How do we get UHC efforts back on track?
Recent years have seen solid progress towards achieving Universal Health Coverage (UHC), comprised of quality of care, service coverage and affordability. Strong gains have been particularly made in strengthening people’s access to a breadth of services. However, the COVID-19 pandemic disrupted progress in UHC across an estimated 92% of countries.
Around a quarter of the world’s population are now facing catastrophic health spending, resulting from rising poverty and shrinking incomes connected to the current global economic recession. Many countries – from low to high income - are facing debt crises, affecting their ability to finance public policies and services to meet the basic needs of their populations. The World Bank projects that government spending capacity in 18 low and middle income countries will lag below pre-COVID-19 levels through to 2027.
We have also clearly witnessed that viruses such as COVID-19 pose the greatest risk to people who were already in situations of greater vulnerability, such as those living in poverty, older people, people with disabilities, women and children, migrants and refugees. In a matter of months, entire regions that were making progress on eradicating poverty and narrowing inequality have been set back years. COVID-19 has brought home the importance of basic public health, strong health systems and emergency preparedness, as well as the resilience of populations in the face of a new virus or pandemic. All we have seen and learnt lends ever greater urgency to the quest for UHC.
The benefits to the economy of effective epidemic control have also been highlighted. Low financial barriers can stimulate demand for health services and facilitate early case detection, one of the foremost factors in dictating the course of an outbreak. High healthcare expenditures push people into poverty, further increasing their long-term risk of ill health, including of emerging infectious diseases. UHC protects people from financial catastrophe and countries against wider economic downturn. There is also an obvious societal benefit in creating a more equitable and just system of health whereby the poor do not bear a disproportionate burden of disease.
So, where from here? The link between UHC and improved global health security needs to be recognised and better understood in an era of emerging pathogens, globalisation and a need for (even more) rapid development of health system resilience. Strengthening health systems based on a primary health care orientation remains crucial given 90% of essential UHC interventions can be delivered through primary health care. UHC focused initiatives require measurement of availability, quality and distribution of public health services, a heightened emphasis on epidemiological surveillance which is linked across sectors (relating to both human and animal diseases, as well as antimicrobial resistance and food security for example), and research and development, so as to further integrate global health security and health system strengthening efforts.
We also need a sensitive focus on equity, with a gaze on the most vulnerable. Key health systems barriers to UHC progress need to be addressed. These include poor infrastructure, weaknesses in the design of policies to limit the harmful effects of out-of-pocket payments, shortages and inefficient distribution of qualified health workers, prohibitively expensive good quality medicines and medical products, ineffective means for measuring quality of care, and lack of access to digital health and innovative technologies.
Country-level analysis based on a multi-sectoral and ‘systems view’ is also needed. ‘Systems thinking’, which involves exploring the characteristics of components within a system (such as financing, task allocation, technology, or demand for services) and how they interconnect and evolve over time, can improve understanding of how outcomes emerge from various efforts. This approach can help better understand the journey towards and impact on the achievement of UHC.
To get UHC back on track, whilst also strengthening health security, we need to make health systems everybody’s business. Its prioritisation reflects a political choice, and yet a moral imperative. We all have a part to play to ensure we leave no-one behind.
Clare Strachan, Principal Advisor at the Nossal Institute for Global Health, recently led a session on UHC in the post Covid-19 context at the annual conference of the Australasian Society for Infectious Diseases (ASID).