Investing in leadership for universal health coverage
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2019)

On Sept 23, our sights focus once again on universal health coverage (UHC), and, in the words of the partnership organisation UHC2030, on “the last chance before 2023, the mid-point of the SDGs, to mobilise the highest political support to package the entire health agenda under the umbrella of UHC and sustain health investments in a harmonised manner”. The UN High-Level Meeting, ahead of the 74th UN General Assembly in New York, will see governments debate and commit to a high-level political declaration, and as WHO Director-General Tedros Adhanom Ghebreyesus has said on many an occasion, UHC is a political choice. Political choices require leadership and governance—the topic of a plenary session at the AFREhealth Symposium in Lagos, Nigeria, last month. Renowned leader and Executive Director of the African Centre for Global Health and Social Transformation, Francis Omaswa, began discussions in a provocative fashion. Why, he posed, are countries such as Malaysia, Singapore, and South Korea now donors to countries such as Uganda despite emerging from colonial rule at a similar time? It was because governance, leadership, and accountability were lagging behind in Africa, he suggested, and because ordinary Africans—including the assembled researchers, health professionals, and educators—were accustomed to “accepting the intolerable”. It was time to make a personal commitment, he said, to “good character”—both within ourselves, among the political leaders we vote for, and among the donors we choose to partner with: those who share a genuine vision of social justice and to leaving no one behind. This concept of commitment was taken up by former Nigerian Minister of Health Isaac Adowole. In speaking about investing in health, he said that it was not the much-touted political will that was lacking, but political commitment and action. Ministers needed to engage better with national assemblies or parliaments in order to put good intentions into practice. Many pieces of research make an extremely good case for investing in UHC. Most notably, perhaps, the Lancet Commission on Investing in Health demonstrated that pathways that targeted the poorest first, such as publicly financed insurance, could provide financial protection and essential health-care interventions to everyone and that returns on these investments would far exceed the costs. In this month's issue, several papers focus on innovative ways to make coverage of treatments for non-communicable diseases in resource-limited settings more affordable. Thomas Lung and colleagues estimate, on the basis of a randomised trial, that a fixed-dose, triple-pill combination treatment for mild to moderate hypertension would be cost-effective in Sri Lanka, and John Lin and colleagues use mathematical modelling to predict that a polypill containing aspirin, lisinopril, atenolol, and simvastatin for secondary prevention of atherosclerotic cardiovascular disease would be cost-effective in China, India, Mexico, Nigeria, and South Africa. Furthermore, in a retrospective analysis of another randomised trial, Anirudh Krishnan and colleagues show that scaling up a community-based hypertension management programme by female community health volunteers would be very cost-effective in Nepal. So, plenty of evidence is there, and the will is—on the face of it—there too. Why, then, is a UN High-Level Meeting needed? Such meetings are convened when there is a perceived need to engage all sectors to effect developmental, social, and economic change. The realisation of UHC will undoubtedly require that. But what if more insidious elements of our global financial ecosystem are putting the brakes on real progress? In a sobering blog post last month, Remco van de Pas outlined his pessimism regarding the potential for the High-Level Meeting to deliver on its promises within the confines of the “golden straitjacket” of free-market capitalism, in which more equitable redistributive policies are shackled by the demands of the global economy. Indeed, while the speakers at the AFREhealth plenary session were making the case for investing in health in Africa, members of the audience questioned why it wasn't better to focus on increasing GDP. “Sick people can't drive the economy”, replied Isaac Adowole. In future financing projections, and the planned follow-up to the High-Level Meeting in 2023, perhaps the realities of the golden straitjacket should be more honestly faced. Investing in leaders who are prepared to confront global economic realities would also undoubtedly yield returns. Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in HealthIn 2013, the Lancet Commission on Investing in Health published its report, “Global health 2035: a world converging within a generation” (GH2035). The report concluded that a grand convergence in health—a reduction in infectious, child, and maternal mortality to rates seen in the best-performing middle-income countries—is technically and financially feasible for all but the poorest countries by 2035. Mortality from non-communicable diseases could be reduced through inexpensive population-based and clinical interventions, especially fiscal policies such as heavy tobacco taxation. Full-Text PDF Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysisThe programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered. Full-Text PDF Open AccessCost-effectiveness of a fixed-dose combination pill for secondary prevention of cardiovascular disease in China, India, Mexico, Nigeria, and South Africa: a modelling studyThe polypill is projected to be cost-effective compared with current care for secondary prevention of atherosclerotic cardiovascular disease in China, India, Mexico, Nigeria, and South Africa, particularly if it is made available at public-sector pricing. However, achieving meaningful improvements in cardiovascular health will require simultaneous investments in health infrastructure to increase the uptake of the polypill among patients with established atherosclerotic cardiovascular disease. Full-Text PDF Open AccessFixed-combination, low-dose, triple-pill antihypertensive medication versus usual care in patients with mild-to-moderate hypertension in Sri Lanka: a within-trial and modelled economic evaluation of the TRIUMPH trialCompared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease. Full-Text PDF Open Access