Universal Health Coverage in crisis-affected contexts: the rhetoric and the reality
This blog post is part of a wider HSG blog series in the lead up to the Universal Health Coverage Forum 2017, which takes place in Tokyo, Japan from 12 – 15 December. In this series, HSG members provide their perspectives on how Health Policy and Systems Research is fundamental to acheiving Universal Health Coverage by 2030.
By Rachel Thompson, Research Associate at the Centre on Global Health Security, Chatham House
December 12th is Universal Health Coverage (UHC) Day: the annual rallying point for the growing movement for ‘health for all’. But what does it mean for the 125 million people caught up in conflict and other humanitarian crises?
The rhetoric
Championed by the new World Health Organization (WHO) Director General, and embraced by health and development actors, from researchers to politicians – UHC is the current buzz-word in global health. WHO defines UHC as ‘ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services’. UHC is embedded in the Sustainable Development Goals (SDGs), as target 3.8.
Also embedded in the SDGs is the commitment to ‘leave no one behind’ – not just vulnerable and marginalized groups who may have been excluded from previous development processes, but also populations ‘left behind’ by the impacts of conflict and other crises. With many health outcomes significantly worse in conflict affected contexts, it is clear that the SDGs cannot be achieved without a focus on the 125 million currently in need of humanitarian assistance; and that ‘UHC will only be achieved with a strong focus on fragile and conflict-affected states’.
The reality
Across the world, protracted crises are challenging the humanitarian system. Those delivering healthcare are fighting old diseases (e.g. cholera in Yemen), as well as newly emerging ones (e.g. diabetes in Jordan). In all cases, they are struggling. So what does aiming towards UHC mean in reality for actors working in these conflict affected contexts? Is it a useful goal for people and places in crises? Is it realistic? Is it distracting? Or even dangerous and counter-productive as some humanitarians suggest?
The ReBUILD research programme has recently set out some of the issues for UHC in conflict settings, noting three particular challenges:
- Economics: crises are often accompanied by falls in employment, affecting people’s ability to pay for healthcare, and compounded by decreased government income and reduced spending on health.
- Violence: the destruction of health facilities, disruption of systems for procurement and health information, as well as the death of health workers.
- Changing burdens of disease: increased injuries and illnesses associated with violence, reduced food availability, resurgent infectious diseases, mental health problems, and the globally growing burden of chronic disease.
However, the effect of conflict on health is not necessarily a black and white one. An influx of humanitarian organizations during conflict may, in fact, result in improved access and health outcomes. While the strategic use of healthcare by non-state armed groups may also affect, potentially positively, the access to health of certain populations in conflict. Too little is known about such phenomena.
Evidence gaps
The evidence around health systems and UHC in conflict affected contexts is limited, and mainly based on data from post-conflict settings. On UHC Day 2015, the Lancet published a blog entitled ‘Leaving no one behind’: lessons on rebuilding health systems in conflict- and crisis-affected states’. The lessons included how post-crisis is a time of opportunity but also risk, and how rebuilding both trust and institutions (both critical for implementation, but both undermined by conflict) cannot be externally led or imposed. Yet, while these lessons – backed up by evidence from post-conflict research – may be helpful for places where ‘post-conflict’ is a reality in the short- or medium-term, they do not address the issues of protracted crises, or the so-called ‘new normal’ for the 21st century.
In this reality, some conflicts can last a generation, and the average length of displacement is now 17 years. Indeed, the search for UHC for Syrian refugees in Lebanon is a hot topic in a country that has the highest number of refugees per capita, but where affordable healthcare is a distant dream for many Lebanese citizens, not only for refugees. In Greece, another country hosting many thousands of refugees and asylum seekers, integrating refugees into the health system could benefit host communities – but more evidence and longer-term, politically viable approaches are needed.
Not only are conflicts today lasting longer, but the vast majority also involve multiple non-state armed groups. While any meaningful attempt at UHC in conflict-affected settings will surely need to include them, there is little evidence on how to engage such groups in relation to healthcare delivery.
Unresolved tensions
Is it possible to reconcile the optimistic, ambitious rhetoric of UHC and other Sustainable Development Goals with the realities of crises today? Is it possible to join together development and humanitarian objectives? The so-called humanitarian-development nexus and its ‘new way of working’ is one such attempt currently being championed by WHO and other international organizations. Humanitarian health interventions, it is suggested, should focus on integration, early recovery and transition to local authorities as early as possible. At the same time, development programmes should target fragile and conflict-affected areas in a more operational manner.
However, striving for development aims – like UHC – in conflict contexts is not uncontroversial. UHC is a project for the state, but what happens when the state is absent, unwilling, or complicit in human rights abuses? Caught up in these rhetorical tensions are urgent operational realities: how to pay health workers in Yemen, how to immunize stateless children in Myanmar and how to provide dialysis for Syrian refugees in Lebanon? There are no easy answers to these issues, but if UHC advocates are serious about ‘leaving no one behind’, it is time to engage with these difficult questions, difficult places and difficult groups – and UHC Day is a good day to start.
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A version of this blog post also appears on the Chatham House website.
