Parliamentary action on universal health coverage in times of COVID-19

Office of the
Secretary General
Geneva, 26 February 2021
Dear Madam Speaker,
Dear Mr. Speaker,
We are pleased to inform you that the IPU has issued the report “Parliamentary action
on universal health coverage in times of COVID-19”, enclosed to this letter. It is the
first report on the implementation of the IPU resolution Achieving universal health
coverage by 2030: The role of parliaments in ensuring the right to health, which was
adopted in October 2019.
The report highlights that the COVID-19 pandemic has reversed many of the
development gains achieved over the past 25 years, including on universal health
coverage (UHC). Parliaments reported challenges such as the diversion of resources
away from UHC, the disruption of essential health services, and new barriers to
healthcare coverage access to vulnerable and marginalized populations.
However, it is encouraging that parliaments remain committed to UHC and some
countries have been able to use the pandemic as an opportunity to accelerate its
implementation. The report illustrates how investments in UHC enables better
preparedness and response to health emergencies and highlights the roles that
parliaments can play in this regard. Now more than ever there is a need to prioritize
UHC to strengthen health systems and ensure equity in access to health.
Countries worldwide committed to UHC as part of the Sustainable Development Goals
(SDGs) and reiterated their commitment through the IPU resolution on UHC.
Parliaments play a crucial role in turning internationally agreed development goals into
reality for their countries and people. The SDGs offer a globally agreed roadmap to
deliver on resilience for people, planet and the economy, and should be at the heart of
recovery efforts from COVID-19.
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The IPU continues to mobilize parliaments to share good practices and solutions to
inform the global parliamentary community and draw lessons for parliamentary action
on health. We encourage you to keep the IPU abreast of developments on UHC. In
order to address some of the gaps identified in the report, we are pleased to share a
questionnaire to collect information on current legislative processes on UHC and
parliamentary practices on establishing a legal framework to advance UHC and the
right to health. The information collected through this questionnaire will inform the next
report on the implementation of the IPU resolution on UHC to be prepared at the end
of 2021.
The questionnaire can also be accessed and completed at the following link:
https://trello.com/c/Z34jEa4D
We hope you will find the report useful and will continue sharing with the IPU your
Parliament’s initiatives, best practices, and challenges in making UHC a reality for the
people.
Yours sincerely,
Martin Chungong
Secretary General


1
Parliamentary action on universal health coverage in times of
COVID-19
Implementing the IPU resolution Achieving universal health coverage by 2030: The
role of parliaments in ensuring the right to health
The IPU resolution Achieving universal health coverage by 2030: The role of parliaments
in ensuring the right to health was adopted in October 2019 and provides a road map for
parliaments to accelerate progress towards universal health coverage (UHC). This is the
first report on parliamentary action on UHC pursuant to the resolution. It takes stock of
different national experiences and identifies lessons learnt and challenges in the
implementation of the resolution. In the context of the COVID-19 pandemic the report
documents how the pandemic is shaping parliamentary action on UHC. In line with the
IPU’s longstanding engagement on women’s, children’s and adolescents’ health,
particular attention is paid to these groups.
1. Introduction
1.1. Context and background
The resolution Achieving universal health coverage by 2030: The role of parliaments in
ensuring the right to health was adopted at the 141st IPU Assembly in October 2019. It is
the first global parliamentary resolution on universal health coverage (UHC) and calls on
parliaments to take specific actions in terms of legislation, budget allocation, accountability
and advocacy to achieve UHC. UHC emphasizes every person’s right to have equal access
to quality health services as required, without causing financial hardship.
The UHC resolution was a natural progression, based on the positive impact observed from
the IPU’s work associated with its 2012 landmark resolution, Access to health as a basic
right: The role of parliaments in addressing key challenges to securing the health of women
and children, and the subsequent 2017 addendum. Parliaments have a vital role to play in
advancing UHC and positive health outcomes, especially during the challenges of a global
pandemic.
The implementation of the UHC resolution requires a special focus on the barriers to
accessing health care and the challenges faced by vulnerable and marginalized groups. It
should be considered jointly with the 2012 IPU resolution and its 2017 addendum. It should
also be noted that reproductive, maternal, newborn and child health is one of the key
indicators for measuring UHC implementation.
Various models or approaches for successfully implementing UHC may be used, provided
there is compliance with the key principles of quality, equity and universal access to needed
health services, and financial risk protection. The determination of health-care financing is
critical for addressing such protection. With a few exceptions (such as Thailand, a
middle-income developing country), publicly funded systems were historically based on
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general or dedicated taxation, and adopted by a select number of high-income countries
(such as the United Kingdom, the Nordic countries, Spain, Italy and New Zealand).
Health-care financing is also commonly implemented through statutory indemnity (such as in
Australia), private health insurance (the Netherlands) or a mixture of both (Germany).
Parliaments have a significant role to play in financing. This is because of the leverage they
have through specific legislative, oversight and budget allocation functions, as well as
general influence over governance.
Admittedly, global progress has been made in improving various health outcomes, such as
reduced mortality rates for under-fives, infants and mothers. However, even before the
COVID-19 pandemic, it was evident that significant challenges remain. In 2017, an
estimated 295,000 women (808 women daily) died of complications arising from pregnancy
and childbirth. Almost all of those deaths were preventable and most occurred in
low-resource settings. Under-five mortality also remains a significant problem in Africa,
where the rate was more than eight times higher than the European region in 2018.1
At least half of the world’s population still do not have full coverage of essential health
services, and around 100 million people are pushed into extreme poverty by having to pay
for health care. Life expectancy remains profoundly influenced by income and other
interrelated socioeconomic factors. According to Primary Health Care on the Road to
Universal Health Coverage (World Health Organization (WHO) 2019 global monitoring
report), while progress has been greatest in lower-income countries, the poorest countries
and those affected by conflict generally lag far behind. In 2017, the largest population groups
lacking coverage for essential health services were in middle-income countries. The
2019 report (prior to the COVID-19 pandemic) had already noted that the current pace of
progress would make it impossible to achieve the SDG target of UHC for all by 2030.
Despite the gaps in data, trends have begun to emerge illustrating the indirect and likely
long-term impact of the pandemic on overall health. This will set back the progress already
made towards UHC. In particular, women, girls, adolescents and children have been
disproportionately affected through disruption to essential health services, including for
sexual and reproductive health, maternal health and immunization programmes. The likely
consequences include increased rates of child and maternal mortality, unintended adult and
adolescent pregnancies, and increased vulnerability to a range of communicable and
non-communicable diseases (NCD).
Adverse secondary impacts on maternal and child health associated with public health
emergencies have already been well documented through the Ebola epidemic in West Africa
(2014–2016). Maternal and neonatal deaths and stillbirths indirectly caused by the epidemic
eventually outnumbered deaths that were directly related to Ebola. At the time, the use of
reproductive and maternal healthcare services had declined. This was due to women either
being denied care by health-care providers, or avoiding facilities over fears of infection or
increased financial barriers.2
While there is significantly more pressure on lower and middle-income countries to achieve
UHC, serious challenges also remain for higher-income countries, especially on health
equity. These include countries recognized as having long achieved advanced UHC (such
1
WHO, Maternal Mortality (2019): www.who.int/news-room/fact-sheets/detail/maternal-mortality.
2
L. Sochas, A.A. Channon and S. Nam, “Counting indirect crisis-related deaths in the context of a low-resilience
health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone”, Health
policy and planning, 32 (suppl_3) (2017), iii32–iii39.
Also see, United Nations Development Group – Western and Central Africa, Socio‐economic impact of Ebola
virus disease in West African countries: A call for national and regional containment, recovery and prevention
(2015): www.undp.org/content/dam/rba/docs/Reports/ebola-west-africa.pdf, pp. 24 and 54.
3
as Canada, Germany, Singapore and the United Kingdom), where gaps in coverage and
health equity mean that the pandemic is having a disproportionate impact on vulnerable and
marginalized groups, such as ethnic minorities, indigenous people, migrant workers, the
elderly, women, children and people with disabilities. A number of factors contribute to these
disparities, including occupation, living conditions, country of birth and access to health care.
Moreover, evidence indicates that countries across all income categories need to address
other aspects of financial risk protection. For example, Financial Protection in Health
(WHO/World Bank 2019 Global Monitoring Report) noted that evidence from the WHO
European region, South-East Asia region and selected countries, mostly on the African
continent, indicates that out-of-pocket spending on medicines is a leading cause of
catastrophic and impoverishing health spending.
1.2. The accountability framework
UHC and the right to health have a central role in advancing national health agendas and
implementing the Sustainable Development Goals (SDGs). A detailed accountability
framework has therefore been established, with the IPU Advisory Group on Health acting as
the focal point. The objective of this framework is to promote and review the implementation
of the IPU resolution on UHC, including facilitating the sharing of best practices between
parliaments. One of the framework’s mechanisms involves an annual report summarizing
parliamentary actions and activities on UHC, including those related to legislation, oversight,
budget work, and public consultation and awareness-raising.
This report was prepared by drawing on information provided by Member Parliaments
through: the 2020 annual reporting exercise; the IPU webinar on Universal health coverage
in times of COVID-19 – Parliamentary best practices and challenges (17 November 2020);
and further contributions through other IPU processes. Information was received from
22 parliaments, and close to 100 participants from 36 countries attended the webinar. The
terms of reference of this annual summary are limited to documenting only parliamentary
action since the IPU resolution was adopted. Work before this period could therefore not be
reported. Unfortunately, this excluded a few instances of positive parliamentary action where
key UHC-related laws were enacted in the period leading up to the adoption of the
resolution. Nevertheless, these reports from national parliaments will still inform other work
by the IPU secretariat and the IPU Advisory Group on Health.
The COVID-19 pandemic posed challenges to parliamentary activities and the IPU
secretariat’s ability to access Member Parliaments’ reports. It was therefore necessary to
supplement these reports with information on parliamentary activities obtained through desk
research from Member Parliaments’ official websites and data from international partners,
including WHO and UHC2030.
The disruptive effect of the COVID-19 pandemic posed considerable challenges to normal
parliamentary functions, including:
• practical constraints on the activities of many national parliaments through social
distancing requirements;
• legal or constitutional restrictions on movement due to emergency or disaster
legislation;
• the extension of executive authority and powers (including legislative power in some
instances) through emergency or disaster legislation that, under normal
circumstances, would not have been permitted without parliamentary oversight or
approval;
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• delayed or reorganized legislative and parliamentary schedules that limited
legislative and oversight functions;
• the disruption of parliamentary interaction with the public, stakeholders or
constituencies that constrained public consultation and accountability.
2. National parliamentary action on UHC
2.1. UHC and global health security
Clause 29, IPU resolution on UHC (2019)
Also calls on parliaments to take all possible measures to ensure global health security by
preventing the spread of diseases and other public health events, particularly through
systematic immunization campaigns, as well as strengthening surveillance and response
systems, and to advocate for the implementation of the International Health Regulations
(2005) and for the allocation of appropriate resources to meet countries’ obligations and
address critical gaps in their respective public-health core capacities to prevent, detect and
respond to public health risks
In recognition of the connection between global health security and UHC, clause 29 of the
2019 IPU resolution contains detailed provisions on the role of parliaments in response to
public health emergencies or acute public health events, such as outbreaks of disease or
natural disasters. Health security relates to the need for strong and resilient public health
systems that can prevent, detect and respond to large-scale health emergencies.
Ordinarily, health security and health emergency issues have tended to be geographically
restricted to specific countries or regions that were prone to natural disasters, outbreaks of
disease or humanitarian emergencies. This is reflected by the fact that in 2018, the
WHO Contingency Fund for Emergencies provided US$ 37.5 million for responses to
28 health emergencies, including: two Ebola outbreaks in the Democratic Republic of the
Congo (DRC); the largest Lassa fever outbreak on record in Nigeria; and support for an
earthquake response in Papua New Guinea.3
However, the COVID-19 pandemic has
illustrated that health security is globally relevant as a principle and an integral component of
UHC.
i) Disruption to essential services and setbacks to UHC
The pandemic has reversed many of the development gains achieved over the past
25 years, particularly for health and UHC. This was confirmed in reports by the Parliaments
of Bangladesh, the Syrian Arab Republic and the DRC, in which the parliaments reaffirmed
their commitment to UHC, but also noted various setbacks to their national UHC initiatives.
• Progress towards UHC had already begun in Bangladesh before the pandemic.
However, since then, many health resources have been diverted away from essential
health services towards the pandemic response. This has increased health risks for
patients with NCDs (such as heart diseases, respiratory diseases, cancer and
diabetes), which constitute comorbidities if these patients contract COVID-19.
Notwithstanding these challenges, and to indicate its continued commitment, the
Bangladeshi Parliament is setting up a forum on UHC.
• Even before the COVID-19 pandemic, progress towards UHC in the Syrian Arab
Republic had already been constrained by the destruction of public health
infrastructure after many years of civil war. The pandemic response has now
exhausted the national health budget and disrupted other essential health services,
3
WHO, Bulletin of the World Health Organization, Volume 97, Number 4 (April 2019), 248–249:
www.who.int/bulletin/volumes/97/4/en/.
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such as immunization programmes for children, and antenatal care for pregnant and
postpartum mothers. Nevertheless, the Syrian Parliament is persevering, and has
focused its oversight functions on the government’s response to the pandemic,
including the Executive’s prevention strategies and preparation of health-care
facilities.
• The DRC had been actively engaged in moving towards UHC, with its government
having launched a UHC plan in February 2020. However, this momentum slowed
down due to the pandemic. Essential health services were disrupted, including the
treatment of diabetes, arterial hypertension, malaria and waterborne diseases.
Access to health care for vulnerable and marginalized communities has been further
hampered, with misinformation leading them to avoid health services for fear of
contracting COVID-19.
ii) Promoting resilience against pandemics by investing in UHC
Investments in primary health care and public health functions can: enable a country to build
a resilient health system capable of continuing to provide its people with the health services
they need; and enable a better response to major public health events, emergencies or
threats to health security. This assumes the implementation of UHC models that focus on
the same issues that health security initiatives emphasize: prevention, early interventions,
and preparedness and surveillance systems. General progress on primary health care and
UHC also contributes to building public trust, which facilitates public cooperation and the
appropriate behavioural responses for health promotion, disease prevention and health
security.
Reports were received from the parliaments of Thailand, and Trinidad and Tobago in this
regard.
• Since 2002, Thailand has implemented a publicly funded UHC scheme. However,
substantial primary health care reforms and investments as far back as the
1970s have also produced positive health outcomes. In 2017, Thailand scored 80 out
of 100 in a WHO index for measuring UHC service coverage.4
Infection rates and
COVID-related deaths in Thailand have remained low, with high recovery rates, even
though the first known case of COVID-19 transmission outside China was confirmed
in Thailand in January 2020. Thailand’s health security strategy was implemented
swiftly and includes measures such as contact tracing, quarantining or self-isolation
where appropriate, and hospitalizing those with serious symptoms. Thailand can also
use its primary health-care system at community level (such as village health
volunteers) for health surveillance, sharing information and promoting preventive
behaviour.
• In response to the pandemic, Trinidad and Tobago set up a “parallel” public
health-care system, with 400 beds for COVID-19 patients. This was covered under
the normal health budget financed from general income tax, without needing to
increase the annual health budget allocation. Testing and treatment are part of the
standard free public health-care services provided to everyone in Trinidad and
Tobago. Essential health-care services have continued to operate unimpeded. Both
infection rates and COVID-related deaths have remained low.
4
The WHO index measures UHC service coverage among the general public and the most disadvantaged
communities. It is based on 14 tracer indicators related to four categories of essential service: reproductive,
maternal, newborn and child health; infectious diseases; NCDs; and service capacity and access.
WHO, Global health observatory data repository:
https://apps.who.int/gho/data/node.main.INDEXOFESSENTIALSERVICECOVERAGE.
6
The East African Legislative Assembly (EALA) compared Rwanda’s response to other
partner States in East Africa, and reflected on how Rwanda had been better able to respond
to and manage the impact of the pandemic.
• Since its first confirmed case of COVID-19 in March 2020, Rwanda has successfully
implemented a variety of health security measures, including countrywide and partial
lockdowns, contact tracing, free testing, dedicated treatment centres and public
education on prevention. As a result (and notwithstanding its status as a low-income
country), Rwanda has managed to maintain low rates of infection and COVID-related
deaths. Notably, Rwanda began implementing a community-based health insurance
system in 1999–2000 as part of implementing UHC. This has contributed to an
improvement in various health indicators, including an increase in immunization
coverage rates from 30 per cent to 94 per cent between 1995 and 2015. Although
many health and development challenges remain, Rwanda’s progress towards UHC
has already produced positive health outcomes, laying the foundations for increased
public confidence in the public health system. This in turn enables greater public
cooperation with health security and general health-prevention initiatives
implemented nationally and within communities.
iii) Oversight and accountability
The information collected through the IPU campaign “Parliaments in a time of pandemic”
show that most IPU Member Parliaments have been active and involved throughout national
processes and responses to the pandemic. They have been called upon to implement a
range of extraordinary parliamentary processes in support of their governments and health
ministries. This has included enacting disaster or emergency legislation, approving public
health emergency funding and budgetary allocations, and exercising oversight. That said,
the extent to which parliaments have been able to actively defend and exercise their
oversight prerogatives has been highly variable. Executives have sometimes bypassed
parliaments altogether when adopting and implementing emergency health legislation,
including when this has involved decisions about the continued delivery or suspension of
essential health services. For instance, the South African Parliament experienced some
challenges around overseeing public expenditure on the pandemic response. On a more
positive note however, the IPU survey and webinar also reflected the active steps of various
parliaments to formalize and establish dedicated committees, structures or other processes
to ensure oversight and accountability of their Executive’s response to the pandemic,
including in Canada, the Gambia, Romania and Thailand.
The webinar revealed a strong emphasis on the need for collaborative approaches in
responding to the pandemic and progressing towards UHC as a whole. This would entail
parliamentary cooperation across party political divides, support for governments where
appropriate, and the participation and inclusion of civil society and the general public in
developing UHC-aligned programmes. These approaches would be in line with clause 16 of
the 2019 UHC resolution, which calls for a partnership-based approach on a whole-of-
government and whole-of-society basis.
2.2. General state of commitment to UHC
Clause 1, IPU resolution on UHC (2019)
Reaffirms that the devotion of maximum available resources to the progressive realization of
UHC is possible and achievable for all countries even in challenging settings, and calls on
parliaments and parliamentarians to take all applicable legal and policy measures in order to
help their respective governments to achieve UHC by 2030 and to ensure quality, affordable
and accessible health care
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Clause 1 of the IPU’s 2019 UHC resolution outlines the broad, fundamental principles of
UHC. It also calls on all parliaments to advance UHC by enacting and ensuring the
implementation of various UHC laws. The resolution’s remaining provisions are a more
detailed guide to the type and range of laws required to eventually achieve UHC.
Since the adoption of the IPU resolution on UHC and the 2019 Political Declaration of
the UN High-Level Meeting on Universal Health Coverage, a number of parliaments have
adopted their own resolutions, or even enacted legislation, on UHC.
In February 2020, the Congress of the Federated States of Micronesia adopted a resolution
declaring that its goal was to “reach Universal Health Coverage by 2030” and calling upon
the President “to take measures to effectuate that goal”. The Federated States of Micronesia
has made progress in delivering primary health care to rural, remote and vulnerable sections
of its dispersed population.5
Although the Congress has yet to enact UHC legislation,6
the
resolution represents a significant initial step. It hopefully signals further concrete
parliamentary action on UHC, particularly legislative action.
The IPU 2020 reporting exercise provided information on two promising initiatives involving
draft UHC legislation. The Benin National Assembly was considering a draft law on the right
to health, which was adopted in December 2020; and the Health Commission of the El
Salvador Legislative Assembly is discussing draft legislation on an integrated national health
system.
As Benin currently has no UHC legislation7
, individual households provide most health
financing. Mortality and morbidity indicators are relatively high.8
The new law reflects the
potential to advance Benin’s goal of achieving UHC, particularly when combined with the
Beninese Government’s initiatives to pilot a mandatory health insurance project.9
By contrast, El Salvador already has UHC-related legislation. It includes provision for free
primary health-care services and a publicly funded health insurance system. However, the
country is experiencing serious challenges in meeting the public’s needs due to shortages of
supplies and labour, and a growing burden of NCDs.10
The draft law being considered by the
Legislative Assembly aims to regulate care quality in public hospitals and other facilities, and
to ensure equitable and timely coverage.
In its 2020 synthesis report, State of commitment to universal health coverage,
UHC2030 called on all governments to commit to national UHC targets and communicate
these to all stakeholders. UHC2030 notes that, despite their existing global commitments,
very few governments are providing clear, measurable UHC targets in their SDG reporting
through voluntary national reviews, or in global political statements. The absence of clear
targets makes monitoring, accountability and implementation more challenging, especially if
there is no common understanding of what the commitments would mean in practice.
Parliamentarians in particular will have a key role in translating the commitments into UHC
5
WHO, Universal Health Coverage Partnership annual report 2019. In practice: bridging global commitments
with country action to achieve universal health coverage (Geneva, 2020): www.uhcpartnership.net/wp-
content/uploads/2020/11/UHC-annual-report-2019_V23_WEB_SINGLE.pdf. p. 12.
6
UHC Data Portal: www.uhc2030.org/what-we-do/knowledge-and-networks/uhc-data-portal/.
7
Ibid.
8
WHO, Benin: Country cooperation strategy at a glance (2009): www.afro.who.int/sites/default/files/2017-
06/Benin-ccsbrief-en.pdf.
9
WHO, Bulletin of the World Health Organization, Volume 97, Number 9 (July 2019):
www.who.int/bulletin/volumes/97/9/18-222638/en/.
10
WHO, Global Health Workforce Alliance: Country responses – El Salvador:
www.who.int/workforcealliance/countries/slv/en/.
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laws, overseeing their implementation, and approving adequate health budgets and
financing.11
2.3. Leave no one behind – health equity and discrimination
Clause 2, IPU resolution on UHC (2019)
Urges parliaments to put in place a robust legal framework for UHC, to ensure effective
implementation of UHC legislation in reality, and to ensure that the right of everyone to public
health and medical care is guaranteed for all in law and in practice, without discrimination
Canada provided useful insights that illustrated the challenges of equity, including for
high-income countries with a long history of advanced UHC. In 2017, Canada scored 89 out
of 100 on the WHO index for UHC service coverage.12
However, before the COVID-19
pandemic, inquiries into various coverage gaps in the Canadian public health-care system
were already under way.
The inquiries looked at disparities in health coverage for vulnerable communities, such as
indigenous people, migrants and refugees, the elderly, women, children, people with
disabilities, people living in poverty, and geographically dispersed populations. It was noted
that these groups were disproportionately impacted by the COVID-19 pandemic, along with
Canadians identifying as black or of Asian, Latin American, Arab or Middle Eastern origin.
The UHC2030 synthesis report confirms the Canadian experience, and notes that, even in
high-income countries, the elderly, migrant populations, poorer households, homeless
people and other vulnerable groups are being left behind. Countries such as Germany and
Singapore, which have performed relatively well in containing COVID-19, have experienced
more severe outbreaks in migrant communities, which were subject to poorer health
conditions, lower social protection and crowded housing.13
2.4. Prevention, education, behaviour-related initiatives
Clause 7, IPU resolution on UHC (2019)
Encourages States to implement prevention and education programmes to promote the
health literacy of their citizens and to address behaviour-related health concerns, such as
alcohol and tobacco use, occupational health and safety, obesity and sexually transmitted
diseases
Clause 7 highlights the need to address health promotion and prevention as part of UHC,
with an emphasis on NCDs and lifestyle-related health conditions. According to the WHO,
almost 70 per cent of all deaths worldwide are associated with conditions such as heart
disease, stroke, cancer, diabetes and chronic respiratory diseases. NCDs or chronic
diseases disproportionately affect people in low and middle-income countries where more
than three quarters of global NCD deaths (32 million) occur. This highlights the need for
public interventions to address the four primary risk factors: tobacco use, physical inactivity,
the harmful use of alcohol and unhealthy diets.
11
UHC2030, State of commitment to universal health coverage: synthesis, 2020 (2020):
www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/Key_Issues/State_of_UHC/SoUHCC_synthesis_2020
_final_web.pdf. p. 30.
12
WHO, Global health observatory data repository:
https://apps.who.int/gho/data/node.main.INDEXOFESSENTIALSERVICECOVERAGE.
13
UHC2030, State of commitment to universal health coverage: synthesis, 2020 (2020):
www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/Key_Issues/State_of_UHC/SoUHCC_synthesis_2020
_final_web.pdf. p. 28.
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In December 2019, the Congress of the Philippines passed Republic Act No. 11346, which
increases excise tax on tobacco and vapour products. The legislation is intended to
discourage behaviours and lifestyles that contribute to poor health outcomes. It also
supplements existing taxes on tobacco products, alcohol and sugar. A proportion of the tax
revenue is to be ringfenced to fund the implementation of the 2019 Universal Health Care
Act and the national Health Facilities Enhancement Program. The legislation therefore
addresses the additional objective of facilitating UHC financing.14
Elsewhere, the Parliament of Romania has indicated that it adopted a legislative proposal on
the early prevention and detection of diabetes in 2020.
According to a 2018 WHO report (Saving lives, spending less: a strategic response to
noncommunicable diseases), for every one US dollar invested in addressing NCDs in low
and lower-middle-income countries, the return to society is at least seven US dollars in
increased employment, productivity and longer life. Yet NCDs receive less than 2 per cent of
global health funding. This highlights the need for an increased parliamentary focus on
ensuring dedicated funding that targets the treatment and prevention of NCDs.15
2.5. Sexual, reproductive, maternal, child and adolescent health services
Clause 9, IPU resolution on UHC (2019)
Calls on parliaments to strengthen health systems so as to reduce maternal, newborn, child
and adolescent mortality and morbidity by strengthening sexual, reproductive, maternal,
newborn and adolescent health and nutrition services, promoting in particular breastfeeding,
systematic immunization campaigns and early childhood development interventions, as well
as by providing information on and access to the broadest possible range of safe, effective,
affordable and acceptable modern methods of family planning
Clause 9 of the resolution focuses on sexual and reproductive health, as well as more
broadly on maternal, newborn, child and adolescent health, and the role of immunization.
Here, the role of parliaments includes legislative, oversight and budget-allocation functions
on the one hand, and public and constituency awareness-raising, and educational and
behavioural change activities on the other.
The IPU’s longstanding engagement on these issues includes support to national
parliaments in strengthening their action on women’s, children’s and adolescents’ health.
Following elections to the Parliament of Rwanda, and building on successful collaboration
with the Parliament, a capacity-development workshop held in January 2020 enabled
parliamentarians to identify gaps in existing legal provisions that restricted access to sexual
and reproductive health services for adolescents. The workshop also emphasized the need
to reinforce mobilization campaigns on comprehensive sexual education for all categories of
young people, and to build capacity among male partners for fighting gender-based
violence. This also responded to clause 10 of the resolution, stressing the need to protect
sexual and reproductive health and rights (SRHR) through a multisectoral approach that
tackles the gender determinants of health.
The UHC2030 synthesis report cautions that sexual and reproductive health services are
essential services, and should therefore not have been disrupted as a result of COVID-19
restrictions. However, service disruptions were reported in various countries of all income
14
Information on Philippines’ Tobacco Tax Law was obtained through desk research:
Republic of the Philippines Department of Finance: https://taxreform.dof.gov.ph/tax-reform-packages/package-
2plus-sin-taxes/.
15
WHO, Saving lives, spending less: A strategic response to noncommunicable diseases (Geneva, 2018):
https://apps.who.int/iris/bitstream/handle/10665/272534/WHO-NMH-NVI-18.8-eng.pdf.
10
levels, including France, Kenya, Malawi, Nigeria and Peru.16
As noted earlier, these
disruptions have likely had serious consequences in terms of reversing previous gains made
in reducing maternal and child mortality. This highlights the need for parliaments to inquire
into the nature and extent of the disruption to SRHR and other essential health services
during this period. Ideally, this should also include identifying action to prevent the disruption
of essential services during any future public health emergencies.
Against this background, it is worth noting an example of parliamentary SRHR work that
continued in the midst of the pandemic. The Namibian Parliament ran a
capacity-development workshop on SRHR, HIV and AIDS for a group of its members in July
2020. It was part of the second phase of a project funded by the Swedish embassy. The
intended parliamentary follow-up will include tabling motions and scrutinizing relevant bills
about: sexual and gender-based violence, and gender inequality; early and unintended
pregnancy, and safe abortions; commodity security and UHC; comprehensive sexuality
education; non-discrimination and protecting key populations.17
2.6 Nutrition
Clause 12, IPU resolution on UHC (2019)
Calls on parliaments to ensure that national policies to implement UHC address malnutrition
in all its forms, with special attention to the nutritional needs of adolescent girls, pregnant and
lactating women and children during the first 1,000 days
Clause 12 of the resolution focuses on nutrition. Good nutrition is fundamental to health and
well-being, and access to quality nutrition services is essential to achieve UHC. In a letter to
all parliaments, the IPU Secretary General urged legislators to sustain efforts and
investment in nutrition.
In 2020, Zambia adopted the Food and Nutrition Act, which provided for the implementation
of a national food and nutrition programme. In response to the IPU Secretary General’s call,
the Parliament of Zambia organized a seminar about making nutrition a cross-cutting
parliamentary priority by strengthening oversight on the implementation of the 2020 Food
and Nutrition Act.
2.7. Access to and regulation of essential medicines, medical devices etc
Clause 13, IPU resolution on UHC (2019)
Also calls on parliaments to promote and foster access to essential, affordable, safe, effective
and good-quality medicines, medical devices, contraceptives, vaccines, diagnostics and other
technologies, without discrimination, to combat counterfeit and falsified medicines, and to
support innovation, research and development in medicines and vaccines for communicable
and non-communicable diseases
According to WHO, “essential medicines are those that satisfy the priority health-care needs
of the population”. Medicines and other pharmaceuticals have significant cost implications
for both developing countries and low-income households. UHC laws and policies requiring
parliamentary action on this subject may include: publishing national lists of essential
medicines to regulate pricing and guide procurement; regulating pharmaceutical industries to
16
Ibid, pp. 34 and 42–43.
17
Parliament of Namibia, “Lawmakers to put SRHR issues under scrutiny”, (July 2020):
www.parliament.na/index.php/component/content/article?layout=edit&id=473.
11
address pricing, access, quality and safety; and even promoting local manufacturing
capacity.18
A Pharmacare Bill is currently before the Canadian Parliament, with the first vote expected in
February 2021. The Bill would provide for universal access to prescription medication, the
lack of which has long been considered a gap in Canada’s federal UHC laws. If enacted, the
Bill would address concerns of affordability and therefore of access to prescribed or
essential medicines.
2.8. Immunization
Clause 14, IPU resolution on UHC (2019)
Urges parliaments to promote the immunization programmes of their respective governments,
as the most effective preventive measure against infectious diseases, and to enact measures
that will tighten patient safety regulations during the clinical testing of new vaccines to allay
public fears of vaccination
Clause 14, along with clauses 9 and 29, set out various provisions to guide the role of
parliaments in immunization programmes, which are vital for advancing the preventive
objective of UHC. In addition to implementing their legislative and oversight responsibilities,
parliaments have a valuable role to play in raising awareness and promoting support for
immunization among constituencies, communities and the public. This includes the global
roll-out of COVID-19 vaccines that is currently under way.
Legislatively, in addition to regulating the pharmaceutical industry for safety, quality and
access, some parliaments may opt for compulsory immunization. In 2019, the Parliament of
Pakistan and the German Bundestag each adopted legislation on compulsory vaccination,
namely the Islamabad Compulsory Vaccination and Protection of Health Workers Act, and
the Act on Protection against Measles and Strengthening Vaccine Prevention (Measles
Protection Act).19
In addition to immunization against communicable diseases such as measles and rubella,
vaccinating girls between the ages of 9 and 13 against human papillomavirus, and screening
women between the ages of 30 and 49, would be key primary health-care interventions to
reduce the incidence of and mortality from cervical cancer. In 2018, Asia and Africa
accounted for around 76 per cent of new cervical cancer cases and 80 per cent of deaths
from cervical cancer. While most high-income countries now routinely implement the human
papillomavirus vaccine in their immunization programmes for adolescent girls, it is not
offered in many low and middle-income countries.20
18
WHO, Strategizing national health in the 21st century: a handbook (Geneva, 2016):
https://apps.who.int/iris/bitstream/handle/10665/250221/9789241549745-chapter10-
eng.pdf?sequence=1&isAllowed=y, chapter 10, p. 17.
19
The Parliament of Pakistan submitted a report to the IPU survey.
Information on the German Measles Protection Act was found through desk research:
German Federal Ministry of Health, “The Bundestag adopts the Measles Protection Act”, (November 2019):
www.bundesgesundheitsministerium.de/measles-protection-act.html.
20
WHO, Primary Health Care on the Road to Universal Health Coverage: 2019 Monitoring Report (Geneva,
2019): www.who.int/healthinfo/universal_health_coverage/report/2019/en/. p. 67.
12
2.9. Sustainable health financing and financial protection
Clause 19, IPU resolution on UHC (2019)
Calls on parliaments to consider the Addis Ababa Action Agenda on Financing for
Development and to allocate adequate domestic resources for the progressive realization of
UHC through sustainable health financing, including through increased budgets where
needed, as well as through measures to promote efficiency, equity, quality, cost containment
and a stable basis for funding, mindful of the nominal minimum target for domestic resources
identified by WHO as equivalent to 5 per cent of GDP
Clause 22
Also calls on parliaments to ensure financial protection in order to reduce out-of-pocket
payments for health services and to eliminate financial barriers that prevent access to health
Clauses 19 and 22 deal with sustainable UHC financing, and protecting individuals from
financial risk or hardship linked to health-care user fees. Parliaments have a vital role to play
in influencing the adoption of budgets that are aligned with UHC objectives and, as
stipulated in the resolution, in ensuring a minimum target equivalent to 5 per cent of GDP.
IPU Members submitted reports on increased allocations to health budgets for 2020 and
2021, especially in light of the COVID-19 pandemic. These included:
• The National Assembly of Nicaragua, which approved its country’s 2020 annual
general budget in December 2019. The budget allocated 16,022,872,579 cordobas
to health. This exceeded the 2019 budget of 14,051,812,191 cordobas, and
positioned health as a key budget priority.
• The Shura Council of Qatar, which allocated 11 per cent of total expenditure in
2020 to the health-care sector.
• The National Assembly of Thailand, which approved a 2021 budget allocation of
US$ 4,672,000,000 for UHC, representing 4.33 per cent of the total budget.
The UHC2030 synthesis report also noted that a number of governments had significantly
increased their budgets, particularly to ensure sufficient resources to manage the pandemic
response. These included:
• Ireland, which increased its 2020 and 2021 annual health budget by 12 per cent and
24 per cent respectively.
• Morocco, which allocated about a third of US$ 1.1 billion to a special COVID-19 fund.
This was a 19 per cent increase in the 2020 annual health budget. The 2021 national
health budget is projected to increase by 11 per cent, with the specific objectives of
advancing equitable access to health services, and extending compulsory health
insurance to an additional 22 million people by the end of 2022.
All of the above examples illustrate a commitment to ensuring adequate domestic health
resources, as required under clause 19. However, despite the ongoing COVID-19 pandemic,
it is important for parliaments to continue their budgetary oversight work so that sufficient
resources are also allocated to essential health services, including neglected and priority
issues such as NCDs and SRHR. Morocco’s additional budget allocation to extend
compulsory health insurance aligns with clause 22 on providing financial risk protection; and
at the same time, it is also an effective illustration of how the COVID-19 pandemic may be
used as an opportunity to accelerate the implementation of UHC.
On a different note, in July 2020, the Romanian Parliament adopted a law on the
organization and financing of health-promotion and disease-prevention services. The law
requires that the budget allocation for those services is to be no less than 3 per cent of total
health expenditure. This enables payments to be made for health promotion, in addition to
general health-care services paid for through the existing social health insurance system.
13
Health promotion and disease prevention are key elements of UHC strategy, which is
designed to reduce the risks of developing chronic diseases and other morbidities. Even
though these elements enable a more efficient use of health resources, they still continue to
be insufficiently prioritized over other services, such as treatment and diagnosis.
One webinar contributor outlined how a proposal for the accelerated introduction of
compulsory national health insurance had been supported by all political parties in the South
African Parliament. This example emphasized that UHC legislation should be well crafted so
that public resources are properly used and protected from corruption.
It is therefore relevant that the 2020 report of the Independent Accountability Panel for Every
Woman, Every Child, Every Adolescent (IAP) underlines the importance of both allocating
sufficient health resources and ensuring good governance and accountability over health
expenditure. The IAP notes that, over the past 10 years, inefficiencies and corruption have
led to an estimated 20–40 per cent of global health expenditure being wasted. Without
proper administration and appropriately targeted investments, countries can record divergent
health outcomes, even if their per capita health expenditure is similar.21
These findings highlight that, while it is important to make adequate allocations to the health
budget, parliaments need to play an equally crucial role in promoting budget transparency
and accountability through legislation and oversight.
3. Inter-parliamentary and international engagement towards national accountability
and capacity
Clause 32, IPU resolution on UHC (2019)
Requests parliaments to facilitate and support the learning and sharing of UHC
experiences, best practices, challenges and lessons learned across IPU Member
Parliaments and their parliamentarians
Clause 33
Also requests the agencies of the United Nations system, in particular WHO, to provide
countries with coordinated, multifaceted support aimed at achieving UHC, to collaborate in
monitoring the achievement of UHC, considering WHO’s mandate to evaluate health
indicators, and to boost the capacity of parliaments and parliamentarians to develop
and monitor national UHC policies through the establishment of strong, learning health-
care systems
The principles of UHC are premised on a whole-of-government and whole-of-society
approach. They enjoin parliaments not only to engage constituencies, stakeholders, the
public and international agencies, but also to take part in inter-parliamentary exchanges to
enable capacity-building. In addition to the activities promoted by the IPU, there have been
various initiatives undertaken by regional parliamentary organizations. These have sought to
endorse UHC, improve the capacity of national parliaments and promote their accountability,
particularly in response to both the UN General Assembly Political Declaration and the IPU
resolution on UHC.
21
IAP, Caught in the COVID-19 storm: women’s, children’s, and adolescents’ health in the context of UHC and
the SDGs (2020): https://iapewec.org/reports/annual-reports/iap-2020-report/. pp. 32 and 37.
14
Examples of regional inter-parliamentary action on UHC:
1) In December 2019, the Asian Parliamentary Assembly adopted a detailed resolution,
Collaboration on Health Equity in Asia.22
2) In September 2020, the Asia-Pacific Parliamentarian Forum on Global Health convened
a virtual meeting entitled Investing in Universal Health Coverage for the Future. The
meeting objectives were: to obtain updated information from WHO on the COVID-19
situation in the Organization’s Western Pacific and South-East Asian regions; to share
experiences on the importance of investing in UHC for COVID-19, and share knowledge
about parliamentary action to secure national investments in health; and to consider how
the Forum could support investments in UHC, including health security response and
preparedness.
3) The European Parliament has undertaken a number of activities that may contribute to or
support national parliamentary action and capacity on UHC, including:
a. Adopting a resolution in April 2020 on EU-coordinated action to combat the
COVID-19 pandemic. It called on Member States and the EU institutions to
monitor and uphold access to SRHR, including emergency contraception and
access to abortion care. It also strongly rejected any attempts by Member States
to backtrack on SRHR and LGBTI rights.23
b. Adopting a resolution in July 2020 that called for a European health response
mechanism, which would respond to all types of health crisis through better
coordination and management of the strategic reserve of medicines and medical
equipment.
c. Adopting a resolution in November 2020 on the EU4Health programme. The
objective was to establish a dedicated funding programme for 2021–2027
designed to build resilient health systems in the EU.
d. Awareness-raising and education initiatives, including the publication of the
Cervical Cancer Prevention Policy Atlas 202024
and the Contraception Policy
Atlas Europe 2020.25
4) At the IPU webinar, EALA reported that it had developed an impact assessment tool,
which examines the preparedness of individual partner States and the management and
mitigation of the COVID-19 pandemic. EALA also indicated that, by December 2020, it
would produce a report with recommendations to partner States on strengthening their
health systems, increasing budget allocations for health to a minimum of 15 per cent of
the overall annual budget, and ensuring the engagement of relevant stakeholders.
5) The Parliamentary Forum of the Southern African Development Community has
undertaken a number of activities that may contribute to or support national
parliamentary action on UHC, including:
a. Adopting a resolution on UHC at its 46th and 47th Plenary Assembly Sessions
(December 201926
and October 2020 respectively).
22
Asian Parliamentary Assembly (2019):
www.asianparliament.org/uploads/Documents/Resolutions/2019/1-Social%20and%20Cultural/3-
Resolution%20on%20Collaboration%20on%20Health%20Equity%20in%20Asia.docx.
23
European Parliamentary Forum for Sexual and Reproductive Rights, “European Parliament calls on Member
States to guarantee safe and timely access to SRHR”, (April 2020): www.epfweb.org/node/530.
24
European Parliamentary Forum for Sexual and Reproductive Rights, Cervical Cancer Prevention Policy Atlas
2020 (January 2020): www.epfweb.org/node/553.
25
European Parliamentary Forum for Sexual and Reproductive Rights, European Contraception Policy Atlas
2020 (October 2020): www.epfweb.org/node/669.
26
Parliamentary Forum of the Southern African Development Community, press release (December 2019):
www.sadcpf.org/index.php/en/media-release/press-release/148-universal-health-coverage-tops-as-sadc-pf-
plenary-meets.
15
b. Issuing Guidelines for SADC National Parliaments to Address the COVID-19
Outbreak.27
The guidelines advise that:
i. The objective to attain Universal Health Coverage (UHC) and fulfil
Sustainable Development Goal 3 relating to health and well-being for all
should remain overarching guiding principles to inform policy and
legislative responses across SADC.
ii. Whilst priority should be given to mobilise resources to address the
COVID-19 outbreak, access to other equally essential health-care
services should not be mitigated.
c. A concept note was circulated with the outline of an SADC model law on public
finance management. The model law will be published in 2021 and will include
provisions to ensure that international commitments, such as the SDGs, UHC or
gender-based budgeting, are mainstreamed into national budgets by ministries
and public departments.28
6) In 2019, the African Union adopted the Treaty for the Establishment of the African
Medicines Agency. The Agency is designed to provide a harmonized and strengthened
regulatory system for medicines and medical products, with an emphasis on access to
safe, effective, good-quality and affordable essential medicines and health technologies
on the African continent.29
The treaty is not yet in force, as it requires ratification (i.e. not
merely signature) by a minimum of 15 African Union Member States. This process
requires parliamentary approval and the transposition of the treaty into domestic law.
The pace of ratification has been slower due to the COVID-19 pandemic, and five
countries have ratified thus far: Burkina Faso, Ghana, Mali, Rwanda and Seychelles.
4. Conclusion
“There is no blueprint or secret recipe for managing COVID-19. Learning and adapting holds
the key to effective and successful prevention and control of the pandemic. Every country
must learn from its experience. Every country must adapt and correct its response in real time
based on complex and evolving conditions.”
Ms. Pechdau Tohmeena, Member of Parliament, Thailand; member of the IPU
Advisory Group on Health
The contributions of IPU Members, the UHC webinar, and desk research on parliamentary
activities all make clear that most parliaments remain committed to the realization of UHC.
Despite the constraints, some countries have been able to use the pandemic as an
opportunity to accelerate UHC, as demonstrated by various examples in this summary.
However, many challenges remain, including for countries with well-developed UHC
systems.
Noting the suddenness with which the world was plunged into a global pandemic and the
constraints this imposed, it was to be expected that parliamentary momentum on UHC would
decrease (particularly on UHC legislation). Nevertheless, action programmes designed to
achieve UHC by 2030 are still needed.
27
Parliamentary Forum of the Southern African Development Community, press release (April 2020):
www.sadcpf.org/index.php/en/media-release/press-release/161-sadc-pf-guidelines-for-sadc-national-parliaments-
to-address-the-covid-19-outbreak.
28
Parliamentary Forum of the Southern African Development Community, concept note:
https://new.sadcpf.org/index.php/en/secretariat/procurement/262-concept-note-for-a-sadc-model-law-on-public-
financial-management-by-the-sadc-parliamentary-forum.
29
African Union, Treaty for the Establishment of the African Medicines Agency: https://au.int/en/treaties/treaty-
establishment-african-medicines-agency.
16
There is no one-size-fits-all approach to UHC. This is evidenced by factors including:
variability of resources; social, economic and geographic factors; differences in governance
and constitutional systems; and ensuring that UHC models are responsive to the specific
needs of different population groups. Inter-parliamentary exchanges are a vital part of the
process to impart lessons and provide support.
The IPU will continue to promote the implementation of the UHC resolution in collaboration
with its partners, and with an emphasis on the right to health for vulnerable and marginalized
groups. As the focal point for accountability on the UHC resolution, the IPU Advisory Group
on Health will continue assessing national experiences to facilitate exchanges and provide
recommendations on UHC best practices. The IPU will also develop specific tools to support
and promote the capacity of national parliaments. Upcoming examples include a partnership
with WHO to develop handbooks on UHC and global health security, and a workstream on
health taxes. The IPU has also joined the Legal Solutions Network, an initiative to support
governments and policymakers in developing legal tools for UHC. Other Network members
include the United Nations Development Programme, UNAIDS, WHO and the Georgetown
University O’Neill Institute.
Owing to the constraints of the current period, it was not possible to undertake as
comprehensive a review of parliamentary action on the UHC resolution as would have been
desirable. Nevertheless, the information gathered has provided useful insights and lessons.
It has also helped to identify interesting UHC initiatives and programmes for follow-up and
further reporting in 2021. These include:
• Updates from countries with draft UHC legislation that had not been finalized by the
end of 2020. Examples include Canada and El Salvador.
• Countries that enacted legislation before the IPU resolution, and so could not be
included in this summary. Parliamentary action on implementation and oversight may
be submitted for the 2021 summary, or to other processes under the accountability
framework.
• Parliamentary action on other clauses of the UHC resolution that have not been
covered in this summary.
• Parliamentary action on UHC for marginalized, vulnerable and key population
groups, with an emphasis on the principles of health equity.
• UHC health indicators generally, and specifically in relation to SRHR, and women’s,
children’s and adolescents’ health.
• Analysis of UHC setbacks associated with the pandemic, and parliamentary
programmes to reverse them.