BARCELONA — When crafting out an approach to tackle improved access to health care, it’s important to ensure nobody is left behind. According to Stefan Peterson, UNICEF’s chief of health and associate director of programs, this means the most disadvantaged of any country must be put front and center of any approach to achieving universal health coverage.
“The distinct part of UNICEF is that we are actually multi-sectoral. We're not just about health; we’re also about water and sanitation, nutrition, education,” he said. “Then there’s the aspect of equity and reaching the disadvantaged and making sure that we don't leave anyone behind. Ideally, we’d like to start from the most disadvantaged.”
Sitting down with Devex, Peterson explained that the process of UHC begins with pregnancy and continues throughout a child’s life, discussing how UHC can be achieved in practice, and why, ultimately, it’s cost effective to focus on the most disadvantaged.
Below are more highlights from the conversation, edited for length and clarity.
“Being Swedish, IKEA comes to mind. They made furniture available at a lower cost for many rather than expensive furniture for the few. We need to take this model to a new level.”— Dr. Stefan Peterson, chief of health and associate director of programs, UNICEF
How do approaches to achieving UHC differ when you put children front and center?
We believe that you need to start from the most disadvantaged children. Then you need to focus on primary preventive and curative care, delivered through strong health systems that reach into communities, rather than focusing first on high-tech interventions that primarily reach better-off groups in urban centers.
We like to talk about the lifecycle, which starts before pregnancy and continues through childhood and into adolescence. Obviously you need to have a healthy pregnancy, which requires, among other things, good nutrition. You need good antenatal care, good quality delivery care, good quality post-natal care. And you need to promote immediate and exclusive breast-feeding, immunization, good supplementary feeding, and you need good health services delivered where they are needed, including through schools and other community platforms, throughout childhood and into adolescence. Finally, you have to help the adolescent with delaying marriage and conception. The services and promotion need to continue and deliver consistent messages along the whole lifecycle. That should be a starting point for achieving UHC, with focus on the most deprived.
What are the biggest challenges faced in reaching children in remote and rural areas?
The challenge is not just about reaching children in remote and rural areas, which we often think of as being the main challenge. Many people who live in urban slums, which might be situated right next to a big hospital, may suffer from a lack of access to that very same hospital because of social or economic factors. The same goes for marginalized, vulnerable, and poor groups. Also, what we'd like everyone to have, of course, is access not to just any care but to good quality care that is affordable and accessible.
Personally, I like to talk about the “first mile” health system. That is, the care that is available within a mile of your frontdoor. This is typically the distance most people are willing to go to access primary health care and I think it’s a challenge we need to address as service providers, to make sure that there’s good access to good quality care within that first mile of people's doors. And again, that care must be affordable and accessible to everyone, including groups vulnerable due to poverty, geographical location, or membership of a minority ethnic or cultural group. UHC must be truly universal and must start with those who need it the most.
What is your sense from talking to ministries and actors on the ground in-country about how systems are changing in order to achieve UHC?
How do we ensure that people worldwide get the care they need without the risk of being pushed further into poverty? Achieving universal health coverage will need collaboration, innovation, investment, and partnerships. Devex examines some of the challenges in working toward health care access for all and explores the solutions.
The big issue here is not a technical one; it's about political will. Achieving UHC requires political commitment. I think some of the history — for instance, the U.K.’s National Health Service, which was actually a political project in a period after the Second World War — shows that this is a choice that countries make. Japan is another example, beginning in the early 1960s, of a country that emphasized improving access to services and promoting engagement at the community level. If you can build the political will, then I think the technical issues can be sorted.
You need champions at the global and regional level. You need to use regional bodies like the African Union or the European Union and regional and subregional organizations, to get leaders inspired and to learn from each other. Secondly, I think you need civil society to be a strong voice for the voiceless and to push on the political agenda. Civil society can also have a very important role in holding service providers to account, by saying “where are our health services and what about the quality of our health services?” Civil society can play a role in mediating between the community and service providers to set up social contracts. Here, accountability becomes a two-way process — as a patient, I come on time and I expect my health worker to be there, treat me courteously and have the necessary supplies and equipment. Finally, you need political champions at country level, who can promote the social, economic, and even political rationale for UHC. This has been noted, and resulted in high levels of coverage in many countries with different social and political contexts, from Rwanda to China and, recently in the Philippines and Indonesia.
Where will investments in UHC come from?
I think everyone needs to be chipping in. Certainly, most of the investments will come from domestic resources. Donor and international funds can supplement that, but even if you look at the poorest countries, domestic funding is the biggest one. Domestic funding comes first from the government, i.e. taxation, but it also comes, to a large extent, from people's pockets. At present, half of the total health expenditure in many countries actually comes in the form of out-of-pocket payments. We need to ensure that these out-of-pocket resources are spent efficiently, equitably, and effectively — and this requires good governance and stewardship of the health sector, both public and private. Private companies also have a very important role in making investments in technology and providing services.
I think it's about making sure that you're actually innovating around affordable solutions. The focus is on the needs of the many, rather than a high price for the few. Being Swedish, IKEA comes to mind. They made furniture available at a lower cost for many rather than expensive furniture for the few. We need to take this model to a new level. I think India is an example where such innovation has been taken to a large scale. For instance, cataract procedures and the artificial lenses, which used to be expensive, are now affordable or provided free for those who need them.
And, in fact, we've even shown that it's more cost effective to focus on the most disadvantaged. A recent UNICEF study showed that every million dollars invested in improving the health of the most deprived children saves 1.8 times more lives than an equivalent amount that doesn’t reach those groups. Pro-equity investments achieve bigger “bang for the buck,” as they say.
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.
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