Universal Health Coverage

In 1978, the Alma-Ata Declaration established a bold plan for global health action and social justice, identifying primary health care as the lynchpin for achieving health for all.1 Several years later, the Ottawa Charter for Health Promotion, responding to growing health challenges within industrialized societies, formally recognized underlying determinants as an integrated and vital part of health for all.2 United Nations agencies, national governments, and a range of civil society organizations endorsed these declarations, recognizing access to health care and underlying determinants as a human right. Implicit in this recognition was the emerging obligation of nations to establish health policies responsive to underlying determinants and to ensure universally accessible primary health care. This early consensus for universal health care was soon challenged by political and economic developments of the 1980s, when neoliberalism and structural adjustment programs delivered a devastating blow to the health sector and the objectives of Alma-Ata.3 World Bank economists and other development actors successfully exported the case for user fees and private sector financing, which subsequently shaped the trajectory for health systems in many lowand middle-income countries for more than three decades.4 These user fees have left a devastating legacy, deepening inequality, and poverty, and are referred to by the current World Bank president as “unjust and unnecessary.”5 For those countries isolated from neoliberalism during the Cold War, specifically in Soviet bloc countries, state-run, centralized health bureaucracies flourished, where excessive biomedical treatments and specialization were privileged at the cost of evidence-based prevention, health promotion, and respect for the human rights of all users of health services—particularly undermining the values expressed in Ottawa. These publicly financed health systems, while claiming universalism, left an equally devastating legacy of inequality, corruption, and systematic human rights abuse within health care systems. How we overcome these inherited legacies of health financing, how we define health, and how we achieve equitable access is at the heart of the current struggle for universal health coverage (UHC), one of the most ambitious global health developments of our time. Calls from the World Health Assembly urging states to strive for “affordable universal coverage and access for all citizens on the basis of equity and solidarity” signal a welcome return to the principles of Alma-Ata and Ottawa.6 The World Bank’s current president, Jim Yong Kim, has promisingly affirmed that the values of Alma-Ata must be harnessed in the movement toward UHC.7 UHC is now part of the Sustainable Development Goals, a global political com-