Mobilizing for Health Equity

Attaining Universal Health Coverage through Primary Health Care

Von Eduardo Missoni

For 5.6 billion people in low- and middle-income countries, over half of all health-care expenditure is through out-of-pocket payments, emphasises the World Health Report 2008. Health Care makes people poor. Moving towards universal coverage, means dealing with inequalities by establishing sufficient supply of service networks, where families are protected against the impoverishment that may occur from seeking care.

Eduardo Missoni (Bild: Christoph Engeli)

More than thirty years ago the World Health Assembly established the goal of “Health for All by the year 2000” and with the Alma Ata Declaration (1978), Primary Health care was identified as the strategy to reach that objective. The attention was soon diverted from that ambitious goal and for the following three decades resources and energies were devoted to the selective control of diseases, rather than to comprehensive health promotion and care.

The HIV/AIDS pandemic added unprecedented challenges to the health and social systems that two decades of macroeconomic neo-liberal reforms and structural adjustment programs had dismantled. UN and the multilateral system came under attack and the collaboration with the private sector became the panacea to any problem. Several Global Public-Private Partnerships (GPPPs) were established, and centrally steered global initiatives were launched to face few selected health problems through out-put oriented, quick-fix, technological solutions.

Health system as part of the social determinants

Global Health Initiatives surely contributed to a considerable increase of funding for health, however heavily earmarked (mainly to fight HIV/Aids), and facilitated access to specific drugs, vaccines and devices (such as bednets for malaria prevention). Nevertheless, their managerial approach further fragmented and debilitated national and local institutions. They increased the administrative burden both at global and at country levels without significantly attracting resources from the private sector, whose voice and vote was now granted in the GPPPs boards though.

Health is the result of deeply rooted social determinants that need to be taken into consideration if this fundamental human right is to be granted. The Health system is but one of those determinants, whose characteristics (such as equity in financing and access) reflect the fairness of the society in which they are embedded.

In 2008, the WHO Commission on Social Determinants of Health (CSDH) recognised that access to health services is vital to good and equitable health. It called for healthcare systems to be based on principles of equity, disease prevention and health promotion with universal coverage through focusing on primary health care, regardless of ability to pay. That same year the World Health Report insisted on universal coverage and people-centred health systems. In 2009 “The goal of universal access to health services, especially through primary health care” was included in the G8 final communiqué. Thirty years after Alma Ata, a systemic approach to health rather than a “vertical” action on disease control, was back on the global agenda with universal coverage being increasingly recognised as a political goal related to fundamental rights and a unifying theme and purpose for health systems strengthening. Universal coverage will also be the focus of the upcoming World Health Report 2010.

Economic and cultural norms

Moving towards universal coverage, means dealing with inequalities by establishing sufficient supply of service networks, where financial and other barriers to access are removed, and where families are protected against the financial consequences and impoverishment that may occur from seeking care.

Health systems and organisations are dynamic, complex and context-specific, and they are not simply the sum of their individual components, thus no “global” approach to strengthening health systems for universal coverage can work. The specific nature of service delivery models and financing schemes will vary depending on nations' economic and cultural norms, but universalism requires the widest possible base for pooling of resources and substantial equity in their collection and redistribution through services.

The identification and targeting of health priorities at national and local levels is part of the strategic and managerial function of any national system. It is not a question of whether “vertical” and “horizontal” initiatives can be mutually reinforcing, as stated by those who try reconciliation among the two schools of thought, nor to introduce a “diagonal” approach. Just as health reforms under structural adjustment plans, the “vertical” approach responded to global and donors steered initiatives, not to local needs and interests. This needs to be reversed.

Universal Health Coverage (UHC) can only be achieved through a sound sector strategy embedded in a broad national strategy and linked to financing through a medium-term expenditure framework and a regularly reviewed annual budget. To ensure UHC substantial inflows of external resources will be essential, but it is critical that these inflows are channelled, monitored and used in a way that strengthens national financing capacity and institutions. The use of beneficiaries’ country systems is the main principle for more effective international aid.

The Bellagio Statement (2009) , endorsed by several scientists, emphasises: “to be effective in attaining UHC, the overall global agenda and action in all sectors, including financial and economic policies, should be consistent with and supportive of that goal”.

Eduardo Missoni is coordinator of theGlobal Health and Development Group, Center for Research on Health and Social Care Management - CERGAS, Bocconi University, Milano, Italy. Contact:


  • Missoni E. (editor) “Attaining universal health coverage. A research initiative to support evidence-based advocacy and policy-making”, Egea, Milano, 2010
  • Attaining Universal Health Coverage. A research initiative to support evidence based advocacy and policy making. Bellagio Statement. 10th and 11th November 2009, Bellagio, Italy (