By Sara Bennett and Fadi El-Jardali
Universal Health Coverage (UHC) is normally understood as ‘people being able to access curative, preventive and palliative health services without incurring financial hardship’. Yet this interpretation is only one part of the overall picture of health. This week global leaders came together at the UN General Assembly (UNGA) to agree on a political declaration to achieve UHC by 2030. However, if they are to turn this into a reality their ambitions must reach beyond this definition.
Health systems, particularly in poorer countries, were designed to address short-term health needs, such as malaria, malnutrition and vaccine-preventable diseases. In most instances, they are ill-equipped to handle the increasingly complex demands being placed upon them in the twenty-first century. An outbreak of Nipah virus in Kerala State, India last year illustrates this all too well.
The outbreak caught authorities off guard. While the virus is well-known in the so-called ‘Nipah Belt’ encompassing Bangladesh and adjacent parts of West Bengal in India, it had not previously travelled as far South as Kerala. Nonetheless, the government in Kerala was quite effective in diagnosing and isolating this outbreak: a total of 19 people were infected, of whom 17 died.
Nipah can be transmitted to humans directly from wild reservoirs (typically bats), or from animals that have come into contact with bats such as pigs, dogs and horses, and occasionally via human-to-human contact. Unexpected outbreaks and changes in patterns are also occurring elsewhere, likely due to climate change (higher temperatures and increased humidity) and unplanned urbanization – recent dengue cases in Latin America and Florida, where it was previously eliminated for decades, exemplify this.
To mitigate and prepare for such environmental and societal changes and the subsequent impact on our health there are at least three major ways in which our health systems need to radically transform.
1. Health systems across the world continue to be predominantly ‘sick care’ systems.
Despite the success of immunization campaigns, the availability of contraceptive services and other preventive interventions, most investment in the health system is in healthcare facilities that provide primarily personal, curative health services. The World Health Organization estimates that low- and middle-income countries direct only 11-12 per cent of their total health spending towards preventive services.
The Nipah virus in Kerala was brought under control relatively quickly, but the state has a long-standing commitment to public health, including recent undertaking to develop a separate public health cadre. Many countries, however, lack such a commitment and do not have adequately trained and dedicated staff for public health services.
All too frequently public health, as opposed to clinical services, lacks a separate identity, is poorly funded, and of low prestige. Refocusing health systems towards preventive services is critical.
2. Animal and wildlife information systems vary enormously across countries in their objectives and structure but rarely interact with systems for tracking human health.
This means that opportunities to identify dangerous viruses and diseases in the animal population before they crossover into humans are frequently missed.
Similarly, systems of social protection often identify people living with physical and mental health disabilities, but this information, which could help channel and direct health investments are rarely available to those working in the health sector. Up-to-date, reliable data integrated across multiple providers and different parts of government (both health and non-health) form the next frontier in ensuring evidence-based strategies to promote health.
Developed countries such as the US are currently grappling with challenging technical questions regarding the exchange and use of information, as well as ethical questions regarding privacy and patient rights, but action on this front in developing countries lags far behind.
3. At the UNGA the community of academics and activists concerned with non-communicable diseases were vocal, and rightly so.
We know both how to prevent and treat such diseases, however, health systems, especially those in developing countries, are spectacularly ill-equipped to respond. Again, global trends in urbanization, the consumption of processed foods and climate change are likely only to exacerbate these problems, as without intervention, people will become more sedentary, obese and likely to consume less nutritious foods.
Certainly, traditional health systems must be strengthened to cope with the onslaught of non-communicable diseases, and preventive interventions are also key. But, is simply strengthening of existing systems enough? The scale of this epidemic and the intense demands it places on low resourced health systems is forcing a shift in how we think about service delivery. Increasingly, care for such illnesses will be provided in the home and community, not the clinic, likely with support from new digital technologies and community health workers that can guide patients in how to manage their own ill health.
During the past forty years or so, policymakers and international organizations have talked about health systems in terms of the organization, financing and governance of health care services (pdf). We need to move away from this narrow view of ‘sick care’ to one that prepares for and acknowledges the complexities and challenges of our time. If we don’t reframe the way we think about health systems, then our efforts to achieve universal health coverage will fall well short.