In its newest estimates, published this week, the World Health Organization has predicted that low- and middle-income countries will require an additional $134 billion per year between now and 2025 to reach health-related targets under the Sustainable Development Goals, leading to universal health coverage.
Universal health coverage has been one of the most prominent goals under the 2030 sustainable development framework, catapulting even the world’s most influential leaders to reference it during their recent high-level meeting in Hamburg.
“We recall universal health coverage is a goal adopted in the 2030 [Sustainable Development] Agenda and recognize that strong health systems are important to effectively address health crises,” noted the G-20 communique. “We call on the U.N. to keep global health high on the political agenda and we strive for cooperative action to strengthen health systems worldwide, including through developing the health workforce.”
To be sure, civil society played a huge part in its inclusion — and given the chance, they would have preferred stronger wording in the document. Yet the fact remains: UHC is going to be a mainstay in the global health discussions through 2030.
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But what it will take to reach UHC depends on a number of factors. This includes generating significant resources to build the necessary infrastructure — such as hospitals and clinics — the tools and diagnostics for proper health assessment and treatment, increase the number of health workers, and more.
Placing a figure on how much is actually required is complex, given uncertainties such as governments’ stability, ability and willingness to invest in the health sector, as well as future price changes on everything from medication to infrastructure.
But WHO has taken on the task of creating estimates in the hopes of helping inform discussions on investment strategies as well as advocacy efforts on health under the sustainable development goals.
The organization predicts that the $134 billion figure will grow to $371 billion per year in the last stretch of the SDGs timeline to reach the health-related targets under the goals. This includes targets such as ending all forms of malnutrition (SDG 2.1), access to safe and affordable drinking water (SDG 6.1), and sanitation and hygiene (SDG 6.2), as well as clean energy sources (SDG 7.1). The bulk of investments is projected to be on health infrastructure and equipment, health workforce, and commodities and supplies, considered as the three most resource-intensive components in a health system.
The estimates are based on what WHO referred to as an ambitious scenario, where most countries achieve the global health targets in the SDGs. Under this scenario, the estimated mean total cost per person per year is at $271 (range $74-$984) for the 67 low- and middle-income countries included in the analysis.
Back in 2009, WHO’s estimates for cost per capita was at $59. A Chatham House report in 2014 pegged minimum spend per capita meanwhile at $86 to attain universal primary health care services in low-income countries. The new estimates however may not be comparable to the previous ones, given the different factors involved, including the inclusion of more middle-income countries in the analyses, according to the report.
“The next message that we will have to take on board is that if it is technically feasible and financially feasible, then it’s a political issue.”— Agnès Soucat, director of WHO’s health systems governance and financing division
The estimates do not include certain specific interventions such as on suicide prevention, some cancers such as child leukemia and oral cancer, and hepatitis, as the experts weren’t able to identify existing models or treatment protocols on which to base resource needs, according to the report.
If the resources were to be met, countries are projected to have more than 23.6 million health workers, including 3 million medical doctors and 10.5 million nurses and midwives. A total of 415,000 health facilities would also be made available, the bulk of which would be primary health centers in both rural and urban areas.
Services and interventions done at the primary-level care are likely to consume more than half of the additional resources required. These include treatment of sexually transmitted infections, tuberculosis as well as management and treatment of noncommunicable diseases.
“These services require more than a brief interaction with a health worker. They also require the health worker to have a certain level of skills and diagnostic tools,” according to the report.
Interventions based on information dissemination and policy regulations as well as those provided within a given time frame — and therefore not necessarily required as much the services of health workers, such as distribution of insecticide-treated bed nets, routine vaccination or implementation of policies banning smoking in public places — are deemed to generate lower costs.
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As is the rhetoric under the SDGs, most of the billion dollar figure is expected to come from the countries themselves.
“Most countries would be able to afford [the costs]. Most middle-income countries would have the necessary resources,” said Karin Stenberg, technical officer from WHO’s health systems governance and financing and the lead author of the report. “We projected GDP by year in countries, and what would be a reasonable allocation toward health, and then compared it with costs.”
Some countries, especially those that are currently in fragile situations, will still require external assistance, she added.
Convincing governments to make the necessary investments however will be an uphill climb.
“Of course, what remains, and that’s the next message that we will have to take on board, is that if it is technically feasible and financially feasible, then it’s a political issue,” Agnès Soucat, director of WHO’s health systems governance and financing division, said in a press briefing. “We know that UHC with health services is a social contract — so it’s about citizens getting together and agreeing and putting pressure on their parliaments and governments for this to happen.”
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