Opinion: What does UHC look like in the climate change era?

When the World Health Assembly convened last month, there was one predominant message: Universal health coverage is the central priority in global health.

This year, the World Health Organization’s decision-making body was foregrounding UHC in preparation for the U.N. High-level Meeting on Universal Health Coverage in September. UHC — access to quality health-care services, from prevention to palliative care, for all, without inducing financial hardship — is justifiably toward the top of the agenda. By focusing on UHC, WHA signaled its renewed commitment to a healthier, more equitable world.

But the WHA is not preparing for that world. It is running down a checklist with the boxes out of order. Health system resilience should be at the top of the list, or at least on par with UHC.

Within the next few decades, extreme weather events will become more common due to climate change, damaging hospitals and clinics. Flooding will exacerbate the spread of waterborne disease, overwhelming health systems with sudden spikes in diseases like cholera. And, droughts will jeopardize food security for already malnourished populations. As climate change undermines health gains, UHC will be perpetually out of reach.

Forty years of falling short

Access to equitable health care has been a challenging ideal for decades. Before the late 1970s, the global health community focused primarily on disease eradication and control. Although the decades of top-down, disease-specific campaigns saw some major successes, such as the eradication of smallpox in 1979, these strategies could not address systemic health challenges.

In 1978, the Declaration of Alma-Ata called for a shift toward primary health care, which focused on health promotion and prevention, people-centeredness, and equity. However, within a few years, these goals had been replaced with selective primary health care, which lasted until the 1990s. Seen as more attainable, selective primary health care prioritized targeted, low-cost interventions over those that took a systems-level approach.

2010 marked the beginning of WHO’s new emphasis on UHC. Similarly, the Millennium Development Goals set the stage for the 2015 Sustainable Development Goals, which embraced UHC in 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.”

Will another try work in a changing climate?

Now we’re in the era of climate change. UHC can no longer stand on its own, and if WHO fails to meaningfully prioritize resilience alongside the UHC agenda, these fragile goals of equity will slide back once again. It’s like a sandcastle eroded by the tide: “Leaving no one behind” in health is a grand idea that has always faced setbacks, at least until activists and policymakers chose to rebuild its ideals. Now, it is facing a hurricane. The question can no longer be how we put the collapsed sand back together. It’s whether we should be building with sand at all.

Climate change is more than a health emergency — it is a health coverage emergency. Under climate change, the most vulnerable people will be further at risk of both health issues and the loss of access to quality health services.

Disasters and climate-related disease are going to affect cities around the world. If we aim for resilient UHC, we will still get hit, but at least our fundamental systems will remain standing.

Pharmaceutical companies can invest in high-quality software to monitor their supply chains. With real-time data, they can better anticipate shocks, make early rerouting decisions for last-mile locations, and quickly ramp up production in nearby but unaffected locations in preparation for recovery efforts. And, governments can make power grids more robust to extreme conditions or even invest in new solutions so that hospitals are less prone to grid energy losses. For example, solar photovoltaics can provide facilities relief from short-term outages.

A promising future for climate-resilient UHC

The Lancet Editor-in-Chief Richard Horton declared a planetary emergency at WHA, and some WHA draft documents do briefly mention resilience as well. But this is far from a robust — let alone implemented — joint approach to UHC and climate change. Climate-resilient health systems are no longer just a part of UHC. They are a precondition.

Fortunately, in 2015, WHO released a guide on creating climate-resilient health facilities, so it has the potential to align UHC with existing research and tools on resilience. The framework includes incorporating climate change into health workforce training, setting up monitoring systems, adapting health facility construction specifications to climate risks, and retrofitting public health infrastructure. While these recommendations do not have specific funding sources, WHO does house a list of institutions that finance climate resilience for health who could back these actions.

The fundamental goals of resilience and UHC are the same: Ensure equity without exception, mitigate health risks, and empower everyone to lead their healthiest lives. The concepts strengthen one another, and at the next annual WHA, they should be better reflected in one another by approving a new, integrated resolution on climate-resilient UHC. An early draft of the political declaration for September’s high-level meeting does include climate resilience, but the U.N. should elevate it to be a priority, which must then carry over to WHA with equal force.

The world has experienced tremendous health gains over the past 20 years. Resilience not only protects those gains but allows for progress to continue and reach more people. As always, shocks and stresses are inevitable. Our vulnerability doesn’t have to be.

For a closer look at the innovative solutions designed to push for progress on universal health coverage around the globe, visit the Healthy Access series here.