Leaving no one behind: The role of law in advancing Universal Health Coverage

Published by: McCabe Centre for Law & Cancer
Date: July 2020

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Key messages

  • Universal Health Coverage (UHC) provides a mechanism to address the global noncommunicable disease (NCD) burden.
  • UHC contributes to the realisation of everybody’s right to enjoy the highest attainable standard of health.
  • Increasing knowledge and effective use of law is critical to advancing UHC globally. This includes strengthening the legal capacity of the health workforce and the broader workforce for health — other actors in a range of fields who can impact health and health governance. All these actors are active participants in law and regulation.
  • State and non-state actors must recognise and prioritise the effective use of law in realising UHC and commit to building the necessary capacity of the health workforce and the workforce for health to do so.
  • UHC has been a longstanding tenet of global health and is Target 3.8 of the Sustainable Development Goals (SDGs). In September 2019, world political leaders recommitted to realising UHC by 2030 by adopting the first Political Declaration on Universal Health Coverage at the United Nation’s first High-level Meeting (HLM) on Universal Health Coverage. 
  • The Political Declaration commits all UN Member States to expand quality health services to one billion more people by 2023 and all people by 2030. It identifies key action areas to frame the political objectives, guide implementation and accelerate action toward UHC, and some targets to track progress.
  • Law, strong governance and regulatory mechanisms play a critical role in advancing UHC.
  • The Political Declaration acknowledges the role of law in progressing UHC and includes commitments by Member States to promote and implement legislative and regulatory measures to advance UHC to meet the 2030 Agenda for Sustainable Development.
  • UN Member States will report on their efforts to advance UHC at the second United Nations High-level Meeting on Universal Health Coverage in 2023.

NCDs and the need for UHC

What are NCDs and what is the burden of NCDs?

NCDs — such as cancer, cardiovascular disease, chronic respiratory diseases, diabetes, psychosocial disabilities and neurological disorders — are the leading causes of global death and disease worldwide, and a major burden on health systems and economies due to their chronic nature.

Today, at least half the world’s population lack access to essential health services, 930 million spend more than 10 per cent of their household budget on health care. Almost 100 million people are pushed into extreme poverty each year because of health care costs, contributing to the 41 million deaths from NCDs every year — equivalent to 71% of all deaths globally. Over 60 per cent of people living with NCDs have experienced catastrophic health expenditure, a large proportion of which are due to NCDs.

The burden of NCDs is disproportionately experienced by low- and middle-income countries and by marginalised and disadvantaged communities, even within high-income countries. With NCDs expected to be the leading global cause of disability by 2030, addressing the NCD burden is a pressing development and human rights law issue. When people live healthy and productive lives, their families, communities and countries benefit.

What is Universal Health Coverage (UHC)?

UHC means ensuring that all people have access to promotive, preventative, curative, rehabilitative and palliative health services that are of sufficient quality to be effective without exposing people to financial hardship.

UHC is Target 3.8 of the SDGs and a political promise which UN Member States have committed to achieve by 2030. But UHC is also considered a driver and outcome of other SDGs. To progress towards UHC, governments need to progressively expand priority health services, increase population coverage and reduce out-of-pocket payments. This requires strengthening an entire health system, and multisectoral collaboration.

As states have different and changing resources and health priorities, UHC will look different in different countries (and in different sub-national jurisdictions) and will be an ongoing, dynamic process. However, addressing the social determinants of health and existing inequalities and inequities is key to UHC in all settings. This in turn relies on reducing exposure to disease risk factors through effective prevention and health promotion measures, as well as improved primary health care.

As states have limited resources, ensuring that fewer people need access to essential treatment and supportive care is paramount, and investing in NCD prevention and health promotion is critical to the sustainability and success of UHC measures across the globe. UHC and NCD prevention are therefore mutually reinforcing agendas – UHC is a powerful tool to accelerate action against the burden of NCDs.

Law and UHC

Law and regulation as essential enablers of UHC

Effective law and regulation are powerful enablers of creating and maintaining a healthy society. Law is a significant tool in advancing UHC because law occupies a critical place in health system design, implementation and governance; the delivery of health care across the life course; health promotion and disease prevention and control. Law can also reduce social inequalities because of its power to regulate the environments in which we live by modifying the structural determinants leading to inequalities.

Law therefore plays a critical role in progress towards UHC and in advancing the right to the highest attainable standard of health, which is recognised in the International Covenant on Economic, Social and Cultural Rights and referenced in other international treaties such as the Universal Declaration of Human Rights.

The importance of law in achieving better health outcomes is clear in major international frameworks for health and sustainable development including the 2030 Agenda for Sustainable Development, the Global Non-Communicable Diseases Agenda, the WHO Framework Convention on Tobacco Control, and most recently, the 2019 United Nations Political Declaration on Universal Health Coverage. In these instruments, states commit to implementing interventions that can only be achieved using law.

Law takes various forms, including treaties, constitutions, legislation, delegated legislation (including regulations, decrees, ordinances, by-laws), decisions of courts and tribunals, enforcement practices, and mechanisms to monitor or enforce compliance with international obligations. The variety and breadth of law underline its ability to affect progress towards UHC — and address the NCD burden — in many ways, and at multiple levels, by a range of actors.

Law is an important tool that may be used to progress UHC but is usually employed most effectively in coordination with other interventions involving non-legal measures and/or non-state actors such as policy initiatives, educational and advocacy campaigns or standards set by professional bodies.

How do law and regulation strengthen health systems for UHC?

Law and regulation enable progress towards UHC and the attainment of other health and non-health SDG targets in many ways, such as legal and regulatory measures that:

  • Define the powers and duties of health workers, health agencies and health systems, and legal and regulatory measures to ensure that health systems and their participants are accountable
  • Allow for the collection and use of health information at individual and population levels, for example through population-based cancer registries, to support health research and provide data for the development, implementation and evaluation of UHC measures to ensure effective, evidence-based health interventions are introduced
  • Establish mandatory qualification, training and continuing education requirements for health practitioners — including building the capacity of health practitioners to understand and apply relevant laws and policies — to protect the public from unskilled and poorly trained health professionals
  • Protect the rights of people affected by illness through non-discrimination and equal opportunity laws as well as employment protections, regulatory measures to ensure access to insurance, and laws to protect the needs of particular populations such as children and indigenous communities
  • Regulate the cost of essential medicines, medical devices and services to promote access to medicines, reducing the risk of catastrophic financial hardship due to high out-of-pocket health care costs and promoting health equity
  • Empower national medicines regulators to regulate the quality, safety and efficacy of medicines and medical devices, and to use a range of compliance and enforcement measures to address misleading and fraudulent practices to protect people from unproven and/or unsafe therapies
  • Protect against exposure to risk factors, such as tobacco control laws implementing the World Health Organization (WHO) Framework Convention on Tobacco Control
  • Establish institutional structures and mechanisms at local, national and international levels through which countries respond to public health emergencies, including infectious disease outbreaks which can disproportionately affect people living with NCDs — such mechanisms include the International Health Regulations and laws relating to national pandemic response plans

Law and the health workforce

These examples of the role of law and regulation in strengthening health systems demonstrate that all actors who make up the health workforce — from practitioners, to health policymakers, to health regulators — work both with and within law and regulation. The health workforce contributes significantly to the development, enforcement and evaluation of health-related laws and public health measures like UHC. Health professionals and the communities they serve have much to gain, and can be empowered, from better understanding the role of law and regulation and how they engage with them.

Law and the broader workforce for health

When it comes to health issues like UHC, law is not just a matter for lawyers, the health workforce and institutions that have an explicit health mandate, such as the WHO. Other actors that make up a broader workforce for health — those who do not necessarily have an explicit health mandate, but have a direct and indirect impact on health — also need to actively engage with law. These include actors in the fields of trade, education or environment and extends to international institutions involved in global governance for health such as the United Nations General Assembly, the United Nations Development Programme, the World Trade Organization and non-governmental actors. Strengthening the legal capacity of all actors that directly and indirectly impact health and providing them with support for law-related activities is critical for UHC to be realised.

Engaging with law at all stages is crucial

Law and regulation should not be considered as separate to the development of a country’s UHC (and NCD) policies, but as fundamental parts of it; law, as a public policy tool, can translate evidence and normative guidance into action.

Legal expertise can and should be effectively used at all stages of policy research, development, implementation and evaluation. Engaging legal expertise throughout the policy process and across sectors and government ministries necessary to progress UHC — for example, the health, trade and finance sectors — fosters necessary coordination and support across government. This helps to both generate and maintain the political will for action and to ensure that evidence-based laws and regulations are enacted, enforced and evaluated. It also minimises the risk of inappropriately developed or poorly implemented law, which can hinder progress towards UHC and deepen social inequalities. For example, laws that regulate the availability of morphine as a ‘controlled’ drug can impede its availability for palliative care.

Additionally, a commitment to the rule of law is essential to realising UHC. The public must have confidence that the state is held accountable to keep commitments made to progress UHC, and that implementation of UHC will be in a just and inclusive manner. The rule of law means a commitment by the state that its law-making process is transparent; laws are enforced fairly; courts and tribunals are independent; and that the administration and implementation of law is consistent with international human rights standards. Without the rule of law, neither public health nor broader development goals can be fully attained.

Global health governance and international cooperation

Law is also an important element in establishing the institutional and governance mechanisms to support UHC and other health functions, including NCD risk factor prevention. This includes mechanisms at the national level to implement a whole-of-government approach to policy implementation, and to advance such positions at the regional and international levels.

Development of this capacity within national institutions will be supported by greater international cooperation. This involves exchanging legal and regulatory best practice — not only through shared examples of domestic regulation, but by building knowledge of how effective UHC measures can be achieved within the context of international legal frameworks, including global public health law, international human rights law, international intellectual property law and international trade and investment law.

It is important that this capacity building extends beyond knowledge sharing between public health lawyers to other professionals also working to achieve UHC to integrate scientific, health and legal expertise.


Progressing global action on UHC: Outcome of the first UN High-level Meeting on UHC

The first UN High-level Meeting on UHC held on 23 September 2019 was a landmark meeting of Heads of State and Government who further committed to existing pledges to address the burden of NCDs through UHC.

The Political Declaration on UHC forms the basis of global efforts to progress UHC and provides a framework for national UHC plans and action. The Political Declaration includes commitments from Heads of State and Government to strengthen legal capacity, support the effective use of law at the national level, and promote multisectoral collaboration and capacity building. Law and regulation must be at the centre of national UHC action plans for the 2030 target of achieving UHC to be realised and for no one to be left behind.

The commitments made under the Political Declaration provide Member States an opportunity to work together in developing the necessary legal and non-legal capacity to progress the global NCD and UHC response. UN Member States will report on progress on commitments made in the 2019 Political Declaration on UHC at the second United Nations High-level Meeting on Universal Health Coverage in 2023.


About the McCabe Centre for Law & Cancer

The McCabe Centre for Law & Cancer is the only centre of its kind in the world advancing law to prevent cancer and to protect people affected by it. Through world-leading research and capacity building programs, the McCabe Centre upskills lawyers and policymakers to use law as an effective tool to prevent and control cancer, and other noncommunicable diseases.

The McCabe Centre is a World Health Organization (WHO) Collaborating Centre for Law and Non-Communicable Disease and the designated WHO Framework Convention on Tobacco Control Knowledge Hub on legal challenges to the Convention’s implementation. Established in 2012, McCabe Centre is a joint initiative of Cancer Council Victoria, the Union for International Cancer Control (UICC) and Cancer Council Australia, based in Melbourne, Australia with Regional Coordinators in the Pacific, Asia and Africa.

For more information or enquiries, please contact us at info@mccabecentre.org


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