25 January 2017

Universal Health Coverage

Adopted by leaders in government and civil society, these ideas lie at the heart of a growing political movement to make health outcomes more equitable and health systems more resilient.  This movement is integral to the 2030 Agenda for Sustainable Development, given that people’s ability to achieve good health without sustaining massive financial losses is key to their being able to avoid poverty.  It is also critical for women to be healthy and to thrive while controlling their fertility and enjoying good sexual and reproductive health.  Although the principles of UHC are increasingly being pursued within nations, they are hard to put into practice because of emphasis on equity of access.  There are many hurdles to be tackled in relation to equity of access too.  These relate to locality, scope of services, quality, cost and supervision.   The application of UHC principles to the realities of ministers responsible for health systems is at the core of the WHO’s technical work at local and national level.  The agenda for this work includes health financing and human resources for health, as well as accessibility of medicines and health care technologies. 

UHC - Equity, Resilience and the Right to Health

Universal Health Coverage underpins the idea that health is a right for all and not a privilege for the few. But many countries are finding that universality of access and financial protection can be a tough challenge, particularly where citizenship rights are contested or where large migrant populations are involved.  Quite frequently there is a different standard of care for indigenous people and immigrants, or access to and costs of services may not be the same.  Health leaders also recognize the risks that occur when significant groups of people or parts of a country are excluded from health care. Not only does a fundamental right remain unfulfilled, but it is also increasingly evident that the capacity to detect and respond to outbreaks depends on a health care system that reaches everyone.

UHC – Sustainable Development Goals (SDGs) and the Determinants of Health

While UHC is a key strategy within the health sector, the achievement of several SDG health targets will be more dependent on decisions and policies in other sectors. For example, in relation to NCD risk factors, nutrition, access to pharmaceuticals and road safety.  Equally, policies in areas such as rural roads, social protection and pensions and urban planning will influence peoples’ access to health care. The central position of UHC as part of the SDG agenda emphasises the importance of these linkages.

UHC - Elements of the Technical Agenda

The road that any country takes towards UHC depends on its own history and circumstances. Nevertheless, the principles of UHC provide a robust guide when it comes to key technical and policy issues.  Protecting people from catastrophic or impoverishing expenditures when they fall ill, for instance, requires that risks be pooled (so that the healthy help to subsidise the costs of those falling ill). Whether pooling is achieved through social insurance, taxation or a mixture of the two does not matter. On the other hand, contribution does need to be mandatory if it is to achieve universal financial protection.  

Access to medicines, vaccines and other health technologies is important in its own right as an aspect of access to services – but in many countries the cost of medicines, paid for out of pocket, is also a major driver of poverty. Affordable access to safe and effective medicines is therefore a significant contributor to the financial protection aspect of UHC.  

UHC - Global Policies, National Implementation

The focus of UHC is national. Nevertheless, global and regional policies have a major influence on the cost and thus the availability of medicines. Similarly, the availability of health workers is strongly influenced by the movements of people between and within countries, in turn influenced by a range of other global, social and economic factors. The WHO’s work on Universal Health Coverage therefore needs to link the local with the global, using evidence from countries to influence global policies.

Approaches

UHC affects all aspects of the WHO’s work – it is not merely the exclusive preserve of a single programme or region. I would expect WHO to contribute towards:

  • Standard-setting to aid  strategy development and design of service provision;
  • Technical expertise and capabilities to support the development of capacities among key personnel within Member States (often doing this in conjunction with partners);
  • Policy-development and diplomatic expertise to build trusting relationships within countries and to offer to coordinate multiple actors as they (a) align efforts in pursuit of agreed strategies and outcomes, (b) agree on what contributions they will make to outcomes, and which resources they will make available; (c) agree on procedures for implementation and management, and (d) decide on reporting protocols; and
  • Support for research and innovation, including the use of Information Technology and the development of new products and systems, to aid priority setting, monitoring, effectiveness and efficiency.

At country level, WHO should be a catalyst – working with governments and other partners. Many request the help of WHO to establish standards using transparent processes, to enable them to obtain evidence-based technical support, to encourage sharing of experience, to foster partnering and to monitor progress.

Challenges

In recent months, I have become increasingly aware of the complex challenges being faced by Ministers of Health everywhere.  I have seen the different ways in which they are being explored and have appreciated the important role of WHO and multilateral organizations in helping those who seek to resolve them.  To finish this reflection I set out 10 such challenges, none of them easy to resolve, but that I aim to work on with ministers and heads of state as WHO Director-General:

  • First: Exploring how public and private service provision can be blended together in ways that ensure accessible care for all, that are adapted to the national context, reflect the needs and circumstances of people needing care, and take account of current and potential options for service provision.
  • Second: Deciding how best to allocate the scarce human and financial resources available to governments between many competing priorities.
  • Third: Identifying ways to engage both health system professionals and patient groups in decision making – in ways that are transparent in their inclusion of all concerned parties.
  • Fourth: Establishing fair means for financing health systems in ways that share risk and generate adequate resources without undermining access for those most in need.
  • Fifth: Ensuring that talented staff can be trained and retained, and then enabled to provide services in ways that are both responsive and effective.
  • Sixth: Ensuring transparency about decisions and accountability for results so that people who are using health services can be informed about the effectiveness of care, the performance of services and the choices that are being made with regard to priorities.
  • Seventh: Maintaining openness on issues related to the price paid for medicines and services, so that those who deliver services as well as those who use them can appreciate what the costs are and appreciate the kinds of trade-offs necessary when choices are made about resource allocation. 
  • Eighth: Commissioning research and encouraging innovation so as to establish more efficient health system functioning and to overcome blockages and difficulties that have affected health care in ‘advanced’ settings.
  • Ninth: Ensuring that the critical health system functions which benefit populations (public health) receive the attention they deserve even though there are many pressures to prioritize spending on services that are needed by individuals with specific (and often life-threatening) challenges.
  • Ten: Constantly checking and, as necessary, upgrading administrative processes across all aspects of health systems so as to maximize effectiveness and efficiency.  

Conclusions

There are no simple answers to any of the challenges faced by those responsible for UHC, but there is an important role for WHO in providing (a) venues in which they can be addressed and (b) in assisting the sharing of (and comparisons of) the various approaches being used in different local and national settings.   Such work will continue to be needed at all levels of the organization.   I will seek to nurture it and ensure that it is of highest quality.