Universal Health Coverage
Universal Health Coverage is a WHO policy that has gained much attention since it appeared in 2010. Defined by the WHO as ensuring that all people can use the health services they need without financial hardship, Universal Health Coverage is a powerful concept that approaches public health as a matter of justice and obligation and is included in the Sustainable Development Goals.
About the Project
UNIVERSAL HEALTH is an anthropological project that critically examines moves towards Universal Health Coverage, and particularly the expansion of health insurance, in five African countries.
Moves towards UHC present important sites to explore the social and political collectives forming around struggles for health-care in Africa. The project approaches UHC as a lens to explore the social contract between citizens and the state, and the relations between private markets and public goods. We follow the frictions that universal concepts accompanying UHC, such as obligation, solidarity and the public good, may have among policy-makers, state bureaucrats, health workers and citizens.
A study of UHC in Africa is important for several reasons
UHC is particularly important in Africa, where structural-adjustment policies undermined state capacity, promoted privatization and pushed the burden of payment onto the poor. Recent global health initiatives have done little to address the neglect of national health-care systems and citizens’ lack of trust in them.
In these contexts, UHC is interesting because it reinserts questions of state responsibility and the public good into health-care. Despite its progressive goals, the ways UHC addresses such issues remains unclear as it is often surrounded by conflicting interests. UHC is thus not a universal model but a contested field, making it an intriguing site for anthropological research.
For example, post-colonial African states have only partially pursued the public good and are often stereotyped as inefficient or corrupt. Anthropological research has shown, however, that concerns for the public good are not absent among civil servants despite the erosion of state capacity and growing material scarcity. This raises a challenge. How do African state bureaucracies actually work to achieve UHC? In these contexts, how are public goods defined and contested? Furthermore, how does UHC gain traction in countries where there is little consensus about the public good, and where citizens have little trust in the state?
The project examines the debates that UHC engenders and the frictions that surround it.
A focus on health insurance
Attempts to reform and extend health insurance have become a cornerstone of UHC policies. Yet insurance schemes have been criticized for exacerbating inequalities and engendering fragmentation. In much of Africa, insurance schemes have been limited to people in formal employment. Extending coverage means including people in the informal economy whose incomes are precarious. Governments are trying to extend health insurance coverage through public-private partnerships, with companies that approach the poor as a potentially profitable market. How is the public good being defined and pursued under these conditions? And how are African governments and citizens approaching these challenges?
Study countries include Kenya, Tanzania, Ghana, Zambia, and Madagascar
The countries chosen represent four geographical and political regions of East Africa, West Africa, Madagascar, and Southern Africa, which, due to differences in histories of state formation, colonialism, welfare, and transnational involvement in healthcare, offer comparative potential. In each of these regions, several countries have implemented UHC reforms and are piloting various ways of expanding health insurance.
For example, in Kenya, the government, the World Bank and the Rockefeller Foundation are developing a Health Insurance Subsidy Programme targeting the 9 million people living in extreme poverty. In August 2018, four Kenyan counties introduced pilot schemes that will expand health insurance to previously uninsured citizens. Watch this site for our research blogs on these developments!