A sustainable approach to universal health coverage
Authors: Maarten Paul Maria Jansen, Leon Bijlmakers, Rob Baltussen, Etiënne A Rouwette, Henk Broekhuizen
Journal: The Lancet Global Health (2019)

In their Comment (April, 2019), the Partners In Health team1Mukherjee JS Mugunda JC Shah A et al.A practical approach to universal health coverage.Lancet Glob Health. 2019; 7: e410-e411Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar presents a tool that they claim "represents one pragmatic method to advocate for adequate resources to align inputs with the disease burden, rather than starting with the limitations of a truncated budget envelope". In our opinion the title of their Comment is slightly misleading. Yes, the tool can be used to convince external donor agencies who wish to support health facilities in addressing the local disease burden. However, the real challenge for local health authorities is to set fair and sustainable priorities in what services to provide first under the progressive realisation of universal health coverage. Very few countries or regions are as fortunate as Lesotho to receive generous donor support that allows the full upgrading of health facilities' service packages. Additionally, the proposed approach ignores the fact that external financial support always comes to an end at some point. What then is the tool's practical value for health facilities that do not, or no longer, receive such external support? Local health authorities need guidance on how they can set fair and sustainable priorities. The framework of evidence-informed deliberative processes (EDPs) can facilitate these choices for universal health coverage.2Baltussen R Jansen MP Bijlmakers L Tromp N Yamin AE Norheim OF Progressive realisation of universal health coverage: what are the required processes and evidence?.BMJ Global Health. 2017; 2e000342 Crossref Scopus (14) Google Scholar The EDP framework provides procedural guidance on how (local) health authorities can best organise their decision-making process and evidence collection to make these choices in a legitimate and publicly accountable manner.2Baltussen R Jansen MP Bijlmakers L Tromp N Yamin AE Norheim OF Progressive realisation of universal health coverage: what are the required processes and evidence?.BMJ Global Health. 2017; 2e000342 Crossref Scopus (14) Google Scholar, 3Tromp N Prawiranegara R Siregar A et al.Translating international HIV treatment guidelines into local priorities in Indonesia.Trop Med Int Health. 2018; 23: 279-294Crossref Scopus (6) Google Scholar It provides a stepwise, iterative approach to universal health coverage that explicitly takes stakeholder knowledge and values into account. Recently, EDPs have been used by health authorities in Indonesia to translate international HIV treatment guidelines into local priorities.3Tromp N Prawiranegara R Siregar A et al.Translating international HIV treatment guidelines into local priorities in Indonesia.Trop Med Int Health. 2018; 23: 279-294Crossref Scopus (6) Google Scholar Moreover, making realistic implementation plans is notoriously difficult and any large health sector investment can cause a chain of consequences, intended or unintended, and sometimes detrimental.4Chambers DA Glasgow RE Stange KC The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change.Implement Sci. 2013; 8: 117Crossref PubMed Scopus (672) Google Scholar Unintended consequences are particularly likely if no demand-side barriers are taken into account, which the authors consider justifiable because such barriers are linked to social determinants of health. Although demand-side barriers can be hard to capture, methods such as group model building and system dynamics can be used, even if only to assess and account for the most prominent dynamics.5Northridge ME Metcalf SS Enhancing implementation science by applying best principles of systems science.Health Res Policy Syst. 2016; 14: 74Crossref Scopus (44) Google Scholar We declare no competing interests. A practical approach to universal health coverageGiven the 400 million people who do not have access to essential health services,1 the UN has included achievement of universal health coverage (UHC) by 2030 in the Sustainable Development Goals.2 UHC has two fundamental and interconnected commitments: the equitable access to high-quality health services and the promise of financial protection for all.3 To date, the global movement to achieve UHC has mainly focused on demand-side barriers by encouraging countries to increase their domestic financing for health to provide social health insurance and to decrease out-of-pocket expenditures. Full-Text PDF Open AccessA sustainable approach to universal health coverage – Authors' replyIn response to our Comment, Maarten Jansen and colleagues suggest that the use of their framework for evidence-informed processes is a better way for health authorities to set "fair and sustainable priorities in what services to provide first in the progressive realisation of universal health coverage". To base health priorities on evidence, as Jansen and colleagues suggest, is indeed an improvement over using cost-effectiveness alone.1 Yet, prioritisation exercises based solely on choosing interventions that are considered sustainable on the meagre health budgets of impoverished countries will ultimately preserve the unacceptable and inequitable status quo. Full-Text PDF Open Access