Rethinking assumptions about delivery of healthcare: implications for universal health coverageBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1716 (Published 21 May 2018) Cite this as: BMJ 2018;361:k1716
All rapid responses
There is currently no UHC indicator that explicitly monitors household and community participation and action for health. The demand side of UHC is critical for supporting health promotion, wellbeing and building societies that enable healthy lifestyles, and for influencing the habits of individuals and the behavior of institutions. It facilitates effective engagement of the people and the community in building strong, resilient and responsive health systems. This population ownership and engagement should not be optional because people have a duty and a right to influence their own health and health care.
We know that achieving health outcomes and designing effective health services delivery programs at country level are constantly faced with the challenge of getting the right balance between health promotion and disease prevention on the one hand and treatment of diseases on the other. At the World Health Summit (WHS) in Berlin (14 – 16 October, 2018) questions were still being asked whether UHC was about providing health care and not about ensuring the enjoyment of holistic health as defined in the constitutions of WHO and the Universal Declaration of Human Rights.
There were similar debates during the 71st World Health Assembly in May, 2018, on what the face of our effort on SDGs and UHC ought to look like. Will it be actions to promote healthy living so as to ensure that people do not lose their existing inborn health and that they delay the need for health care for as long as possible? Will it be health financing and health insurance for accessing services to treat illness and diseases? At the WHO Afro Regional Committee in August, 2018 statements by several Health Ministers suggested that enacting National Health Insurance schemes is all that they needed to do to achieve UHC.
This is a matter for concern particularly when Dr. Tedros the Director General of WHO frequently states that “all roads lead to UHC.” The “Global Action Plan for healthy lives and well-being for all” was launched by WHO and eight partner health institutions at the Berlin WHS where, among others, Dr Tedros stated that “health is made and sustained by families” in their homes and communities.
Surely the face of the effort to achieve SDGs and UHC will need to be the visibility and success on both. The WHO definition of UHC states: “Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. This language is balanced and addresses health promotion, disease prevention and treatment of illness and the need for financing. The framing of the UHC definition implies that a public health approach precedes the medical interventions. This is smartly captured in the language of SDG 3; stated as “Ensure healthy lives and promote wellbeing for all at all ages”. Monitoring and measurement of progress in SDGs and UHC is needed in order to guide, motivate and ensure action, results and accountability at all levels. There is currently one SDG Target and two indicators on UHC as follows:
Target 3.8 “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” There are two indicators to monitor this target as follows:
Indicator 3.8.1 “Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged population)”.
Indicator 3.8.2 is “Proportion of population with large household expenditures on health as a share of total household expenditure or income”. This indicator will measure the cost of treatment of illness and diseases.
The indicator 3.8.2 on household expenditure for access to services for treatment of diseases and other medical interventions including vaccinations for disease prevention is explicit and will monitor the financial implications of UHC to households. However, indicator 3.8.1 is not explicit in calling for specific monitoring and measurement of household and community behavior and actions that enable healthy people to remain healthy through their own participation. Such an indicator would respond to the call for “all people and communities can use the promotive, preventive services” in the definition of UHC.
The framers of these indicators have fallen into the usual trap in health system design; namely that the pressures to society and governments to pay more attention to repairing and restoring lost and broken individual and community health are stronger than those aimed to promote, sustain and protect existing health. The drama of providing urgent health care to restore damaged individual and community health is easily the more visible face of the health system and accordingly receives more attention and more resources than health promotion that focuses on important health needs that may not be immediately visible and do not demand immediate action. Getting the balance right is a challenge to all health systems and will be helped by having an explicit and specific UHC indicator that monitors and measures health action by households and communities.
We the undersigned are making a call for correction of this important omission of an explicit indicator on health promotion through community participation. SDG targets and indicators are regularly reviewed and the next review will take place in 2020. We therefore call for the inclusion of at least one explicit target and indicator on community participation in health promotion and wellbeing in the official UN SDG Indicator Classification. The process for this should be taken up urgently, and should be led by Member States, Civil Society and the WHO.
Francis Omaswa, Executive Director, African Center for Global Helath and Social Transformation.
Ilona Kickbusch, Director, Graduate Institute of International and Development Studies, Geneva, Switzerland.
Githinji Gitahi, Group CEO, Amref Health Africa, Nairobi, Kenya
Margaret Kaseje, Vice Rector Tropical Institute of Community Health and Development (TICH in Africa).
Suwit Wilbulpolprasert, Ministry of Health, Thailand
Yoswa M Dambisya, Director General, East Central and Southern African Health Community, Arusha, Tanzania
K. Srinath Reddy. President, Public Health Foundation, of India, Delhi, NCR
Gabriel Leung, Dean of Medicine, Helen and Francis Zimmern Professor in Population Health, Hong Kong University, Hong Kong
Nigel Crisp, House of Lords, London, UK
Jo Ivey Boufford, President, International Society on Urban Health, New York, USA
Paulo M Buss, Fundação Oswaldo Cruz Fio Cruz, Brasil,
Oyewale Tomori, President Nigeria Academy of Medicine, Abuja, Nigeria
Gorik Ooms, Professor of Global Health Law and Governance, London School of Hygiene and Tropical Medicine, London, UK
Marielle Bemelmans, Executive Director, Wemos, Netherlands
Competing interests: No competing interests
Das et al. in their article Rethinking assumptions about delivery of healthcare: implications for universal health coverage, highlight the dichotomy between “access oriented” Universal Health Care (UHC) and a system that is “truly effective”.(1) As primary care researchers in Canada, we would like to draw attention to the fact that such dichotomy may also be observed in high-income countries like Canada while an ‘access-quality’ synergy is needed. In Canada, the government has offered UHC since 1968.(2) However, Canada remains the only country to offer UHC without providing universal coverage of prescription drugs.(3) This absence of drug coverage is associated with unequal access to medically-necessary prescription drugs; on the other hand, inappropriate prescribing is present in Canada, and can lead to serious patient harm. The House of Commons’ Standing committee on Health released report in April 2018 calling for a publicly-funded universal drug coverage program, including the establishment of a national drug formulary and national data systems to monitor prescription drug use.(2)
The purpose of this rapid response is to advocate for a national universal drug coverage program across Canada, dubbed Pharmacare, which has the potential to improve the access to and quality of our health care system.
With respect to access to care, the current Canadian healthcare system is administered by the provinces and territories. In accordance with the Canada Health Act of 1984, all health services provided by hospitals and physicians are insured. (4) The insured services include only drugs administered in hospitals,(2) even though prescription drugs are a central component of the treatment provided by physicians outside of hospitals. The latter are covered to varying degrees across provinces through public and private drug plans.(2)
This lack of universal drug coverage renders Canadian citizens vulnerable to inequity in access to medication. Among 11 high income countries, Canada’s cost-related non-adherence to pharmaceuticals among older adults is second only to the United States.(5) Overall 10% of Canadians, and 17% of those with below-average income reported not using a medication as prescribed due to cost; the average of ten countries with universal public systems was 6%.(6, 7) Prescription drugs often constitute medically-necessary care which should be universally accessible to all Canadians, and as such need to be included as an insured health service in order to make our UHC truly comprehensive.
Regarding quality of care, we echo the idea put forth by Das et al., that “without quality, access may be irrelevant”(1). Inappropriate prescribing occurs when a drug is prescribed which leads to increased risk for an adverse event where an alternative, more effective or lower-risk treatment exists. (8) Inappropriate prescribing, including off-label use of drugs without evidence to support such use, is currently a problem in Canada and leads to significant patient harm: an estimated 300,000 Canadians suffer serious to fatal harm from inappropriate prescribing each year. (2, 9, 10) The development of a universal Pharmacare program provides opportunities to address issues that may be contributing to the problem of inappropriate prescribing through the establishment of an evidence-based Canadian drug formulary and national data systems to monitor prescription drug use, and their real-world safety. Currently, local drug regulators from each province and territory independently negotiate with the pharmaceutical industry to gain access to safety data for the development of local formularies, which vary across the country. (11) A national drug formulary would provide regulators with greater bargaining power to access all industry data and allow for evidence-based decisions about coverage of new drugs. The appropriate use of all approved drugs should then be monitored, and subjected to national post-marketing surveillance to continuously refine and improve the formulary.
In conclusion, as primary care researchers in Canada, we believe that a carefully implemented universal public drug insurance program, with a transparent process for establishing and maintaining a national drug formulary, and data systems to monitor drug use, can be an effective avenue to improving access to higher-quality care in Canada.
1. Das J, Woskie L, Rajbhandari R, Abbasi K, Jha A. Rethinking assumptions about delivery of healthcare: implications for universal health coverage. BMJ. 2018;361:k1716.
2. The Standing Committee on Health BCc. Pharmacare Now: Prescription Medicine Coverage for All Canadians. 42nd PARLIAMENT, 1st SESSION, 2018 April 2018. Report No.
3. Morgan SG, Daw JR. Canadian pharmacare: looking back, looking forward. Healthcare Policy. 2012;8(1):14.
4. Canada Health Act. 1984, c. 6, s. 1.
5. Morgan SG, Lee A. Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries. BMJ open. 2017;7(1):e014287.
6. Information CIfH. How Canada Compares: Results From The Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, ON: CIHI, 2017.
7. Morgan S, Gagnon M, Charbonneau M, Vadeboncoeur A. Evaluating the effects of Quebec's private-public drug insurance system. CMAJ: Canadian Medical Association journal= journal de l'Association medicale canadienne. 2017;189(40):E1259.
8. Gallagher P, Barry P, O'Mahony D. Inappropriate prescribing in the elderly. Journal of clinical pharmacy and therapeutics. 2007;32(2):113-21.
9. Pringsheim T, Gardner DM. Dispensed prescriptions for quetiapine and other second-generation antipsychotics in Canada from 2005 to 2012: a descriptive study. CMAJ open. 2014;2(4):E225.
10. Drug Use Among Seniors in Canada, 2016. Ottawa, ON: Canadian Institute for Health Information, 2018.
11. Lexchin J, Wiktorowicz M, Moscou K, Eggertson L. Provincial drug plan officials' views of the Canadian drug safety system. Journal of health politics, policy and law. 2013;38(3):545-71.
Competing interests: No competing interests