Barbara McPake, Nossal Institute for Global Health, University of Melbourne, and Vice Chair, Health Systems Global
The goal of Universal Health Coverage (UHC) continues to gather momentum, six years on from its unanimous adoption at the United Nations General Assembly on 12th December 2012. Making the goal a reality is a challenge in all settings. Even OECD countries exhibit significant income related inequalities in access to critical services such as cancer screening (largest in Belgium, Estonia, France and the USA), and around a quarter of health expenditure in Switzerland is out of pocket. All countries struggle to manage the tensions between expanding coverage to include new technologies in high demand and ensuring that worthy and proven technologies, especially in prevention and promotion, continue to attract sufficient investment.
Recent decades have seen major shifts in the world economic order. Most of the world’s population now resides in transitioning middle-income countries. While, according to World Bank data, the population living in extreme poverty roughly halved between 1990 and 2013, most countries in the world have seen inequalities substantially increase. A few exceptions such as Brazil and Mexico where inequalities have reduced have occurred in contexts of extremely high starting points. Brazil’s Gini coefficient, a measure of income inequality ranging from 0 to 1, declined from above 0.6 at the beginning of the 1990s, and South Africa’s from nearly 0.7 after 2009. (As a reference point US levels of inequality were about 0.4 in 2013.)
Fertility and demographic transition has accompanied these economic transitions to transform the world. In the 1960s, two distinct groups of countries existed. One had large family sizes and short lives; the other had small family sizes and long lives. Now much of the world, apart from about half of sub-Saharan Africa, has joined the latter group. Epidemiological transition has transformed burdens of disease, now dominated in the middle-income world by chronic, largely non-communicable conditions including cardiovascular conditions, diabetes, cancers and mental ill health.
So, for middle-income countries the tensions between expanding the range of services to which people have access and ensuring investment in interventions that are cost-effective and support growing health equity are pronounced. There is an expectation that UHC will ensure the widespread availability of the latest technologies responding to complex chronic health conditions. At the same time, without adequate investment in health promotion and prevention and constructing a health system around a strong primary care base, the volume of demand for such technologies will outstrip the capacity of even the wealthiest of the transitioning countries to respond to it.
And above all, recognition of the social determinants of health and the changing social gradients of different conditions question the health equity implications of prioritization decisions. At early stages of epidemiological transition, non-communicable diseases (NCDs) tend to be the preserve of the rich, but this changes to the point that NCDs disproportionately affect the poor in advanced stages of the transition. While infectious diseases and other conditions borne disproportionately by children and by women across the reproductive cycle are diminishing in terms of the share of the national disease burden, they are likely concentrated in the poorest populations.
The research and information needs to navigate these tensions are large and the research and information itself, largely absent. For example, nearly all the evidence to support new technologies to address NCDs has been produced in high income countries – only 11 of the 24 WHO ‘best buys’ have been evaluated in a low or middle-income country. And there are good reasons to query the direct transferability of that evidence such as differences in disease burden, health system and even apparently in pathology – the elevated susceptibility to diabetes in India is an ongoing puzzle for example.
The dilemmas facing transitioning middle-income countries in which most of the world’s population live about how rather than whether to progress to UHC are large. Those faced with making the momentous decisions needed require much more support from the research community – commissioners, funders and researchers themselves, than they have had to date.