Health: providing free health for all, everywhere

20 May 2020

By Winnie Byanyima, UNAIDS Executive Director — First published in World Economic Forum's Insight Report (May 2020)

Recognizing the public-health catastrophe

As we have seen in wealthier countries, economic and social determinants of ill-health are strong predictors of the likelihood of dying from COVID-19. The greatest risk will be for poor people in poor countries who have a much higher burden of existing illness, and of whom hundreds of millions are malnourished or immunocompromised. For the quarter of the world’s urban population who live in slums, and for many refugees and displaced people, it is not possible to socially distance or to constantly wash hands.

Half the world’s people cannot access essential healthcare even in normal times. While Italy has one doctor for every 243 people, Zambia has one doctor for every 10,000 people. Mali has three ventilators per million people. Average health spending in low-income countries is only $41 per person a year, 70 times less than high-income countries.

The pressure the pandemic will place on health facilities will not only affect people with COVID-19 – anyone needing any care will be impacted. This has previously been the case. During the Ebola epidemic in Sierra Leone there was a 34% increase in maternal mortality and a 24% increase in the stillbirth rate, as fewer women were able to access both pre- and post-natal care.

The International Labour Organization predicts 5 million-25 million jobs will be eradicated, and $860 billion-$3.4 trillion will be lost in labour income. Mass impoverishment will make treatment inaccessible for even more people. Already every year 1 billion people are blocked from healthcare by user fees. This exclusion from vital care won’t only hurt those directly affected – it will put everyone at risk, as a virus can’t be contained if people can’t afford testing or treatment.

Lockdowns without compensation are, at their crudest, forcing millions to choose between danger and hunger. As in many developing country cities, over three quarters of workers are in the informal sector, earning on a daily basis, many who stay in will not have enough to eat and so large numbers will ignore lockdown rules and risk catching the coronavirus.

As we have seen in the AIDS response, governments struggling to contain the crisis may seek scapegoats – migrants, minorities, the socially excluded – making it even harder to reach, test and treat to contain the virus. Donor countries may turn inwards, feeling they can’t afford to help others and, as the presence of COVID-19 anywhere is a threat to people everywhere, this will not only hurt developing countries, it will also exacerbate the challenge in donor countries too.

And yet, amid the pain and fear, the crisis also generates an opportunity for bold, principled, collaborative leadership to change the course of the pandemic and of society.

Seizing the public-health opportunity

Contrary to conventional wisdom that responding to a crisis takes away the capability needed for major health reforms, the biggest steps forward in health have usually happened in response to a major crisis – think of the post-Second World War health systems across Europe and in Japan, or how AIDS and the financial crisis led to universal healthcare in Thailand. Now, in this crisis, leaders across the world have an opportunity to build the health systems that were always needed and which now cannot be delayed any longer.

Universal healthcare

This pandemic has shown that it is in everyone’s interest that people who feel unwell should not check their pocket before they seek help. As the struggle to control an aggressive coronavirus rages on, the case to end user fees in health immediately has become overwhelming.

Free healthcare is not only vital for tackling pandemics: when the Democratic Republic of the Congo instituted free healthcare in 2018 to fight Ebola, healthcare utilization improved across the board with a more than doubling of visits for pneumonia and diarrhoea, and a 20%-50% increase in women giving birth at a clinic – gains that were lost once free healthcare was removed. Free healthcare will also prevent the tragedy of 100 million people driven into extreme poverty by the cost of healthcare every year.

Because COVID-19 has no vaccine yet, all countries will need to be able to limit and hold it. The inevitability of future pandemics makes permanent the need for strong universal health systems in every country in the world.

Publicly funded, cutting-edge medicines and healthcare must be delivered to everyone no matter where they live. To enable universal access, governments must integrate community-led services into public systems. This crisis has also highlighted how our health requires that the health workers who protect and look after us are themselves protected and looked after.

Given the interconnectedness between health and livelihoods, all countries will also need to strengthen social safety nets to enhance resilience. COVID-19 has reminded the world that we need active, accountable, responsible governments to regulate markets, reduce inequality and deliver essential public services. Government is back.

Financing our health

Many developing countries were already facing debt stress leading to cuts in public healthcare. In recognition that worldwide universal healthcare is a global public good, lender governments, international financial institutions and private financial actors need to both extend and go beyond the temporary debt suspensions that have been announced recently. The proposal by the Jubilee Debt Campaign and hundreds of other civil society organizations sets out the kind of ambition required.

Bilateral donors and international financial institutions, including the World Bank, should also offer grants – not loans – to address the social and economic impacts of the pandemic on the poor and most vulnerable groups, including informal sector workers and marginalized populations. Support to developing countries’ ongoing health system costs needs to be stepped up. It would cost approximately $159 billion to double the public health spending of the world’s 85 poorest countries, home to 3.7 billion people. This is less than 8% of the latest US fiscal stimulus alone. It is great to see donor countries using the inspiring and bold language of a new Marshall Plan – but currently pledged contributions are insufficient.

Business leadership

A new kind of leadership is needed from business too; one that recognizes its dependence on healthy societies and on a proper balance between market and state. As President Macron has noted, this pandemic “reveals that some goods and services must be placed outside the rules of the market”. ’The past decade has seen a rapid increase in the commercialization and financialization of healthcare systems across the globe. This must end.

As a group of 175 multimillionaires noted in a public letter released at the World Economic Forum Annual Meeting 2020 in Davos, it is time for “members of the most privileged class of human beings ever to walk the earth” to back “higher and fairer taxes on millionaires and billionaires and prevent individual and corporate tax avoidance and evasion.” Responsible business leaders should support corporate tax reform, nationally and globally, that will necessarily include higher rates, removing exemptions, and closing down tax havens and other tax loopholes.

Despite the lessons from AIDS, monetizing of intellectual property has brought a system of huge private monopolies, insufficient research into key diseases and prices that a majority of the world can’t afford. Countries will need to use all available flexibility to ensure availability of essential health treatments for all their people, and secure new rules that prioritize collective health over private profit. There needs to be prior international agreement that any vaccines and treatments discovered for COVID-19 will be made available to all countries. The proposal by Costa Rica for a “global patent pool” would allow all technologies designed for the detection, prevention, control and treatment of COVID-19 to be openly available, making it impossible for any one company or country to monopolize them. Developing countries must not be priced out or left standing at the back of the pharma queue.

Leadership is needed in reshaping global cooperation: the COVID-19 crisis has exposed our multilateral system as unequal, outdated and unable to respond to today’s challenges. We will face even greater threats than this pandemic, which only an inclusive and just multilateralism will enable us to overcome.

All of us need all of us

The COVID-19 pandemic is simultaneously a crisis worsening existing inequalities and an opportunity that makes those inequalities visible.

The HIV response proves that only a rights-based approach rooted in valuing everybody equally can enable societies to overcome the existential threat of pandemics. Universal healthcare is not a gift from the haves to the have-nots but a right for all and a shared investment in our common safety and wellbeing.


The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.