4 radical shifts required to achieve universal health coverage worldwide

World Health Day 2019 lands on 7 April, with the World Health Organization (WHO) declaring universal health coverage (UHC) as this year’s focus. The choice of theme is fitting given UHC’s prioritization by the current WHO director-general, Dr Tedros Adhanom Ghebreyesus. His institution estimates that about 400 million people around the world lack access to essential health services, while 150 million suffer financial catastrophe annually from out-of-pocket expenditure on health services, and another 100 million are pushed below the poverty line.

UHC refers to health systems in which every single person has access to the health services they need, when and where they need them, without facing financial hardship. UHC is distinct from “universal health access” in that it goes beyond the availability of free health services to disclose whether or not populations are using the services available to them.

UHC is included as a target under UN’s Sustainable Development Goal #3(“Ensure healthy lives and promote well-being for all at all ages”), reflecting worldwide recognition that UHC is fundamental to development. However, achieving the targets set will not simply require the expansion of existing healthcare systems around the world. Instead, healthcare will have to be radically redesigned. Here are four key ways in which countries will need to dramatically reshape their health systems to achieve UHC:

1. Primary care

The delivery of UHC is closely tied to economic and disease transitions worldwide. Recent decades have seen major shifts, with the majority of the world’s population now residing in middle-income countries and the global disease burden shifting from infectious diseases to chronic, non-communicable diseases including cardiovascular conditions, diabetes, cancer and mental health. There is an expectation that UHC will ensure the widespread availability of treatment for these complex chronic conditions. However, no health system will be able to afford to simply treat the growing demand for chronic disease care. Instead, investment is urgently needed in strong primary care systems that focus on “best buys” in health promotion and disease prevention.

2. Health workforce transformation

Health systems only work with the availability of quality healthcare workers. The global economy is projected to create demand for 40 million new health workers by 2030, while low and lower-middle income countries alone need 18 million more health workers if they are to achieve UHC. Based on current investments in workforce development, a shortage of more than 14.5 million healthcare workers is projected in 2030. Moreover, future jobs are likely to be overly concentrated in high-income countries, leaving the regions of South-East Asia and Africa with the most severe shortages, despite high population demands. Notably, medical doctors only account for a small percentage of the health workforce needed. We also need investment in a more diverse and sustainable skills mix. Countries will need to substantially transform and invest in workforce training and delivery models to meet UHC needs or the mismatch in healthcare service supply and demand will only widen.

3. Price transparency for medicine

UHC requires the provision of essential medicines to all who need them at the lowest cost possible. Current drug prices make some essential drugs largely inaccessible, although it is not exactly clear why the medicines remain so expensive. Without this knowledge, it is difficult to assess whether or consumers (both public and private) are getting a fair deal. As part of the push for UHC, the World Health Assembly is set to debate a resolution this May entitled “Improving the transparency of markets for drugs, vaccines and other health-related technologies”. The resolution, if passed, asks national governments to demand greater price transparency as part of regulatory processes, and also gives the WHO a clear global mandate to track and compare drug prices nationally and worldwide. However, more dramatic action will likely be needed to overcome pharmaceutical company reluctance to submit to price transparency and ensure universal essential drug availability.

4. Emphasis on equity

UHC will require that health systems reach diverse populations where they are at, with treatments and modes of delivery that they need and will use, regardless of age, gender, geographic location or financial means. This will require new approaches to reaching marginalized groups that current systems often fail to reach. For example, any successful UHC program will have to take into account the impact of growing numbers of older people and their unique health and social needs. In 2017, there were 926 million people over 60 years old on the planet, with 62% living in developing countries. However, we currently lack data on their illnesses, condition and general health, which means that governments cannot effectively plan for the delivery of health services they need. Likewise, without an intentional and relentless political commitment to gender equality, including the training of more female physicians and other healthcare providers, UHC programmes are likely to fail to meet the specific needs of girls and women.