Eduardo Missoni (Bild: Christoph Engeli)
More than thirty years ago the World Health Assembly established the goal of
“Health for All by the year 2000” and with the Alma Ata Declaration (1978),
Primary Health care was identified as the strategy to reach that objective.
The attention was soon diverted from that ambitious goal and for the following
three decades resources and energies were devoted to the selective control of
diseases, rather than to comprehensive health promotion and care.
The HIV/AIDS pandemic added unprecedented challenges to the health and social
systems that two decades of macroeconomic neo-liberal reforms and structural
adjustment programs had dismantled. UN and the multilateral system came under
attack and the collaboration with the private sector became the panacea to any
problem. Several Global Public-Private Partnerships (GPPPs) were established,
and centrally steered global initiatives were launched to face few selected
health problems through out-put oriented, quick-fix, technological solutions.
Health system as part of the social determinants
Global Health Initiatives surely contributed to a considerable increase of
funding for health, however heavily earmarked (mainly to fight HIV/Aids), and
facilitated access to specific drugs, vaccines and devices (such as bednets
for malaria prevention). Nevertheless, their managerial approach further fragmented
and debilitated national and local institutions. They increased the administrative
burden both at global and at country levels without significantly attracting
resources from the private sector, whose voice and vote was now granted in the
GPPPs boards though.
Health is the result of deeply rooted social determinants that need to be taken
into consideration if this fundamental human right is to be granted. The Health
system is but one of those determinants, whose characteristics (such as equity
in financing and access) reflect the fairness of the society in which they are
embedded.
In 2008, the WHO Commission on Social Determinants of Health (CSDH) recognised
that access to health services is vital to good and equitable health. It called
for healthcare systems to be based on principles of equity, disease prevention
and health promotion with universal coverage through focusing on primary health
care, regardless of ability to pay. That same year the World Health Report insisted
on universal coverage and people-centred health systems. In 2009 “The goal of
universal access to health services, especially through primary health care”
was included in the G8 final communiqué. Thirty years after Alma Ata, a systemic
approach to health rather than a “vertical” action on disease control, was back
on the global agenda with universal coverage being increasingly recognised as
a political goal related to fundamental rights and a unifying theme and purpose
for health systems strengthening. Universal coverage will also be the focus
of the upcoming World Health Report 2010.
Economic and cultural norms
Moving towards universal coverage, means dealing with inequalities by establishing
sufficient supply of service networks, where financial and other barriers to
access are removed, and where families are protected against the financial consequences
and impoverishment that may occur from seeking care.
Health systems and organisations are dynamic, complex and context-specific,
and they are not simply the sum of their individual components, thus no “global”
approach to strengthening health systems for universal coverage can work. The
specific nature of service delivery models and financing schemes will vary depending
on nations' economic and cultural norms, but universalism requires the widest
possible base for pooling of resources and substantial equity in their collection
and redistribution through services.
The identification and targeting of health priorities at national and local
levels is part of the strategic and managerial function of any national system.
It is not a question of whether “vertical” and “horizontal” initiatives can
be mutually reinforcing, as stated by those who try reconciliation among the
two schools of thought, nor to introduce a “diagonal” approach. Just as health
reforms under structural adjustment plans, the “vertical” approach responded
to global and donors steered initiatives, not to local needs and interests.
This needs to be reversed.
Universal Health Coverage (UHC) can only be achieved through a sound sector
strategy embedded in a broad national strategy and linked to financing through
a medium-term expenditure framework and a regularly reviewed annual budget.
To ensure UHC substantial inflows of external resources will be essential, but
it is critical that these inflows are channelled, monitored and used in a way
that strengthens national financing capacity and institutions. The use of beneficiaries’
country systems is the main principle for more effective international aid.
The Bellagio Statement (2009) , endorsed by several scientists, emphasises:
“to be effective in attaining UHC, the overall global agenda and action in all
sectors, including financial and economic policies, should be consistent with
and supportive of that goal”.
Eduardo Missoni is coordinator of theGlobal Health and Development Group,
Center for Research on Health and Social Care Management - CERGAS, Bocconi University,
Milano, Italy. Contact: eduardo.missoni@unibocconi.it
Ressources
- Missoni E. (editor) “Attaining universal health coverage. A research initiative
to support evidence-based advocacy and policy-making”, Egea, Milano, 2010
- Attaining Universal Health Coverage. A research initiative to support evidence
based advocacy and policy making. Bellagio Statement. 10th and 11th November
2009, Bellagio, Italy (http://www.g7.utoronto.ca/conferences/2010/ghdp/bellagio.pdf)
