Universal Health Coverage and public health: a truly sustainable approach
Authors: Robert Verrecchia, Rachel Thompson, Robert Yates
Journal: The Lancet Public Health (2018)

Universal Health Coverage (UHC) is driving the global health agenda; it is embedded in the Sustainable Development Goals (SDGs) and is now designated by an official United Nations UHC day on December 12. According to WHO's definition, UHC is achieved when "all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship."1WHOWhat is health financing for universal coverage? Geneva: World Health Organization.http://www.who.int/health_financing/universal_coverage_definitionDate accessed: November 19, 2018Google Scholar UHC is built on the foundations of human rights and equity, with health services allocated according to people's needs and funded according to their ability to pay. With its commitment to decrease inequalities and provide "health for all",1WHOWhat is health financing for universal coverage? Geneva: World Health Organization.http://www.who.int/health_financing/universal_coverage_definitionDate accessed: November 19, 2018Google Scholar UHC aims to help fulfil the 2030 SDG agenda's pledge to leave no-one behind. Although synergies have been explored between UHC and global health security,2Erondu N Martin J Marten R Ooms G Yates R Heymann DL Building the case for embedding global health security into universal health coverage: a proposal for a unified health system that includes public health.Lancet. 2018; 392: 1482-1486Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar primary health care,3Chan M From primary health care to universal coverage – the "affordable dream".in: Ten years in public health 2007–2017. World Health Organization, Geneva2017: 5-12http://www.who.int/publications/10-year-review/en/Date accessed: November 19, 2018Google Scholar and health systems,4Kieny M Bekedam H Dolvo D et al.Perspectives. Strengthening health systems for universal health coverage and sustainable development. World Health Organization, Geneva2017http://www.who.int/bulletin/volumes/95/7/16-187476Date accessed: November 19, 2018Google Scholar how UHC relates to public health has been under less consideration. Although promotive and preventive services are included in the definition of UHC, most efforts and resources to date have focused more on the provision of personal health services and less on public health. This situation is concerning because public health interventions often offer better value for money than curative services (especially specialist tertiary hospital care) and can result in increased equitable health benefits. Increasing the coverage of public health services will also involve allocating resources beyond the remit of the traditional health sector. Good examples of the need for increased upstream investment in public health are diseases associated with smoking—eg, 80% of tobacco-attributable deaths will occur in low-income countries5Schmidt H Gostin LO Emanuel E Public health, universal health coverage, and Sustainable Development Goals: can they coexist?.Lancet. 2015; 386: 928-930Summary Full Text Full Text PDF PubMed Scopus (119) Google Scholar—with similar inequities associated with air pollution in rapidly developing low-income and middle-income countries.6Fuller R Rahona E Fisher S et al.Pollution and non-communicable disease: time to end the neglect.Lancet Planet Health. 2018; 2: e96-e98Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar Without robust public health interventions (eg, taxation), health-care reform will not decrease health inequity. Since the 2014–16 west Africa Ebola virus disease epidemic, substantial resources have been invested in global health security.7Heymann DL Chen L Takemi K et al.Global health security: the wider lessons from the west African Ebola virus disease epidemic.Lancet. 2015; 385: 1884-1901Summary Full Text Full Text PDF PubMed Scopus (293) Google Scholar Many funding mechanisms are supporting the ability of African countries to comply with the International Health Regulations via increased preparedness and capacity to respond to future epidemics.8Global Capacities Alert and Response (CGR)Activity report 2012. World Health Organization, Geneva2012http://www.who.int/ihr/publications/activity_report_2012Date accessed: November 28, 2018Google Scholar Although the global agenda of health security provides an opportunity to increase investment in public health systems, the focus on health protection will not necessarily lead to improvements in the other two public health domains: health improvement and health services. As exemplified by the UK Department for International Development's forthcoming Tackling Deadly Diseases in Africa Programme, there is a risk that so-called securitisation of health could deflect resources from major public health challenges—ie, endemic infectious diseases that pose less acute international risk, and the growing burden of non-communicable diseases. Expanding the definition of global health security to include public health and UHC issues could offer a way forward.7Heymann DL Chen L Takemi K et al.Global health security: the wider lessons from the west African Ebola virus disease epidemic.Lancet. 2015; 385: 1884-1901Summary Full Text Full Text PDF PubMed Scopus (293) Google Scholar Another concern regarding the current implementation of UHC is the population captured by the term universal. When coverage expands via hospital-based curative services, often the individuals who are in high socioeconomic groups benefit first9Rodney AM Hill PS Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success.Int J Equity Health. 2014; 13: 72Crossref PubMed Scopus (62) Google Scholar and vulnerable groups such as migrants and refugees are not provided for. Even in high-income countries, access to health care can be restricted despite the public health and economic benefits that could be gained by providing early stage and preventive care.10Bozorgmehr K Razum O Effect of restricting access to health care on health expenditures among asylum-seekers and refugees: a quasi-experimental study in Germany, 1994-2013.PLoS One. 2015; 10: e0131483Crossref PubMed Scopus (171) Google Scholar UHC should be provided via a rights-based approach so that the people who are most vulnerable are not left without access. Making the case for public health investment is always a challenge. Despite the cost-effectiveness of many public health interventions, they are often under-resourced and take the most drastic cuts in times of austerity. Barriers to investment in public health include that the effects of interventions can take a long time to arise and that such interventions do not benefit a so-called identifiable victim.11Richardson A Investing in public health: barriers and possible solutions.J Public Health (Oxf). 2012; 34: 322-327Crossref PubMed Scopus (23) Google Scholar These barriers makes investment in public health less attractive to policy makers. Also, no clear consensus exists on what proportion of public expenditure on health care should be allocated to public health services. Moreover, applying such a proportion to low-income and middle-income countries comes with its own challenges. UHC reforms are an inherently political process, and public health advocates will need to do more to promote not only the health benefits of public health interventions but also the economic and political benefits too. Crucially, as UHC continues to be championed and rolled out globally, all people working in global health need to reinforce the importance of including the full scope of public health in health system reforms; only then can the full potential of UHC be realised—a true reduction in health inequities. For the WHO website on health security see http://www.who.int/health-securityFor more on the Tackling Deadly Diseases in Africa Programme see https://devtracker.dfid.gov.uk/projects/GB-1-205242 For the WHO website on health security see http://www.who.int/health-security For more on the Tackling Deadly Diseases in Africa Programme see https://devtracker.dfid.gov.uk/projects/GB-1-205242 We declare no competing interests