Background
Sturmberg and Martin 1 p1 report that UHC means that all people and communities can use the promotive, preventative, curative, rehabilitative and palliative health services they need, of suffiient quality to be effective and ensure using these services without financial hardship. UHC is mainly about financing whereas PHC is primarily concerned with providing the right care at the right time to achieve best possible health outcomes for individuals and communities.’ 1 p 1
The current global coronavirus crisis has thrown into relief the role of policy and funding in the distribution of healthcare within nations. Countries are now needing to find resilience in healthcare funding in the face of COVID–19. 2 Access to healthcare varies according to national political economy and political ideology governing and enacting how and under what circumstances a person is eligible for healthcare. The vast interplay between political ideologies, health policy and economic policies have impacts on the health and wellbeing of individuals’ lives beyond access to healthcare. In other words, access to healthcare is only one part of access to health.
The World Health Organisation (WHO) called on researchers in health to suggest ways of strengthening ‘the three ’pillars’ of primary health care (1) enabling primary care and public health to integrate health services, (2) empowering people and communities to create healthy living conditions, and (3) integrating multisectoral policy decisions to ensure UHC that achieves the goal of ”health for all”’ 1 p1. Sturmberg and Martin argue that “pillars” sends the wrong message for researchers and policy makers. However, calling on the health research community to make such suggestions to achieve ‘health for all’ neglects that they are subject to the political economy of the nation most often through funding, in which this is being undertaken.
In this article we argue that to ensure that universal health coverage (UHC) addresses inequalities in access to healthcare and strengthens primary health care it is important to analyse how ideologies and policies actively influence health inequities and additionally impact on the scope and efficiency of health services to deliver optimum healthcare. Where neoliberal ideologies hold sway, governments may reduce their funding, hold views about citizens’ abilities to pay and erode the ‘universal’ in UHC.
Political Economy Context
The WHO 3 defines UHC as all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ . However, adopting UHC to provide healthcare to a population is inherently a political process.4 It is also subject to changing political landscapes and the views of health financing. Sparkes et al 4argue that the amount of money involved in any healthcare makes it subject to external influences.
Reich 5, 6 suggests a political economy analysis focusing on power and resources, how they are distributed and contested in different country and sector contexts, and the resulting implications for achieving both UHC and health. Analysis of political economy issues requires explorations of the roles of government policies, social movements and commercial interests. It can reveal that inequalities exist within UHC itself such as unequal funding of public health and prevention activities, primary and tertiary care. These exist because of differing powers within a society. It also means that within a healthcare system illnesses will receive differing funding.
Sparkes et al 4 argue that in the pursuit of universal health coverage analysis of political issues is required. A political economy analysis can aid more effective approaches for managing political issues that arise. Reich 5 maintains that many policy makers in the health sphere do not know how to undertake political economy analysis despite seeing the need for it. ‘The World Health Organization (WHO) can promote evidence-based political economy analysis to assist health policy-makers in managing change more effectively, for instance to move towards universal health coverage (UHC) or to advance other health-related SDGs (Sustainable Development Goals).’5 p514. Understanding political economy has important implications.
Why is this important to people’s health? The decisions made by policy makers across all sectors of government have importance for people, both well and ill and impact their decision-making. It allows for questions of ‘in whose interests’ are some policies implemented. This in turn has implications for the functioning and levels of satisfaction of patients in PHC and eventual outcomes for UHC.
Bambra Fox and Samuel argued in 2005 there was little mainstream debate on how politics, ideology and power affect the health of people, with some rare exceptions. 7 Before that the WHO had said these issues had been resolved but that claim is contentious. In 2006, Boxall and Short 8 argued that some researchers suggest that neo-liberal economies use welfare and labour market policies leading to greater inequality and diminished health outcomes. However, while Australia adopted neoliberal policies its public health remained the best in the world. This claim ignored that health outcomes comparisons internationally are relative. Since 2006 however, economic and social inequities are growing in Australia. 9Increasing inequalities pervade the health system so that inequalities exist across within populations and among health conditions.
People experience health, illness and healthcare within a political economy. However, it is usually only when they become ill (or face a pandemic) that the impacts of that political economy become evident. These impacts are broad: access to healthcare, to welfare, transport, employment and retaining social integration will be made harder or easier based on the political economy in which they live.
The following are two examples of conditions demonstrating the impact of Australian political economy on the health and well–being of individuals. They demonstrate that policies related to employment, welfare and income all play a role in well-being of those who become ill. At the same time those policies control individuals’ access to employment, welfare and income, which in turn can have its own impact on the nation’s economy and costs to the health system.