Comment
Universal health coverage: not why, what, or when—but how? proportion of interventions provided. Their theoretical discussion offered a helpful thought experiment about the necessary trade-off s that are needed in designing policies to reach UHC. What this discussion lacked was a set of real world case studies of countries in the midst of their difficult quest to achieve UHC. The Lancet Series on UHC in Latin America begins to fill this gap. The Series, 4–7 and an accompanying Health Policy paper,8 chart the complex political, economic, and social forces that shape health policy making in any society. Latin America is a laboratory to study the mechanics of implementing UHC. A common enemy for these governments during the past 20 years has been social inequality. Notions of solidarity, civil society activism, and collective action have therefore been important guiding principles for decision makers. Policies directed at achieving equity, combined with economic growth to create fiscal space for investments in health, have seen 60 million people lifted out of poverty. 4 But despite these successes, Latin American health systems face considerable challenges—persistently wide disparities in health outcomes, fragmentation of health systems, inequitable financing, health services poorly adapted to population needs, and sustainability. These challenges are facing other countries struggling to protect and strengthen their advances towards UHC—eg, in China, Thailand, and even Japan. Can the
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61742-6
Published Online October 16, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61742-6 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)61646-9, http://dx.doi.org/10.1016/ S0140-6736(14)61647-0, http://dx.doi.org/10.1016/ S0140-6736(14)61494-X, and http://dx.doi.org/10.1016/ S0140-6736(14)61467-7 See Online/Health Policy http://dx.doi.org/10.1016/ S0140-6736(14)61780-3
Viviane Moos/Corbis
The argument about universal health coverage (UHC) has been won, and won remarkably quickly. It was only in 2010 that WHO advanced the case for UHC in its World Health Report on health systems financing.1 That report triggered unprecedented demand from countries for advice and assistance about how to deliver UHC. As the end of the Millennium Development Goal era approached, advocates for UHC saw an opportunity to embed their vision for stronger and more equitable health systems into the post-2015 development framework. So far, they have succeeded. The Open Working Group’s proposal for the Sustainable Development Goals (SDGs) includes UHC within its draft health SDG—”Goal 3: Ensure healthy lives and promote well-being for all at all ages”. 2 A sub-goal promises to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”. Although some donor nations and influential foundations have expressed doubt about the wisdom, let alone the feasibility, of UHC as an SDG, it seems almost certain that UHC will make it into international development objectives after 2015. But saying and doing are two very different things. The task of delivering UHC for countries most in need of resilient health systems has barely started. And it is in this realm of complex policy making that little progress has been made. It is no longer a case of “why, what, or when” UHC. It is now about “how”. In setting out their vision for ending preventable mortality within a generation, Dean Jamison and colleagues3 offered the most rigorous framework yet for thinking about how to deliver UHC. They emphasised the value of “progressive universalism”, an efficient and fair means to achieve financial protection and coverage with essential health services.3 Progressive universalism signals a commitment to include the least well off from the very beginning of the journey towards UHC. Jamison and his team tried to answer the question about how to navigate one’s way across the famous cube of UHC—satisfying the three coordinates of proportion of population covered, proportion of population financially protected, and
1
Comment
experience of Latin American nations provide evidence to assist countries facing similar predicaments? The great gap that now exists for countries trying to deliver UHC is access to a library of knowledge—evidence, experience, and resources—to assist their decision making. If countries had a reliable and independent source of information about the advantages and disadvantages, benefits and unanticipated harms, of one particular policy over another, each nation might be able to avoid the mistakes of the past. At present, no such library exists. This Series could provide the basis for such a regional and eventually global resource—and enable a post-2015 target for UHC to be a realistic hope.
1 2
3 4
5
6
7
8
Richard Horton, Pamela Das The Lancet, London NW1 7BY, UK
WHO. World Health Report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization, 2010. Sustainable Development Platform. Outcome Document—Open Working Group on Sustainable Development Goals. http://sustainabledevelopment. un.org/focussdgs.html. (accessed Sept 29, 2014). Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Atun R, Monteiro de Andrade LO, Almeida G, et al. Health-system reform and universal health coverage in Latin America. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/S0140-6736(14)61646-9. Cotlear D, Gómez-Dantés O, Knaul F, et al. Overcoming social segregation in health care in Latin America. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/S0140-6736(14)61647-0. Monteiro de Andrade LO, Filho AP, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. Lancet 2014; published online Oct 16. http://dx.doi. org/10.1016/S0140-6736(14)61494-X. Frenk J. Leading the way towards universal health coverage: a call to action. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/ S0140-6736(14)61467-7. Titelman D, Cetrángolo O, Acosta OL. Universal health coverage in Latin American countries: how to improve solidarity-based schemes. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/ S0140-6736(14)61780-3.
We would like to thank the Rockefeller Foundation and the Economic Commission for Latin America and the Caribbean for their financial support that made this Series possible.
2
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61742-6
Universal health coverage: not why, what, or when—but how? proportion of interventions provided. Their theoretical discussion offered a helpful thought experiment about the necessary trade-off s that are needed in designing policies to reach UHC. What this discussion lacked was a set of real world case studies of countries in the midst of their difficult quest to achieve UHC. The Lancet Series on UHC in Latin America begins to fill this gap. The Series, 4–7 and an accompanying Health Policy paper,8 chart the complex political, economic, and social forces that shape health policy making in any society. Latin America is a laboratory to study the mechanics of implementing UHC. A common enemy for these governments during the past 20 years has been social inequality. Notions of solidarity, civil society activism, and collective action have therefore been important guiding principles for decision makers. Policies directed at achieving equity, combined with economic growth to create fiscal space for investments in health, have seen 60 million people lifted out of poverty. 4 But despite these successes, Latin American health systems face considerable challenges—persistently wide disparities in health outcomes, fragmentation of health systems, inequitable financing, health services poorly adapted to population needs, and sustainability. These challenges are facing other countries struggling to protect and strengthen their advances towards UHC—eg, in China, Thailand, and even Japan. Can the
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61742-6
Published Online October 16, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61742-6 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)61646-9, http://dx.doi.org/10.1016/ S0140-6736(14)61647-0, http://dx.doi.org/10.1016/ S0140-6736(14)61494-X, and http://dx.doi.org/10.1016/ S0140-6736(14)61467-7 See Online/Health Policy http://dx.doi.org/10.1016/ S0140-6736(14)61780-3
Viviane Moos/Corbis
The argument about universal health coverage (UHC) has been won, and won remarkably quickly. It was only in 2010 that WHO advanced the case for UHC in its World Health Report on health systems financing.1 That report triggered unprecedented demand from countries for advice and assistance about how to deliver UHC. As the end of the Millennium Development Goal era approached, advocates for UHC saw an opportunity to embed their vision for stronger and more equitable health systems into the post-2015 development framework. So far, they have succeeded. The Open Working Group’s proposal for the Sustainable Development Goals (SDGs) includes UHC within its draft health SDG—”Goal 3: Ensure healthy lives and promote well-being for all at all ages”. 2 A sub-goal promises to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”. Although some donor nations and influential foundations have expressed doubt about the wisdom, let alone the feasibility, of UHC as an SDG, it seems almost certain that UHC will make it into international development objectives after 2015. But saying and doing are two very different things. The task of delivering UHC for countries most in need of resilient health systems has barely started. And it is in this realm of complex policy making that little progress has been made. It is no longer a case of “why, what, or when” UHC. It is now about “how”. In setting out their vision for ending preventable mortality within a generation, Dean Jamison and colleagues3 offered the most rigorous framework yet for thinking about how to deliver UHC. They emphasised the value of “progressive universalism”, an efficient and fair means to achieve financial protection and coverage with essential health services.3 Progressive universalism signals a commitment to include the least well off from the very beginning of the journey towards UHC. Jamison and his team tried to answer the question about how to navigate one’s way across the famous cube of UHC—satisfying the three coordinates of proportion of population covered, proportion of population financially protected, and
1
Comment
experience of Latin American nations provide evidence to assist countries facing similar predicaments? The great gap that now exists for countries trying to deliver UHC is access to a library of knowledge—evidence, experience, and resources—to assist their decision making. If countries had a reliable and independent source of information about the advantages and disadvantages, benefits and unanticipated harms, of one particular policy over another, each nation might be able to avoid the mistakes of the past. At present, no such library exists. This Series could provide the basis for such a regional and eventually global resource—and enable a post-2015 target for UHC to be a realistic hope.
1 2
3 4
5
6
7
8
Richard Horton, Pamela Das The Lancet, London NW1 7BY, UK
WHO. World Health Report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization, 2010. Sustainable Development Platform. Outcome Document—Open Working Group on Sustainable Development Goals. http://sustainabledevelopment. un.org/focussdgs.html. (accessed Sept 29, 2014). Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Atun R, Monteiro de Andrade LO, Almeida G, et al. Health-system reform and universal health coverage in Latin America. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/S0140-6736(14)61646-9. Cotlear D, Gómez-Dantés O, Knaul F, et al. Overcoming social segregation in health care in Latin America. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/S0140-6736(14)61647-0. Monteiro de Andrade LO, Filho AP, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. Lancet 2014; published online Oct 16. http://dx.doi. org/10.1016/S0140-6736(14)61494-X. Frenk J. Leading the way towards universal health coverage: a call to action. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/ S0140-6736(14)61467-7. Titelman D, Cetrángolo O, Acosta OL. Universal health coverage in Latin American countries: how to improve solidarity-based schemes. Lancet 2014; published online Oct 16. http://dx.doi.org/10.1016/ S0140-6736(14)61780-3.
We would like to thank the Rockefeller Foundation and the Economic Commission for Latin America and the Caribbean for their financial support that made this Series possible.
2
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61742-6
