After decades of pushing and prodding by thought leaders and politicians first from Japan and then from much of Europe, Mexico, Brazil, and other nations, universal health coverage was adopted as a target in the Sustainable Development Goals. Now the challenge is how to achieve it.
The key will be to avoid dogmatic debates, to demystify the broad concept by focusing on health as the principal outcome rather than building health systems, planning for sustainable financing from the outset, and working country by country rather than proliferating international meetings, documents, and pronouncements.
The Millennium Development Goals, the predecessor of the SDGs, were broadly successful because in several areas — for instance, education, poverty reduction, and health — there was a focus on clear, ambitious, and achievable results. While those unproductive and dogmatic debates about “vertical versus horizontal” programs continued, countries went about the hard work of turning ambition into reality.
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In fact, Japan — the first country to achieve UHC — began by addressing maternal and child health following World War II, and then expanded from there. That experience led them to be the first and most vocal proponent for UHC for decades.
As Julio Frenk, the architect of Mexico’s successful UHC efforts, pointed out many years ago, a diagonal approach that links investments in specific diseases and programs to investments in broader systems is a winning formula. Countries that achieved remarkable progress in the MDGs era against maternal and child mortality, HIV, tuberculosis, malaria, and so on also strengthened key aspects of their health system to achieve those results. The push for results drove the practical need to create systems to deliver them, leaving dogmatic debates behind in the dust.
The SDGs offer a key opportunity to evaluate how systems were put into place to achieve disease specific outcomes and more intentionally implement cross-cutting systems to achieve UHC, but it can sound theoretical. Demystifying UHC is essential in order to focus on concrete goals, targets, and plans with accountable outcomes anchored in health impact. Here are a few ways it can be done.
1. Put people first
First, it is essential to be clear that the goal is healthy people, not a system with building blocks of mortar and bricks and cadres of workers. Japan, and other countries that have promoted and achieved versions of UHC, began with practical ambitions for better health and then built systems over time to achieve them. The goal was not to build systems per se; it was to ensure better health.
If the goal and associated targets is building a system that “covers” the population of hospitals, clinics, and health workers — in other words, a health bureaucracy — that is what will be built. If the goal and associated targets is to achieve concrete and specific health outcomes for people, the systems needed to achieve health will be built.
“It is essential to be clear that the goal is healthy people, not a system with building blocks of mortar and bricks and cadres of workers.”— Mark Dybul, professor at Georgetown University
2. Engage at the community level
The power of community-based, including faith-based, systems cannot be overstated. If we see a health system ending at a clinic, health cannot be achieved. Effectively caring for those who are sick and treating disease is an important part of UHC, but preventing illness is the only path to sustainable UHC. Effective prevention, care, and treatment requires deep engagement in communities, including through well-organized and funded community health workers, and perhaps community prevention workers focused on the health and well-being of the people they serve.
3. Create communities of practice to use data and evidence
Part of a focus on healthy people is a system to ensure quality. A well-developed evidence base in several Nordic countries has shown that when communities of doctors and nurses have access to data about deficiencies in health outcomes, they find innovative solutions and can improve outcomes by 30 to 50 percent in a matter of months.
Ethiopia took the notion of communities of practice to a new level by creating networks from cadres at the community level, to districts, to state and national level, so innovations identified in a village, if verified in several others, could be rapidly scaled up. Health policymakers are also a community of practice, who, when linked to providers, can rapidly drive systematic change and accelerate better health outcomes.
Data also shows that patient and client satisfaction is key to quality services and, therefore, to healthy people. The private sector long ago developed human-centered design, or HCD, to understand what drives people to access health services. It is encouraging that several health organizations, including the Global Fund, are early adopters of this approach. However, health policymakers are also human beings and the application of HCD to communities of practice of providers and policymakers could yield important results.
4. Secure financing
Another step in demystifying UHC relates to securing financing. Ultimately, insurance systems — public, private, or whatever mix best meets the needs of an individual country — are required for sustainable UHC. But establishing insurance systems takes time. No low- and middle-income country or multinational health organization alone has the resources to finance the systems needed for UHC. By breaking UHC into component pieces, creative avenues for financing can open up.
As noted, health workers are a key component. Effective health care also requires efficient supply chains and procurement systems; data management systems that allow communities of practice to focus on health outcomes; human resource; and financial management, among many others.
Each of those systems are forms of infrastructure, as are the roads needed to reach health facilities and the schools needed to educate the providers that fill them. Those systems create jobs — and lots of them. Development banks, regional banks, and institutions such as the World Bank can be accessed. Such systems are also quite attractive to investors from the private sector, either as direct foreign investment or through bonds issued by governments trying to fund health care. Taxes on products that impair health also have potential to finance UHC.
If there is a clear, costed national plan that directs all actions under it, breaking down UHC into its component pieces could provide the short- and medium-term financing needed to pull it all back together under a comprehensive and sustainable insurance system.
Japan in the 1950s and many countries since have shown that UHC can be achieved even without very high income levels. If we focus on the health of people, and join in solidarity to support and serve others country by country, UHC can be achieved.
How do we ensure that people worldwide get the care they need without the risk of being pushed further into poverty? Devex explores the path to universal health coverage. Join us as we ask what it will take to achieve UHC for all by visiting our Healthy Horizons site and tagging #HealthyHorizons, #Health4All and @Devex.