Finding Legal and Financial Pathways for Universal Health Coverage Should Be at the Heart of a Pandemic Treaty
An infant is vaccinated at a primary health care clinic in India.

Discussions about the creation of a new global convention on pandemic preparedness and response have already become a bit like a Christmas tree. 

Last week’s WHO-convened public hearings, saw a wide array of interest groups trying to attach a number of features to the proposed international pandemic instrument, ranging from stronger accountability and transparency measures in reporting outbreaks to ensuring equitable access to vaccines and treatments – and rapid and transparent pathogen-sharing so that new treatments can be quickly created.   

These issues will be further explored in a high-level discussion at the upcoming Geneva Health Forum (GHF) (3-5 May), on the pandemic treaty on the morning of Day 2.

Professor Stéphanie Dagron, Faculty of Law and Medicine at the University of Geneva

However, one important issue that has not yet figured prominently in the discussions is how the new legal instrument could also be used as a tool to concretely advance national social health protection systems that are fundamental to reaching the objective of Universal Health Coverage (UHC), notes Stéphanie Dagron, a professor in international health and social security law at the University of Geneva.

Linking UHC with a pandemic instrument 

Having robust social health protection systems, whether they are entirely tax-financed or based on contributions (through social insurance), or more likely a hybrid of both financing models, is key to getting more people to turn to health care providers when they become ill, she points out to Health Policy Watch ahead of the start of the GHF.

And that, in turn, is critical to identifying emerging disease threats very early on, as well as to rolling out treatments.

 “I’m really convinced that if we want to prevent a novel outbreak, it is absolutely necessary that the population has regular contact with a health system,” says Dagron.  “And without Universal Health Coverage, if people do not have basic access to health care services, they will wait and wait before turning to medical help if an outbreak occurs – and at some point, it will explode

In addition, COVID-19 has shown how people with pre-existing conditions, including obesity and diabetes, are particularly vulnerable to severe illness. So getting non-communicable diseases (NCDs) under control – through the extension of UHC –  is equally critical to pandemic preparedness and response, she points out. 

“In a pandemic, we are not only dealing with communicable diseases. NCDs are a big factor, as well as being the cause of most deaths overall, and that burden is getting bigger and bigger,” says Dagron.

Countries with 50% or less of the population covered by essential UHC services: most are in WHO’s African or Eastern Mediterranean regions. The WHO UHC Service Coverage Index tracks progress on the SDG indicator 3.8.1

Lack of UHC legal and financing frameworks 

But many challenges need to be overcome to make UHC a reality, including legal preparedness. The elements of the system authorizing access to health care services for all should be defined in the national legislation (the benefit package and the collective mechanisms used to cover the cost of care).

Despite constant lip service paid to UHC, current SDG indicators for achieving UHC by 2030 lack any clear reference to the kinds of legal and financing frameworks that countries, and the global community, really need to develop to achieve the goal, she points out. 

Rather, the two existing indicators to track progress on UHC (SDG Target 8.3) look purely at “endpoints” such as UHC essential health service coverage. And even such basic coverage is woefully low – 50% or less in about 65 countries,  mostly in Africa, the Middle East and Asia, according to the latest WHO reporting on the UHC indicator SDG 3.8.1

“There are only two indicators, and they are primarily medical or economic indicators [of healthcare spending] at household level,” Dagron says. “They say nothing about the kind of health coverage schemes that need to be put in place to achieve UHC.” 

Endpoints are important to track, of course. But likewise, tracking also needs to follow progress on what countries are doing to actually create universal health coverage systems – for which a legal framework for the different healthcare schemes, and transparency and sustainability of the main sources of funding for healthcare coverage, are critical.    

“Many countries need help to create the necessary legal and financing structures for social health protection systems – this is one expertise that is missing at WHO, the legal expertise to support countries in creating a basic legislative architecture for UHC,” she points out.  

Pandemic treaty offers an opportunity to advance UHC 

Dagron sees, therefore, an opportunity for the pandemic treaty talks to empower WHO, together with the International Labour Organization (ILO), to help advance UHC by building country capacity to create, fund and implement their own national social health protection systems. 

That could be a win-win for the negotiations, she says, paving the way for some early achievements in the treaty negotiations between WHO member states – which may be more enthusiastic about setting goals for UHC, than for other, highly controversial issues that the treaty’s proponents will eventually need to tackle.  

Currently, international legal frameworks referencing the creation of social health protection systems exist only in piecemeal forms, with norms to be found in human rights and social security standards, she said. 

However, one significant precedent is the  2012 ILO Recommendation (202) on “Social Protection Floors. This Recommendation, approved by the ILO’s General Conference of member states, sets out a framework for countries to establish social security systems – in which access to essential healthcare services based on diverse arrangements for the financing is framed as an essential component. 

A ‘Global Fund’ for UHC?  

Economic initiatives to support countries in extending social health protection systems that foster universal health coverage are similarly lacking, she notes.  By all available indicators, national government spending on health is woefully behind global and regional targets. 

But UHC and NCD advocates have often pointed out that even governments in low-income countries could potentially raise more tax revenues from unhealthy products such as sugary drinks, tobacco, dirty vehicles or fossil fuels – and channel those into health systems – for a win-win approach.   

In the 2001 Abuja Declaration, most African governments committed to increasing public health spending to at least 15% of the government’s budget. 

However, between 2002 and 2014, the share of government spending allocated to health actually decreased in about half of African countries. Only four countries were above the Abuja target in 2014, notes a 2021 World Bank report that reviews the dismal progress on advancing UHC in the African context. As of 2016, only two of 55 AU member states met the target – Madagascar and Eswatini although South Africa, Namibia and Zimbabwe were close to the goal – and some 35 AU states overall had increased spending in the past year. However since then, the AU’s UHC scorecard hasn’t even been updated. 

Only four African countries had met or exceeded the Abuja target of spending 15% or more of the national budget on health as of 2014 (World Bank, 2016).  And that declined to just 2 countries by 2016.

To assist with the rollout of UHC, the global community could create another, new “Global Fund” for UHC modeled along the lines of the successful Global Fund to Fight AIDS Tuberculosis and Malaria – which currently spends about $4 billion a year supporting low- and middle-income countries’ spending on related health programmes – but also creates criteria for such support and a pathway for countries to become financially self-sufficient. 

Solidarity as a principle

Among the big-picture principles that a pandemic instrument should address, Dagron would like to insist on solidarity. 

“There are so many things that people want to pack into a pandemic treaty,” she observes. “You need to define the central principles that are going to be applicable, and for a lawyer, having principles defined at first, is extremely useful because you use the principles to interpret the rest of the convention. 

“Countries with social health protection systems all rely upon the principle of solidarity in their legal frameworks,” says Dagron. “This has implications for the way you define the objectives of your system, finance the services and essential goods needed and the way you organise access to these services and distribute needed goods.  

“The principle of solidarity should guide and structure the activities of the global community.

Barriers to UHC

In order for countries to expand social health protection to achieve UHC, they will have to enshrine the different health care schemes into their national legal framework. To facilitate this, the global community should define a system that offers more support (technical and financial) to member states and an adequate monitoring system.

A monitoring system for the implementation of UHC in the pandemic treaty should assess the actual implementation.

Effective health coverage is different in most countries and certain groups are often excluded from national health schemes or certain benefits. 

At the same time, the fact that exceptions may occur is not a good argument for avoiding the implementation of UHC altogether, she points out. 

“Admittedly, these are complex issues.  You have to define what is an essential health service in a country, and this is something that cannot be decided at the international level. 

“But that is why the ILO recommendation of 2012, to which WHO contributed,  was interesting because it said that states have to do four things, including making sure there is access to a nationally defined set of goods and services, constituting essential health care; adapted to the needs of the population and creating systems of income security for security for children, for older persons and people active in the workplace.”  


See the complete GHF 2022 programme. Register here: Until 2 May fees are CHF 400 for the entire event and CHF 150 for participants from low- and middle-income countries (OECD classification).  Daily rates are also available. 

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Image Credits: WHO/Christopher Black, S. Dagron , WHO Global Health Observatory , UHC in Action: A Framework for Africa .

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