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.