Questioning progress towards universal health coverage for the most vulnerable
Authors: Nora Groce
Journal: The Lancet Global Health (2017)

In this issue of The Lancet Global Health, Jean-Francois Trani and colleagues1Trani J-F Kumar P Ballard E Chandola T Assessment of the progress towards universal health coverage for disabled people in Afghanistan: a multilevel analysis.Lancet Glob Health. 2017; 5: e828-e838Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar present findings on access to health care for people with disabilities in Afghanistan. Using a multilevel modelling approach, they assess data from two large-scale studies carried out in 2005 and 2013 to understand the impact that a decade of international intervention and investment in the Afghan health-care sector has had on a population that has consistently been identified as having significantly less access to health care than the general population.2World Health OrganizationWorld BankWorld Report on Disability. World Health Organization, Geneva2011Google Scholar Their conclusion is striking. People with disabilities report that the availability of health care and positive experiences in the health-care system did not improve between 2005 and 2013. In fact, health services were reported to be less available and less equipped to address their needs than a decade before. These findings are particularly of note because Afghanistan is reported to be making progress in ensuring access to health care. After decades of conflict, which left the health-care system in a poor condition, initiation of a Basic Package of Health Services (BPHS) in 2002 has led to significant improvement in overall population health outcomes.3Peters DH Noor AA Singh LP Kakar FK Hansen PM Burham G A balanced scorecard for health services in Afghanistan.Bull World Health Organ. 2007; 85: 146-151Crossref PubMed Scopus (118) Google Scholar, 4Edward A Kumar B Kakar F Salehi A Burnham G Peters DH Configuring balanced scorecards for measuring health system performance: evidence from 5 years' evaluation in Afghanistan.PLoS Med. 2011; 8: e1001066Crossref PubMed Scopus (83) Google Scholar, 5Newbrander W Ickx P Feroz F Stanekzai H Afghanistan's basic package of health services: its development and effect on rebuilding the health system.Glob Public Health. 2014; 9: S6-S28Crossref PubMed Scopus (83) Google Scholar, 6Alonge O Gupta S Engineer C Salehi AS Peters DH Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan.Health Policy Plann. 2015; 30: 1229-1242Crossref PubMed Scopus (22) Google Scholar A key component has been subcontracting non-governmental organisations (NGOs) to provide essential health services, which has been shown to be effective in fragile states.7Loevinsohn B Harding A Buying results? Contracting for health services delivery in developing countries.Lancet. 2005; 366: 676-681Summary Full Text Full Text PDF PubMed Scopus (216) Google Scholar How such efforts affect people with disabilities, however, is little understood. And despite the fact that the right to health is guaranteed under the UN Convention on the Rights of Persons with Disabilities (CRPD),8United NationsConvention on the Rights of Persons with Disabilities. UN, New York2006Google Scholar a growing body of research shows that people with disabilities continue to be a low priority in general health-care delivery.2World Health OrganizationWorld BankWorld Report on Disability. World Health Organization, Geneva2011Google Scholar There are a number of reasons for this disparity: people with disabilities are disproportionately poor, lacking in access to education and employment, and excluded from social networks. Health-care facilities, equipment, and transportation are often inaccessible. But another significant factor is that people with disabilities face stigma and prejudice2World Health OrganizationWorld BankWorld Report on Disability. World Health Organization, Geneva2011Google Scholar and many people whom they interact with, including health-care providers, have little knowledge or training around disability. These barriers have prompted some to argue that disability should be a bellwether for international development. If people with disabilities are not being reached by anti-poverty initiatives or health-care programmes, then these efforts are not fully effective. And reaching all people is key to the Sustainable Development Goals' call to "leave no one behind". Universal health coverage by 2030 (one target of SDG 3) can only be reached by including everyone—including people with disabilities. There has long been concern that, for vulnerable populations, inequality in access to health increases, rather than decreases, as development moves forward. Wealthier, well-connected individuals, it is argued, will disproportionately benefit from improved services.9Gwatkin DR Ergo A Universal health coverage: friend or foe of health equity?.Lancet. 2011; 377: 2160-2161Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar This has also been discussed in global disability research, where a widening "disability and development gap" has been hypothesised.10Groce N Kett M The disability and development gap. Leonard Cheshire Disability and Inclusive Development Centre Working Paper Series No 21. LCDIDC, London2013Google Scholar When people with disabilities are not included in improved access to health, education, and employment, they remain stationary while their non-disabled peers surge ahead. Trani and colleagues here find that, in fact, their status may even move backwards. Finally, a key recommendation is the need to train health-care workers at all levels to ensure that people with disabilities are routinely included and served. This is important—but there is also a broader concern. Health care in Afghanistan is being delivered by NGOs. However, there is little history of disability focus or inclusion in most mainstream NGO activities. Instead, this is often assumed to be the sole domain of disability-focused organisations—organisations which historically have been small, underfunded, lack national reach, and frequently are left out of international development initiatives. Mainstream NGOs must begin to include disability in their programming. And even if governments allocate responsibility for health-care delivery to NGOs, they still have the legal responsibility under the CRPD, the SDGs, and national laws to monitor and evaluate how effectively their disabled citizens are being reached and served. Trani and colleagues' paper represents an important first step in initiating this discussion. I declare no competing interests. Assessment of progress towards universal health coverage for people with disabilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveysPerceived availability of health care and experience with health-care coverage have not greatly improved for people with disabilities in Afghanistan, particularly in remote areas. Health policy in Afghanistan will need to address attitudinal, social, and accessibility barriers to health care. Full-Text PDF Open Access