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First Time Around: The Rise and Fall of ‘Universal Health Coverage’ as a Goal of International Health Politics, 1942–1952

Martin Gorsky and Christopher Sirrs, Centre for History in Public Health, LSHTM

Universal health coverage (UHC) remains a key ambition of international health in the twenty-first century, though the means to achieve it, especially in low-income countries (LICs), is still hotly debated. The UN Sustainable Development Goals of 2015 have presented a fresh opportunity to place UHC at the heart of the international health agenda, with ‘financial risk protection’ and access to ‘quality essential’ services figuring as target 3.8 of the ‘Good Health and Well-Being’ goal.  Can understanding the past illuminate the prospects for UHC in the present?

The aim of this paper is to trace an earlier history of universal coverage as an objective of international health politics, focusing on the mid-twentieth century. We discuss the activity of the League of Nations Health Organization and the International Labour Organization (ILO), which campaigned in the inter-war years to improve access to integrated national health systems.  A key moment came in the midst of the Second World War, when world leaders approved the ILO’s Philadelphia Declaration (1944). This announced its ambitious goal for the post-war settlement, guaranteeing universal social security, including medical coverage and care.  Once peace came, the ILO attempted to enshrine this in an international Convention, which nation states would strive to ratify.  However, by 1952 it was clear that these efforts had failed, and the final Convention was so watered down that the universalist goal was thwarted.

Our paper analyses this earlier episode of unfulfilled promise, firstly accounting for the consolidation of ideas about social security and health care, then discussing why they subsequently became marginalised in international discourse. On the one hand, this early history evidences the emergence of transnational policy linkages amongst experts, whose worldview transcended narrow national loyalties.

It was they who forged the capacity of international organizations to engage in independent policy development. On the other, we show that the interests of the nation state could be easily reasserted over a matter as politically charged as UHC.  This was particularly so for the United States, the new global superpower, whose own domestic politics of health care made espousal of UHC internationally highly contentious. We also emphasize the role of opposition groups such as employers and organized medicine, and show why the issue was not adopted by the newly launched WHO, which instead prioritised vertical disease eradication programmes.  Finally, in an era of decolonization, LICs had their own reasons for proceeding cautiously with a commitment to UHC.  We conclude with reflection on how these findings might help us, in thinking about the challenges of advancing UHC today.