Advancing towards Universal Health Coverage and reaching global health targets will require significantly higher health spending per capita in low and middle-income countries. Photo: © B. MATHIVET
“Leaving no one behind” is a central principle in the Sustainable Development Agenda (Equality and non-discrimination at the heart of sustainable development: a shared UN framework for action. Report of the High-Level Committee on Programmes (HLCP) at its thirty-second session. United Nations, New York, 2016). Going beyond national averages, health inequalities can exist between subpopulations based on income, education, sex, age, rural-urban, ethnicity and other characteristics. For instance and as reported in the World Health Statistics report 2016 (World health statistics 2016: monitoring health for the SDGs, sustainable development goals. World Health Organization: Geneva, 2016), data from high-income countries show that in almost all countries, higher premature death rates and poorer self-assessments of health are observed in groups of lower socioeconomic status compared with those who are better off (Mackenbach JP, Stirbu I, Roskam AR, Schaap MM, Menvielle G, Leinsalu M et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–81) (Zack MM. Health-related quality of life – United States, 2006 and 2010. MMWR Suppl. 2013;62(3):105–11). In half of the 66 national surveys conducted in low and middle-income countries, stunting prevalence in children aged less than 5 years was at least 15% higher in the children of mothers with no education compared with those children whose mothers had attended secondary school or higher (WHO and International Center for Equity in Health/Pelotas. State of inequality. Reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015). When health inequalities are considered unjust and avoidable/remediable, they are called “health inequities”. Tackling health inequities is one of the most critical challenges facing policymakers, development partners and practitioners in the health sector and beyond in the countdown to 2030.
Universal Health Coverage: Sustainable Development and Equity
Universal Health Coverage (UHC) is the overarching goal for the health sector to strive towards under the 2030 SDGs. This includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. UHC is not an end in itself: the aim is to improve the chances of every person attaining the highest level of health and well-being and contributing to socioeconomic and sustainable development. Advancing towards UHC is thus essential to every nation’s economic productivity, health security, social stability – as well as to every individual’s well-being, security, and productivity (Together on the road to universal health coverage: a call to action. Geneva: World Health Organization; 2017 (WHO/HIS/HGF/17.1).
Investing to reach the SDGs – what is required and what will it cost?
WHO has estimated the costs of expanding services towards universal health coverage and the other SDG health targets. The Health SDG price tag, published in Lancet Global Health in July 2017, estimated the costs and benefits of progressively expending health services in order to reach 16 Sustainable Development Goal (SDG) health targets in 67 low- and middle-income countries that account for 75% of the world’s population (Stenberg et al. Financing transformative health systems towards achievement of the health SDGs: a model for projected needs in 67 low and middle income countries. Lancet Global Health. volume 5, no. 9, e875-887, September 2017). The purpose was to examine the type of investments that would be required on the ground, and the financial implications. The study indicates that 97 million deaths could be averted, and life expectancy could increase as much as 8.4 years in low-income countries. The analysis was modelled on a country by country basis, using available data, and explicitly considered many investments that would favour equity and ensure that specific population groups are not left behind:
Health system investments in primary health care for equitable outcomes
The WHO analysis modelled investments in a primary health care approach that considers the need for higher density of health infrastructure and health workforce in rural and underserved areas, as well as extended community and outreach strategies that can be rapidly scaled up to ensure that the poor and vulnerable are not left behind – providing lifesaving services such as insecticide treated bed nets for malaria, and child vaccines.
Settings with conflict such as northern Nigeria makes it challenging for health sector partners to access people who are most in need of basic health services. Photo: © WHO/ S.Zimble.
Health care interventions targeting specific population groups
The WHO analysis includes interventions which may be considered particularly “pro-poor”, such as clean household fuel, water and sanitation, and prevention and treatment of neglected tropical diseases. The modelled expansion of access to modern contraceptives for family planning would have a favourable impact on gender equality, women’s access to resources and overall poverty reduction (Singh S, Darroch JE, Ashford LS. Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014. New York: Guttmacher Institute, 2014). Moreover, targeted services were modelled to special populations including people injecting drugs, transgender populations and prisoners.
Governance and financing strategies to address inequities and social determinants
While provision of services addresses the supply side, the WHO SDG price tag model also includes cash transfers targeted at poor populations, to stimulate health care seeking. The model also considered a gradual expansion of public health insurance schemes over time, to reduce out of pocket payments. Additional investments will be needed to improve governance and ensure that marginalised populations will have access to care.
An "ambitious" scenario towards achieving the SDG health targets in the 67 countries would require an additional US$ 134 billion in the initial years increasing to an annual amount of $371 billion, or $58 extra per person, as countries approach the 2030 target. The medical interventions, and the equity-enhancing investment strategies, are estimated to be affordable in many countries. However, as many as 32 of the world’s poorest countries are predicted to face an annual gap of up to US$ 54 billion and will continue to need external assistance (Stenberg et al. Financing transformative health systems towards achievement of the health SDGs: a model for projected needs in 67 low and middle income countries. Lancet Global Health. volume 5, no. 9, e875-887, September 2017).
Progressive realization of UHC and the right to health – an issue of prioritization
In UHC reforms that are underpinned by the principles of progressive universalism and realization of the right to health, authorities face the challenges of expanding priority services, including more people, and reducing out-of-pocket payments in ways that benefit the more disadvantaged subpopulations at least as much as their more advantaged counterparts. Hence, the question of prioritization becomes central in governance processes. In each of these dimensions, national and subnational authorities are faced with a critical choice: which services to expand first, whom to include first, and how to shift from out-of-pocket payments toward prepayment in ways that account for equity in financing. A commitment to fairness – and the overlapping concern for equity and gender-responsiveness – and to respecting individuals’ rights to health care must guide this decision-making. The following three-part strategy can be useful for seeking fair progressive realization of universal health coverage (Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. World Health Organization: Geneva, 2014):
- Categorize services into priority classes. In relation to the burden of disease and with due attention to differences between men and women, relevant criteria include those related to cost-effectiveness, priority to the worse off, and financial risk protection.
- First expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds.
- While doing so, ensure that disadvantaged groups are not left behind. This entails adapting models of care to be responsive to heterogeneity among subpopulations, taking into account inequities linked to barriers and greater/different health needs, and ensuring adequate governance and accountability.
A child working on the streets of Manila. Photo: © UNICEF/G. Pirozzi
Looking forward: operationalising commitment at country level
Tackling health inequities requires a fundamental shift in the way health systems work (in terms of overcoming supply-side bottlenecks and demand-side barriers) and intersectoral action on the social and environmental determinants of health. A key challenge is moving from isolated and siloed interventions to address specific barriers. Within health systems, it requires synergistic system-wide adjustments, with equity-oriented approaches to service delivery, human resources for health, governance, financing, health information systems, and essential medicines and technologies. One way to facilitate this is by ensuring a strong coherent focus on leaving no one behind in National Health Policies, Strategies and Plans (NHPSP), many of which will be renewed in the coming years and set the health sector agenda, while also influencing budgeting decisions.
As countries expand service provision and eliminate out of pocket payments while increasing progressive prepayment into health services, strong health information systems need to be in place to monitor the impact. Scaling up the capacity of health information systems to conduct health inequality monitoring will be important to ensure that no one is left behind, and to guide choices regarding equity-oriented prioritization and investments. Different WHO resources (see box) can be useful for this.
Resources to strengthen national health inequality monitoring
The WHO Handbook on health inequality monitoring: with a special focus on low-and middle-income countries is a resource designed to support the development and strengthening of health inequality monitoring systems at national level. The handbook has an accompanying eLearning module.• The handbook is available at: www.who.int/gho/health_equity/handbook/en/
The WHO Health Equity Assessment Toolkit (HEAT) was developed as an online tool for health inequality analysis. HEAT enables users to perform health inequality summary measure calculations using an existing database of disaggregated data, and to create customized visuals based on disaggregated data or summary measures.• HEAT can be accessed at: http://www.who.int/gho/health_equity/assessment_ toolkit/en/
Accessmod is a toolbox that allows countries to examine the geographic accessibility to health services, and how timely access might differ between geographic regions and types of services. For more information see http://who.int/choice/geoaccess/en/
References
- Equality and non-discrimination at the heart of sustainable development: a shared UN framework for action. Report of the High-Level Committee on Programmes (HLCP) at its thirty-second session. United Nations, New York, 2016 http://www.unsystem.org/content/equality-and-non-discrimination-heart-sustainable-development-shared-un-framework-action
- World health statistics 2016: monitoring health for the SDGs, sustainable development goals. World Health Organization: Geneva, 2016. http://www.who.int/gho/publications/world_health_statistics/2016/en/
- Mackenbach JP, Stirbu I, Roskam AR, Schaap MM, Menvielle G, Leinsalu M et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–81. https://www.ncbi.nlm.nih.gov/pubmed/18525043
- Zack MM. Health-related quality of life – United States, 2006 and 2010. MMWR Suppl. 2013;62(3):105–11 http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a18.htm
- WHO and International Center for Equity in Health/Pelotas. State of inequality. Reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015. http://apps.who.int/iris/bitstream/10665/164590/1/9789241564908_eng.pdf
- Together on the road to universal health coverage: a call to action. Geneva: World Health Organization; 2017 (WHO/HIS/HGF/17.1). http://apps.who.int/iris/handle/10665/258962
- Stenberg et al. Financing transformative health systems towards achievement of the health SDGs: a model for projected needs in 67 low and middle income countries. Lancet Global Health. volume 5, no. 9, e875-887, September 2017. http://dx.doi.org/10.1016/S2214-109X(17)30263-2
- Singh S, Darroch JE, Ashford LS. Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014. New York: Guttmacher Institute, 2014 https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-2017
- Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. World Health Organization: Geneva, 2014. http://apps.who.int/iris/bitstream/10665/112671/1/9789241507158_eng.pdf?ua=1
