A practical approach to universal health coverage
Authors: Joia S Mukherjee, Jean Claude Mugunga, Adarsh Shah, Abera Leta, Ermyas Birru, Cate Oswald, Gregory Jerome, Charles Patrick Almazor, Hind Satti, Robert Yates, Rifat Atun, Joseph Rhatigan, Gary Gottlieb, Paul E Farmer
Journal: The Lancet Global Health (2019)

Given the 400 million people who do not have access to essential health services,1WHOUniversal health coverage.http://www.who.int/mediacentre/factsheets/fs395/enDate: 2015Date accessed: February 12, 2019Google Scholar the UN has included achievement of universal health coverage (UHC) by 2030 in the Sustainable Development Goals.2UNSustainable development goals.http://www.un.org/sustainabledevelopment/sustainable-development-g+oalsDate: 2016Date accessed: February 12, 2019Google Scholar UHC has two fundamental and interconnected commitments: the equitable access to high-quality health services and the promise of financial protection for all.3Boerma T Eozenou P Evans D Evans T Kieny M Wagstaff A Monitoring progress towards universal health coverage at country and global levels.PLoS Med. 2014; 11: e1001731Crossref PubMed Scopus (166) Google Scholar 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.4Sachs JD Achieving universal health coverage in low-income settings.Lancet. 2012; 380: 944-947Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 5Yates R Universal health care and the removal of user fees.Lancet. 2009; 373: 2078-2081Summary Full Text Full Text PDF PubMed Scopus (165) Google Scholar Yet, even with increased expenditures and efficiency in domestic financing towards these often-called demand-side barriers, the delivery of care is still hamstrung by insufficient staff, supplies, and infrastructure or so-called supply-side investments.6Kruk ME Gage AD Arsenault C et al.High quality health systems in the Sustainable Development Goals era: time for revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1041) Google Scholar Many countries remain impoverished due to structural factors and still cannot afford to provide quality care to all of those affected by their disproportionately large disease burdens. Even when user fees are removed, health facilities often remain empty. However, despite the insufficiency of health-care systems, the effective implementation of HIV programmes has succeeded in moving towards the once impossible goal of universal coverage of antiretroviral therapy (ART), even in impoverished settings. These advances towards realising full access to HIV care and treatment required a coordinated national-level strategy for care delivery. National programmes linked HIV surveillance data with the supply-side inputs needed to address the entire burden of disease. Projected patient volumes based on epidemiological data and treatment protocols were used to quantify and increase the number of staff for counselling, treatment, and laboratory services. Similarly, the process of estimating patient flow and volume informed the building of infrastructure and procurement of medical products.7The Maximizing Positive Synergies Academic ConsortiumInteractions between global health initiatives and health systems: evidence from countries.http://www.who.int/healthsystems/publications/MPS_academic_case_studies_Book_01.pdfDate: 2009Date accessed: February 12, 2019Google Scholar Due, in large part, to the progressive implementation of these supply-side measures, 21·7 million people across the world were accessing ART in 2017.8Atun R Andrade LOM Almeida G et al.Health system reform and universal health coverage in Latin America.Lancet. 2015; 385: 1230-1247Summary Full Text Full Text PDF PubMed Scopus (341) Google Scholar, 9UNAIDSGlobal HIV & AIDS statistics—2018 fact sheet.http://www.unaids.org/en/resources/fact-sheetDate: 2018Date accessed: February 12, 2019Google Scholar The path to the delivery of care needed to assure UHC is less clear and demands additional planning and resources to establish what interventions will be delivered to what populations. Projection models, such as the WHO OneHealth tool, already exist and the WHO and World Bank have proposed a framework for monitoring a country's progress towards UHC. Yet, although these tools are very useful in elucidating national successes and failures, in most cases such analyses do not make it to the subnational level. There is still a practical need to support the planning and implementation of health interventions at the health-centre level based on linking the disease burden for each specific catchment area with the inputs needed to progressively cover the population's health. Building off of existing UHC measurement methods, the Partners In Health UHC Monitoring and Planning Tool adds specificity for district-level and facility-level planning to allow for scaled expansion and improvement of the delivery of care within the local context by enabling granular forecasting. The user enters demographic inputs regarding the specific unit of analysis and the tool calculates, (1) the burden of disease within a given catchment area, (2) the volume of patient visits that would be expected if 100% of the disease burden was met by standard clinical protocols, and (3) the infrastructure, supplies, and staff needed to cover 100% of the population. In 2006, the Government of Lesotho invited Partners In Health to join its efforts to improve care in seven rural clinics with extremely low overall use. Despite the absence of user fees, antenatal care visits and facility-based deliveries were both exceptionally low, resulting in one of the highest maternal mortality rates in the world.10Hogan M Foreman K Naghavi M et al.Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5.Lancet. 2010; 375: 1609-1623Summary Full Text Full Text PDF PubMed Scopus (1447) Google Scholar Using benchmarks from the UHC tool as a guide, the Partners In Health team increased the required inputs (with financing from The Skoll Foundation and the Government of Lesotho) to ensure that 100% of women could have four antenatal care visits and a facility-based delivery. Based on a national crude birth rate of 3% and the essential service package of four antenatal visits, a 7-day stay in a maternal waiting home for women living more than 2 h from the clinic, and a facility-based delivery for all women in the catchment area, the Partners In Health team estimated the number of delivery tables, waiting home beds, midwives, and delivery packs needed for each clinic. Over 2 years of strengthening the health system, the proportion of facility-based deliveries in the Bobete area rose from 12% to 56%, with no reported maternal deaths in the Bobete clinic (figure).11Satti H Motsamai S Chetane P et al.Comprehensive approach to improving maternal health and achieving MDG 5: report from the mountains of Lesotho.PLoS One. 2012; 7: e42700Crossref PubMed Scopus (25) Google Scholar With clear improvements across all seven clinics, Partners In Health was then asked to support a national reform of primary health-care delivery between 2013 and 2017. The method of aligning staff, drugs, supplies, and infrastructure with the burden of disease was formalised into the Partners In Health UHC Monitoring and Planning Tool and was used to strengthen 70 primary care clinics across Lesotho to ensure the availability of care. Preliminary analyses of the 70 facilities show substantial increases in use over a 2-year period, including a 23-times increase in facility-based deliveries in Mohale's Hoek District, which went from 73 in 2013 to 1742 in 2015. This tool does not address the role of demand-side barriers in the underuse of services. Such barriers are linked to the social determinants of health and cannot be addressed by supply-side inputs alone. Achieving UHC will require substantial improvements in health systems and financing strategies to ensure the availability of effective health services. This tool 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. Partners In Health's forecasts, together with local health leaders in Lesotho, Haiti, Liberia, and Malawi have all been instrumental in procuring additional resources for their facilities and districts. Establishing transparent coverage targets has helped community health councils, traditional authorities, and local officials to assess and support health centres. At Partners In Health, this method is already being expanded to address surgery, oncology, non-communicable diseases, and mental health services. True global success of UHC can only be achieved if we have a clear and specific plan for implementation. We declare no competing interests. A sustainable approach to universal health coverageIn their Comment (April, 2019), the Partners In Health team1 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. 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