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Analysis Universal Health Coverage

Rethinking assumptions about delivery of healthcare: implications for universal health coverage

BMJ 2018; 361 doi: (Published 21 May 2018) Cite this as: BMJ 2018;361:k1716

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Call for indicators on people participation in health promotion for universal health coverage (UHC)

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

22 October 2018
Francis Omaswa
Executive Director
African Center for Global Health and Social Transformation (ACHEST)
Kampala, Uganda, Africa