A sustainable approach to universal health coverage – Authors' reply
Authors: Joia Mukherjee, Adarsh Shah, Jean Claude Mugunga, Paul Farmer
Journal: The Lancet Global Health (2019)

In 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.1Baltussen R Jansen MP Bijlmakers L et al.Progressive realization of universal health coverage: what are the required processes and evidence?.BMJ Global Health. 2017; 2e000342 Crossref Scopus (14) Google Scholar 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. A status quo that is a direct outcome of historical and ongoing oppression of people in the global South.2Mukherjee JS An introduction to global health delivery: practice, equity, human rights. Oxford Univ Press, New York, NY2017: 5-18Google Scholar The chronically underfunded and weak health systems in impoverished countries are a result of colonialism, ongoing resource extraction, neoliberal economic policy, and the continued unequal flow of capital in the era of globalisation.2Mukherjee JS An introduction to global health delivery: practice, equity, human rights. Oxford Univ Press, New York, NY2017: 5-18Google Scholar For example, Jansen and colleagues claim that “few countries…are as fortunate as Lesotho to receive generous donor support”, yet the boundaries of the Kingdom have been tragically shaped by colonialism and resource extraction. Successive wars in the 18th century forced the Basotho to cede the majority of their resource-rich and arable lands to the Boers.3Eldredge EA A South African Kingdom: the pursuit of security in nineteenth century Lesotho. Cambridge Univ Press, Cambridge2002: 3Google Scholar This history is reflected in Lesotho today—a tiny landlocked nation surrounded by the extensive gold reef controlled by private companies in South Africa. This resource distribution has resulted in massive legal and illegal migration of Basotho men to South African mines for employment—a major driver of Lesotho having one of the highest rates of HIV and tuberculosis in the world.4Stuckler D Steele S Lurie M et al.“Dying for gold”: the effects of mineral mining on HIV, tuberculosis, silicosis, and occupational diseases in southern Africa.Int J Health Serv. 2013; 43: 639-649Crossref PubMed Scopus (39) Google Scholar The donor support described in our Comment article is only a small portion of what is actually owed to the nation of Lesotho. Frameworks for policy setting that rely on today's evidence or cost as “fair”, “realistic”, or “sustainable”, without questioning the size of the resource envelope available to finance care lay the groundwork for continued substandard health in impoverished nations. Unless we as a global community believe that the current vision of universal health coverage is only applicable to select populations wealthy enough to afford it, this framework is insufficient and replicates the selective primary health care nihilism of the past.5Walsh JA Warren KS Selective primary health care: an interim strategy for disease control in developing countries.Soc Sci Med. 1980; 14: 145-163Google Scholar As the international movement for HIV treatment access has shown, rooting action in the lived experience of patients, burden of disease, and the right to care can lead to expansion of resources towards an aspiration of universality rather than an acceptance of inequity cloaked in the language of sustainability. Our proposed framework deploys the lessons from the global scale-up of AIDS treatment beginning with the disease burden and then calculating the staff, commodities, and infrastructure needed to address it. This approach stands in direct contrast with the common practices of making a fragmented set of choices under constrained resources. We believe a morbidity-based approach to address the entirety of the disease burden can ultimately lay the foundation for delivering actual universal health coverage and will generate the data needed to advocate for the expansion of resources to realise this promise. 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 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 Access