4 billion dollar gap in funding for Aboriginal healthcare initiatives in 2022, although the burden of disease for Aboriginal and Torres Strait Islander people is twice as high as the burden of disease for non-Aboriginal people. Moreover, research priorities and health investments often do not align with the needs and resources available on the ground, limiting their impact on health. In 2019, it is estimated that LICs received only 0.2% of all direct grants for biomedical research given by major funders, calling attention to a crucial inequity in research financing. These blindspots fragilize the journey to UHC and highlight the importance of global equity in not only the access to care but also in the funding of research and care. 

Photo: Dental supplies and their reflection on a glass countertop by Ibrahim Boran.

Reaching Universal Health Coverage: Where do we go from here?

Working towards UHC includes the strengthening of national health systems, such that there is a limited dependency on external funding. Promoting more equity in external funding and integration of care can prevent overlooking diseases that may seem less cost-effective to donors and better prepare the health systems for potential crises.With all its pitfalls, donor financing remains crucial to achieving UHC since it is an important source of support, however, it must be re-imagined to be inclusive, integrated, and sustainable. External funding should seek to promote the voices of the program participants from identifying their needs to empowering communities through appropriation. Additionally, external funding should seek to promote synergy within the health care sector, push for integration of  care, and take into account the local needs and contexts. Donors should also reflect on their own biases and power dynamics such that they can help promote global health equity in access to care. On this World Health Day, we call on everyone to reflect on the role of donors in financing and encourage synergy across sectors to achieve UHC.

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