Health 2015: A conversation with Davidson Gwatkin on progressive universalism

This this second installment of “Health 2015,” a series of conversations with R4D experts helping to shape the dialogue around the post-2015 development agenda. The recent Global Health 2035 report published by the Lancet Commission that was covered in our last conversation with vaccine finance expert Helen Saxenian, also outlines a pro-poor pathway to achieving universal health coverage, termed “progressive universalism.”

At its core, progressive universalism is a determination to ensure that people who are poor gain at least as much as those who are better off at every step of the way toward universal coverage, rather than having to wait and catch up as that goal is eventually approached

The concept was first introduced by R4D expert Davidson (Dave) Gwatkin in a 2011 paper published in the Lancet, “Universal Health Coverage: friend or foe of health equity.”

Dave is a recognized thought leader on topics at the intersection of poverty, equity, and global health. In addition to his role as a senior fellow at R4D, he has served as an adviser on health and poverty to the World Bank, UNICEF, WHO, the Rockefeller Foundation, the African Development Bank and other agencies. Over the past decade, he has been a leading voice on the subject of how to make health systems more equitable.

In this installment, we sat down with Dave to learn about the origins of progressive universalism and the ongoing challenges to achieving equity for the post-2015 global health agenda.

What lead you and your co-author Alex Ergo to conceive of ‘progressive universalism’ in 2011? How would you describe it?

Dave: Essentially, progressive universalism was our reaction to governments, health planners, and advocates who were promoting the idea of universal health coverage as an equitable approach, without realizing that poor people might be the last to benefit from it.

Programs like “Heath for All” and others involved up to a 25 year time lag in extending access and benefits to the poorest populations, and the rural poor in particular; and in many countries, the poor have yet to benefit.  In fact, we determined there was a lot of evidence that this trickle down approach had become the norm. This was a way of saying to the global community, “we need to come up with ways of doing this that get it done right, that make every effort to reach poor populations from the beginning, not just hoping they trickle down, eventually.”

As we move towards the post-2015 era, what are some of the major challenges to implementing equitable health systems?

Dave: There are a number of barriers to reaching the poor, but the challenges now in a post-2015 era are essentially the same ones that have existed all along, but require renewed determination and careful planning to address.

Some of the major challenges include, expense, distance, and lack of knowledge on the part of poor populations about sickness and disease and the benefits of preventative care. Often, the poor don’t come forward due to discrimination, live in isolated rural areas that are hard to reach, and don’t have the financial resources to pay for these services.

It is also inherently difficult to identify the poor, particularly since they are often undocumented and living in the informal sector. Choosing the criteria and methods to identify and select target populations and effectively delivering benefits to them are both major challenges.

Finally, it takes a lot of political will to focus on the poor, something that can be potentially controversial in terms of favoring one group over others.  It can be done, but it’s not easy.

Are there any specific countries you look to as successful case studies that exemplify equitable approaches?

Dave: First I want to caveat by saying that I am reluctant to generalize and say these can be exactly replicated, but there are certainly very important lessons to be drawn from two specific programs we discussed in our paper that were implemented successfully in Brazil and Mexico. These two programs showed it was possible to reach the poor if programs are designed effectively to do so from the beginning.

The Brazil Family Health Program, first implemented in 1994, did this through geographic targeting that involved a phased roll out that started in the most deprived municipalities, and only later expanded to better off areas.

Mexico’s Popular Insurance initiative, launched in 2004, sought to extend insurance to those not covered and utilized an existing cash transfer program called Oportunidades, using that program’s existing list of beneficiaries to effectively identify the poor and target the insurance program to  those individuals first.

The main lesson here for planners and policy implementers is to go the social welfare ministry, collaborate and see what their experience has been in identifying poor populations.

What is one piece of advice you would give to the decision makers and planners in developing countries on successfully achieving an equitable approach to universal health coverage?

Dave: Well, there are actually several major pieces of advice I would give. First, I would tell them that just because you have adopted universal coverage as a goal, don’t assume your system is equitable in its approach. Second, there are plenty of countries that have done so successfully, so, while not generalizing, look to those examples and try to think about ways of adopting existing pro-poor approaches to your own country’s context. Finally, monitor what you’ve done and put systems in place to evaluate programs for their equity to ensure there is a continued focus on it and ability to learn what works and what doesn’t in terms of reaching poor populations.