Universal health care and political economy, neoliberalism and effects of COVID-19: A view of systems and complexity.

Sturmberg and Martin's application of systems and complexity theory to understanding Universal Health Care (UHC) and Primary Health Care (PHC) is evaluated in the light of the influence of political economy on health systems. Furthermore, the role that neoliberal approaches to governance have had in creating increased inequities is seen as a key challenge for UHC. COVID-19 has emphasized long standing discrepancies in health and these disadvantages require government will and cooperation together with adequate social services to redress these discrepancies in UHC.

Sturmberg and Martin present how a systems approach and complexity theory can inform Universal Health Care (UHC) and Primary Health Care (PHC). They do this by critically evaluating how the World Health Organization (WHO) links both UHC and PHC. We propose that the political economy refers to a socio‐political and economic system that underscores UHC and affects the organization and delivery of PHC. This system can be understood as a complex set of arrangements and relationships that need to acknowledge the political dimension of healthcare. Furthermore, we propose that much can be gained by examining the effects of the COVID‐19 pandemic on the political economy of UHC.

The political economy of health is an important concept in understanding the financing, governance and activities of UHC and of PHC. It can be seen as one of the important bases on which these systems of health care operate. We previously argued that an understanding of political economy was crucial in realizing how UHC operates. The concept political economy began in the 18th century with the writings of Adam Smith. It has different meanings but incorporates economic and political analyses of modes of activities and governance. 'Political economy of health has been in use for a number of decades…(It) is a perspective on health policy which attempts to understand economic, social, political, historical, and cultural factors influencing health issues and associated problems'.

The COVID‐19 pandemic reveals the inequality inherently reproduced by neoliberal economies. Neoliberalism is a policy of maximizing freedom of markets, with little government control and spending, and low levels of taxation. More generally, it is seen to result in increasing social and economic inequity. The pandemic has led to 82 million people worldwide being infected with COVID‐19 by the end of 2020, and by May 2021, an estimated 3.3 million have died , However, those of lower socio‐economic status have been the most affected.

According to Bump et al., morbidity and mortality is worse for migrants, black people, indigenous people and those who have been discriminated against or marginalized. Disease risk is more in precarious work and for groups such as mobile workers. The consequence of COVID‐19 has led to the poor and marginalized suffering disproportionately. Countries having insufficient vaccines and medicines will have least political and economic bargaining bases.

Navarro argues that pursuing neoliberal policies during the COVID‐19 pandemic would at best be foolhardy. He maintains '(O)ne of the key public policies carried out by governments with neoliberal tendencies has been the mass privatization and commercialization of public services…which are so vital for the well‐being of populations'. These conditions during COVID‐19 are ineffective for dealing with national health and prosperity. In addition, social security measures are important to maintaining people's health by giving them access to health services, food, housing and employment. Countries are finding that health spending is not optional. UHC has demonstrated through COVID‐19 that it is essential to move from basically privately funded to compulsory public funding. The free‐market approach will not achieve UHC. It requires political will. UHC is essentially also a political process.

Another facet of neoliberalism that creates and preserves inequality and affects access to healthcare generally are decreased social services. Australia serves as an example of this. Unemployment benefits as well as other social services have been lowered to force people to seek employment, but when COVID 19 meant people were not able to work, governments recognized the need to offer increased assistance including higher unemployment benefits and housing assistance. This was important to the function of the economy. It also demonstrates that retaining improved social services benefits health in terms of affording medicines, food and housing security.

Access to appropriate, timely, comprehensive and quality health service is a requirement for UHC. It should also be financially affordable. Although UHC underwrites PHC systems and allows greater accessibility to health services, it focuses on particular health services and health insurance and tends to neglect infectious disease problems and does not manage public health well.

Hiam and Yates [16, pp. 646‐647] argue that inequity in accessing safe, effective and affordable health care is one of the great inequalities. In the past “universal health reform has often been borne out of crisis… It is therefore possible that, like other crises before it, the COVID‐19 pandemic could catalyse UHC reforms, should global leaders choose to harness the opportunity” Other researchers agree that for most countries, moving to UHC has come from disruption “to the status quo” mostly from moves to democracy or uneven status of the state. Many countries during COVID‐19 have been optimizing opportunities to expand UHC (such as Cyprus and Finland) while the US and Ireland are the only countries in the OECD not to have UHC. However, under Biden they may progress it. Where the welfare of all has needed to be improved, leaders utilizing UHC makes sense from an economic, political and health point of view. This can reduce inequities which have been pronounced as adverse outcomes of COVID‐19. UHC is achievable not only in wealthy countries but also in low and medium wealth countries.

Behzadifar et al., argue that UHC's role is to offset the economic impact of the pandemic's infection. 'This disease cannot be controlled and contained without international cooperation. The experience of the COVID‐19 should be a lesson for further establishing and achieving universal health coverage in all countries'.

Overall, the “regressive” distribution of the virus and competition for supplies and vaccines 'indicate that the political economy of COVID‐19 is the political economy of extraction, following longstanding patterns of exploitation. Extractive relationships are fundamentally unequal and are the opposite of the collaborative fairness embodied in the general ideals and ethics of public health and in the specific calls for solidarity and cooperation made by the World Health Organization' [9, p. 1].

In conclusion, we suggest that to fully understand complexity theories around UHI and PHC and to see them adequately resourced and developed so that universal access becomes a reality requires the evaluation of the limitations of neoliberal policies, especially with regard to social services. Further articulation of the context of the political economy is needed. The advent of COVID‐19 has shown how such economic policies reduce people's abilities to be healthy. This has been the case before the pandemic but was ignored by governments. Unfortunately, if it is not addressed it will be the case after the pandemic.

CONFLICT OF INTEREST

The authors declare no conflict of interest.