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This SP404 essay sample shows how a strong answer to the University of Galway global health reform question can be built: an argued introduction, three challenges, four strategies and a conclusion. It is an extract, not a full 2,000-word submission. You can read the original task on the SP404 essay question page, and our guide to writing the SP404 global health reform essay explains the planning behind it.

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Model answer extract

Introduction

Health systems are expected to meet people’s needs, yet they often fail the people who need them most. The World Health Organization (WHO) argued in 2008 that health systems were drifting away from the values of fairness, participation and universal access that primary health care was meant to protect (WHO, 2008). This essay argues that the main obstacles to reform are not technical. They lie in how care is financed, in the social conditions that make people ill before they reach a clinic, and in a global order that gives wealthy states and donors more say than the populations affected. It then argues that progressive reform is most likely where universal, publicly financed primary health care is backed by durable political commitment and local participation. The discussion moves from three challenges to four strategies, and ends with a judgement on what is realistic at global and local scales.

Challenge 1: financing, commodification and austerity

The first barrier is how health care is paid for. When people meet costs at the point of use, those who are poor delay treatment or fall into hardship. The WHO’s 2010 report on health financing described universal coverage as a system in which everyone can use needed services without financial hardship, and set out ways countries at different income levels can move towards it (WHO, 2010). The difficulty is that reform is rarely a clean break. Fiscal tightening, user charges and the growth of private provision commodify care, turning a social entitlement into a service sold according to ability to pay.

Commodification also fragments systems. Where insured, affluent groups buy private cover, their political stake in the public system weakens, and so does the pressure to fund it well. Austerity compounds this by squeezing the public budgets on which poorer households depend. A balanced reading acknowledges that private and mixed provision can add capacity where the state is weak. The critical point is that unregulated markets tend to allocate care by purchasing power, which runs against the aim of meeting need fairly.

Challenge 2: social determinants and inequality

The second barrier lies outside the health system. The Commission on Social Determinants of Health concluded that unequal daily living conditions, shaped by the distribution of power, money and resources, are the main cause of avoidable health inequities (Marmot et al., 2008). If so, hospital reform alone cannot close gaps in life expectancy. Housing, education, secure work and nutrition shape who becomes ill and how severely.

This creates a practical problem for reformers. Health ministries rarely control the sectors that matter most, and the benefits of action on, for example, early childhood or income support appear slowly, beyond electoral cycles. Reform therefore needs cross-government working, which is harder to achieve and easier to postpone than a new hospital. It also means that evidence of inequality, however strong, does not translate into action by itself. The question is who has the power to act on it.

Challenge 3: political economy and global governance

The third barrier is the structure of global governance. Labonté and Schrecker (2007) examined how globalisation affects the social determinants of health and argued that promoting health equity requires changes in the rules that govern trade, finance and development, not only in national health policy. Their analysis points to a mismatch: the institutions that set economic rules often have stronger enforcement powers than those responsible for health.

Donor priorities illustrate the problem. Funding tied to specific diseases can deliver measurable results, but it may also pull scarce staff and attention away from general services and leave recipient governments less able to set their own priorities. The risk is a patchwork of vertical programmes where a coherent system is needed. Here the argument should stay cautious. Targeted programmes have saved lives, so the issue is how they are designed and whether they strengthen or bypass national systems.

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Strategy 1: universal health coverage and primary health care

The most credible response to the financing problem is a renewed commitment to primary health care within a system aiming at universal coverage. The WHO’s 2008 report argued for reforms that put people’s needs at the centre, with universal coverage, people-centred services and healthy public policies (WHO, 2008). The 2018 Declaration of Astana renewed this commitment and presented primary health care as foundational to universal health coverage and the health-related Sustainable Development Goals (WHO, 2018).

The strength of this strategy is that it addresses access and prevention together. Its weakness is that declarations are cheap. Coverage on paper means little if services are under-resourced or unaffordable in practice, so progress should be judged by whether people can actually use care without hardship.

Strategy 2: universalism versus targeting

A recurring design choice is whether to direct benefits to the poorest or to extend them to everyone. Targeting looks efficient, but it depends on accurate identification of the poor, can stigmatise recipients and tends to attract less political support, which leaves programmes vulnerable when budgets tighten. Universal schemes, by contrast, build a broad coalition of beneficiaries who defend them. The trade-off is cost and time: universal entitlement is expensive to start and may initially favour those who find it easiest to use services. A defensible position is progressive universalism, in which entitlement is universal but additional effort and resources go first to disadvantaged groups. This sits closer to the equity aims of the WHO financing report than a purely means-tested approach does (WHO, 2010).

Strategy 3: community participation and the Kerala lesson

Local experience shows what reform can look like at sub-national scale. A qualitative study of Kerala’s response to the early phase of COVID-19 identified social capital, a robust public health system, participation and volunteerism, and health system preparedness as themes that supported the response (Prajitha et al., 2021). The study draws on interviews and focus groups with 29 participants, so it offers insight into how and why, not a measure of effect, and its authors call for further research on how these factors interact.

The lesson for reform is that decentralised institutions and community involvement can make a public system more responsive, and that such capacity is built over time rather than improvised in an emergency. Critically, Kerala’s context cannot simply be copied. Its history and institutions are specific, and the study does not claim that these themes would work identically elsewhere.

Strategy 4: tax-based financing and global governance reform

At national level, pooled and prepaid financing, whether through general taxation or mandatory contributions, spreads risk across the population and reduces reliance on out-of-pocket payment (WHO, 2010). Tax-based funding is especially fair when the tax system is itself progressive, but low-income countries may struggle to raise sufficient revenue, which is where international support matters.

At global level, Labonté and Schrecker (2007) argue for governance that gives health equity more weight in trade, finance and development decisions. This is the hardest strategy politically, since it requires powerful states to accept constraints. Progress is therefore more likely to come from coalitions that combine national reformers, civil society and sympathetic international actors than from a single global settlement.

Conclusion

Reforming global health systems is difficult because financing models, social inequality and global power relations reinforce one another. No single strategy addresses all three. The strongest case is for publicly financed, universal primary health care, combined with action on the social determinants identified by the Commission on Social Determinants of Health (Marmot et al., 2008) and supported by local participation of the kind documented in Kerala. At global scale, change is slower and depends on political will. Progressive reform is most likely where design choices build lasting public support, and where ambition is matched with honest attention to who pays and who decides.

About the expert

Finn Barry holds an Online MSc in Health Systems from University College Cork. The profile lists health policy, health systems and health economics as subject focus, and describes work on essays, dissertations and coursework following each university’s guidelines.

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References

• Labonté, R. and Schrecker, T. (2007) ‘Globalization and social determinants of health: promoting health equity in global governance (part 3 of 3)’, Globalization and Health, 3, article 7.
• Marmot, M., Friel, S., Bell, R., Houweling, T.A.J. and Taylor, S. (2008) ‘Closing the gap in a generation: health equity through action on the social determinants of health’, The Lancet, 372(9650), pp. 1661–1669.
• Prajitha, K.C. et al. (2021) ‘Strategies and challenges in Kerala’s response to the initial phase of COVID-19 pandemic: a qualitative descriptive study’, BMJ Open, 11(7), e051410.
• World Health Organization (2008) The world health report 2008: primary health care – now more than ever. Geneva: WHO. Available at: https://iris.who.int/handle/10665/43949
• World Health Organization (2010) The world health report 2010: health systems financing – the path to universal coverage. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789241564021
• World Health Organization (2018) Declaration of Astana: Global Conference on Primary Health Care, Astana, Kazakhstan. Available at: https://www.who.int/teams/primary-health-care/conference/declaration