Comment
plausible, suggestion that low grip strength represents poor health. This explanation is not entirely consistent with the findings of other studies3 that show long-term associations between grip strength in young people and subsequent mortality. An intriguing implication is that grip strength might act as a biomarker of ageing across the life course.9 This is not a new idea, but findings from PURE add support. Loss of grip strength is unlikely to lie on a single final common pathway for the adverse effects of ageing, but it might be a particularly good marker of underlying ageing processes, perhaps because of the rarity of muscle-specific diseases contributing to change in muscle function. Interestingly, similar age-related changes have been reported in other species, such as Caenorhabditis elegans.10,11 Life-course normative data12 have been described in a UK setting, and birth and ageing cohort studies, particularly those with long-term longitudinal data,13 provide ideal opportunities to explore this hypothesis. Furthermore, linkage of epidemiological findings to new approaches in muscle biology could yield informative insights into the nature of human ageing.
We declare no competing interests. 1 2
3
4 5
6
7 8
9 10
11 12
13
*Avan Aihie Sayer, Thomas B L Kirkwood MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK (AAS); and Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK (AAS, TBLK) [email protected]
Gale CR, Martyn CN, Cooper C, Sayer AA. Grip strength, body composition, and mortality. Int J Epidemiol 2007; 36: 228–35. Rantanen T, Harris T, Leveille SG, et al. Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. J Gerontol A Biol Sci Med Sci 2000; 55: M168–73. Ortega FB, Silventoinen K, Tynelius P, Rasmussen F. Muscular strength in male adolescents and premature death: cohort study of one million participants. BMJ 2012; 345: e7279. Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging adults. J Geriatr Phys Ther 2008; 31: 3–10. Cooper R, Kuh D, Hardy R, on behalf of the FALCon and HALCyon study teams. Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ 2010; 341: c4467. Leong DP, Teo KT, Rangarajan S, et al; on behalf of the Prospective Urban Rural Epidemiology (PURE) Study investigators. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015; published online May 14. http://dx.doi.org/10.1016/ S0140-6736(14)62000-6. Yusuf S, Rangarajan S, Teo K, et al. Cardiovascular risk and events in 17 low-, middle- and high-income countries. N Engl J Med 2014; 371: 818–27. Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip strength and cause-specific and total mortality in older disabled women: exploring the mechanism. J Am Geriatr Soc 2003; 51: 636–41. Syddall H, Cooper C, Martin F, Briggs R, Aihie Sayer A. Is grip strength a useful single marker of frailty? Age Ageing 2003; 32: 650–56. Herndon LA, Schmeissner PJ, Dudaronek JM, et al. Stochastic and genetic factors influence tissue-specific decline in ageing C elegans. Nature 2002; 419: 808–14. Kirkwood TBL. Untangling functional declines in the locomotion of aging worms. Cell Metabol 2013; 18: 303–04. Dodds RM, Syddall HE, Cooper R, et al. Grip strength across the life course: normative data from twelve British studies. PLoS One 2014; 9: e113637. Stenholm S, Tiainen K, Rantanen T, et al. Long-term determinants of muscle strength decline: prospective evidence from the 22-year mini-Finland follow up survey. J Am Geriatr Soc 2012; 60: 77–85.
Universal health coverage: progressive taxes are key On Dec 12, 2012, a UN General Assembly Resolution was passed unanimously which called on all countries to move their health systems towards universal health coverage (UHC).1 Interestingly, this resolution was cosponsored by the USA—a country not known for having achieved this goal. With UHC now a common objective for all health systems, the debate is shifting to how countries should achieve it. Particularly since publication of the 2010 World Health Report,2 there has been growing interest in how countries should finance their health systems to reach the twin goals of universal coverage of effective health services and financial protection from the costs of these services. Most recent research evidence in this area is now showing that public www.thelancet.com Vol 386 July 18, 2015
financing is the key to achieving UHC.3 For example, in the 2012 Lancet Series on UHC, Moreno-Serra and Smith4 showed that pooled public financing resulted in improved health outcomes; private voluntary insurance had no effect on indicators, and a greater share of out-of-pocket expenditure was associated with higher mortality rates. In The Lancet, Aaron Reeves and colleagues5 reinforce these findings on the benefits of public financing, but now provide new research evidence on which specific public financing mechanisms have the greatest effect on UHC indicators. Using longitudinal data from 89 low-income and middle-income countries from 1995 to 2011, they show that increasing general taxation financing was associated with increased
Published Online May 15, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60868-6 See Articles page 274
227
William Campbell/Corbis
Comment
health service coverage and improved financial protection. These associations were particularly pronounced in countries with low tax revenues (less than US$1000 per capita per year). Here “an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points (95 % CI 0·87–12·6) and the extent of financial coverage by 11·4 percentage points (5·51–17·2)”.5 Furthermore, Reeves and colleagues’ findings show that how tax revenues are sourced also matters: progressive tax revenues from profits, capital, and income are much more effective in generating public funds for health than are consumption taxes. Also, whereas some indirect taxes (for example on luxury goods) are not likely to affect poor people adversely, and other indirect taxes might help improve health outcomes (for example taxes on tobacco and alcohol), other consumption taxes are highly regressive. Health-care user fees and copayments, for example, represent a consumption tax on the sick that take countries away from UHC and adversely affect health outcomes. Reeves and colleagues5 show that infant mortality rates are strongly associated with consumption taxes that include taxes on health services (0·50%, 95% CI 0·18–0·83).5 In presenting their evidence, the authors highlight shortfalls in the quantity and quality of international data for UHC and health financing indicators. If UHC is to be incorporated into the Sustainable Development Goal for health, it will need to be addressed as a top 228
priority. The ongoing work by the World Bank and WHO to develop an appropriate UHC monitoring framework6 and strengthen health information systems should therefore be welcomed. In using existing data sources, a limitation of Reeves and colleagues’ study5 is that the authors seem to downplay the potential role of compulsory social health insurance (SHI) payments to public health financing. Since these contributions are also, in effect, a progressive tax on incomes, this position is unfortunate and might give the impression that SHI financing systems are inferior to those financed by general taxation. This impression would be misleading, because health financing debates are tending to move beyond comparisons of the merits of pure Beveridge (general taxation) and Bismarck (SHI) models.7 In fact, many low-income and middle-income countries are developing hybrid health financing systems that mix SHI contributions and general taxation revenues.8 In recognising the superiority of progressive, compulsory public financing mechanisms over private voluntary health financing, it would be useful if future research in this area could include SHI contributions too. The findings of Reeves and colleagues,5 similarly to those of the 2012 report Transitions in Health Financing and Policies for Universal Health Coverage,9 have profound implications for health development policy. Both of these papers highlight the importance of public financing reforms in delivering UHC, and recognise that political processes are driving these transitions. As Savedoff and colleagues9 argue: “The clearest explanation for the long-term rise in the pooled share of health spending is the persistence of political demands for universalising health coverage.” With this being the case, and with aid financing potentially crowding out domestic tax financing,10 this argument suggests that development agencies should become much more engaged with the political economy of health financing reforms. As Reeves and colleagues5 propose, this involvement could include helping countries to expand their overall fiscal capacity, but could also require encouraging countries to allocate greater shares of their tax revenues to the health sector. The example given of India is an excellent one, where the share of gross domestic product allocated to public health financing and health coverage indicators are www.thelancet.com Vol 386 July 18, 2015
Comment
some of the lowest in the world.11 Furthermore, in view of the size of India’s economy and the political context of the country,12 external aid financing is unlikely to have much effect on closing coverage gaps in India. In view of the experience of other large middle-income countries,13 only domestic health financing reforms will deliver UHC to the Indian population. Such reforms will also have a beneficial effect on global health security, for which extending effective health coverage might provide the best defence against the threat from epidemics of infectious diseases and the growing burden of non-communicable diseases.14 As the current Ebola epidemic and growing rates of multidrug resistant tuberculosis show, it is in everybody’s interests to reach universal coverage of some health services. If UHC is to be realised globally, health development agencies should therefore be paying a much keener interest in helping countries make the transition to financing their health systems publicly.
2
3
4 5
6
7
8
9
10
11
Robert Yates UHC Policy Forum, Chatham House, London SW1Y 4LE, UK [email protected]
12
I declare no competing interests.
13
Copyright © Yates. Open Access article distributed under the terms of CC BY. 1
United Nations. United Nations General Assembly resolution on global health and foreign policy A/67/L.3: resolution adopted by the General Assembly on 12 December 2012. http://www.un.org/en/ga/search/view_ doc.asp?symbol=A/RES/67/81 (accessed April 24, 2015).
www.thelancet.com Vol 386 July 18, 2015
14
World Health Organization. World Health Report. Health systems financing—the path to universal coverage. Geneva: World Health Organization, 2010. Rottingen JA, Ottersen T, Ablo A, et al. Shared responsibilities for health—a coherent global framework for health financing. Final report of the Centre on Global Health Security Working Group on Health Financing. London: Chatham House, 2014. Moreno-Serra R, Smith PC. Does progress towards universal health coverage improve population health? Lancet 2012; 380: 917–23. Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D. Financing universal health coverage—effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries. Lancet 2015; published online May 15. http://dx.doi.org/10.1016/S0140-6736(15)60574-8. World Bank, World Health Organization. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets, May 2014. Geneva: World Health Organization, 2014. Kutzin J, Ibraimova A, Jakab M, O’Dougherty S. Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan. Bull World Health Organ 2009; 87: 549–54. Maeda A, Cashin C, Harris J, Ikegami N, Reich M. Universal health coverage for inclusive and sustainable development: a synthesis of 11 country case studies. Washington DC: The World Bank, 2014. Savedoff WD, Bitrán R, De Ferranti D, et al. Transitions in health financing and policies for universal health coverage: final report of the transitions in health financing project. Washington DC: Results for Development Institute, 2012. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. Public financing of health in developing countries: a cross-national systematic analysis. Lancet 2010; 375: 1375–87. Reddy KS, Patel V, Jha P, Paul VK, Kumar AKS, Dandona L. Towards achievement of universal health care in India by 2020: a call to action. Lancet 2011; 377: 760–68. Gilligan A. India tells Britain: we don’t want your aid. The Telegraph Feb 4, 2012. http://www.telegraph.co.uk/news/worldnews/asia/india/9061844/ India-tells-Britain-We-dont-want-your-aid.html (accessed May 6, 2015). Evans TG, Chowdhury AMR, Evans DG, et al. Thailand’s universal coverage scheme successes and challenges—an independent assessment of the first 10 years (2001–2011). Nonthaburi, Thailand: Health Insurance System Research Office, 2012. Heymann DL, Chen LC, Takemi K, et al. Global health security: the wider lessons from the Ebola outbreak. Lancet 2015; 385: 1884–901.
229
plausible, suggestion that low grip strength represents poor health. This explanation is not entirely consistent with the findings of other studies3 that show long-term associations between grip strength in young people and subsequent mortality. An intriguing implication is that grip strength might act as a biomarker of ageing across the life course.9 This is not a new idea, but findings from PURE add support. Loss of grip strength is unlikely to lie on a single final common pathway for the adverse effects of ageing, but it might be a particularly good marker of underlying ageing processes, perhaps because of the rarity of muscle-specific diseases contributing to change in muscle function. Interestingly, similar age-related changes have been reported in other species, such as Caenorhabditis elegans.10,11 Life-course normative data12 have been described in a UK setting, and birth and ageing cohort studies, particularly those with long-term longitudinal data,13 provide ideal opportunities to explore this hypothesis. Furthermore, linkage of epidemiological findings to new approaches in muscle biology could yield informative insights into the nature of human ageing.
We declare no competing interests. 1 2
3
4 5
6
7 8
9 10
11 12
13
*Avan Aihie Sayer, Thomas B L Kirkwood MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK (AAS); and Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK (AAS, TBLK) [email protected]
Gale CR, Martyn CN, Cooper C, Sayer AA. Grip strength, body composition, and mortality. Int J Epidemiol 2007; 36: 228–35. Rantanen T, Harris T, Leveille SG, et al. Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. J Gerontol A Biol Sci Med Sci 2000; 55: M168–73. Ortega FB, Silventoinen K, Tynelius P, Rasmussen F. Muscular strength in male adolescents and premature death: cohort study of one million participants. BMJ 2012; 345: e7279. Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging adults. J Geriatr Phys Ther 2008; 31: 3–10. Cooper R, Kuh D, Hardy R, on behalf of the FALCon and HALCyon study teams. Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ 2010; 341: c4467. Leong DP, Teo KT, Rangarajan S, et al; on behalf of the Prospective Urban Rural Epidemiology (PURE) Study investigators. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015; published online May 14. http://dx.doi.org/10.1016/ S0140-6736(14)62000-6. Yusuf S, Rangarajan S, Teo K, et al. Cardiovascular risk and events in 17 low-, middle- and high-income countries. N Engl J Med 2014; 371: 818–27. Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip strength and cause-specific and total mortality in older disabled women: exploring the mechanism. J Am Geriatr Soc 2003; 51: 636–41. Syddall H, Cooper C, Martin F, Briggs R, Aihie Sayer A. Is grip strength a useful single marker of frailty? Age Ageing 2003; 32: 650–56. Herndon LA, Schmeissner PJ, Dudaronek JM, et al. Stochastic and genetic factors influence tissue-specific decline in ageing C elegans. Nature 2002; 419: 808–14. Kirkwood TBL. Untangling functional declines in the locomotion of aging worms. Cell Metabol 2013; 18: 303–04. Dodds RM, Syddall HE, Cooper R, et al. Grip strength across the life course: normative data from twelve British studies. PLoS One 2014; 9: e113637. Stenholm S, Tiainen K, Rantanen T, et al. Long-term determinants of muscle strength decline: prospective evidence from the 22-year mini-Finland follow up survey. J Am Geriatr Soc 2012; 60: 77–85.
Universal health coverage: progressive taxes are key On Dec 12, 2012, a UN General Assembly Resolution was passed unanimously which called on all countries to move their health systems towards universal health coverage (UHC).1 Interestingly, this resolution was cosponsored by the USA—a country not known for having achieved this goal. With UHC now a common objective for all health systems, the debate is shifting to how countries should achieve it. Particularly since publication of the 2010 World Health Report,2 there has been growing interest in how countries should finance their health systems to reach the twin goals of universal coverage of effective health services and financial protection from the costs of these services. Most recent research evidence in this area is now showing that public www.thelancet.com Vol 386 July 18, 2015
financing is the key to achieving UHC.3 For example, in the 2012 Lancet Series on UHC, Moreno-Serra and Smith4 showed that pooled public financing resulted in improved health outcomes; private voluntary insurance had no effect on indicators, and a greater share of out-of-pocket expenditure was associated with higher mortality rates. In The Lancet, Aaron Reeves and colleagues5 reinforce these findings on the benefits of public financing, but now provide new research evidence on which specific public financing mechanisms have the greatest effect on UHC indicators. Using longitudinal data from 89 low-income and middle-income countries from 1995 to 2011, they show that increasing general taxation financing was associated with increased
Published Online May 15, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60868-6 See Articles page 274
227
William Campbell/Corbis
Comment
health service coverage and improved financial protection. These associations were particularly pronounced in countries with low tax revenues (less than US$1000 per capita per year). Here “an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points (95 % CI 0·87–12·6) and the extent of financial coverage by 11·4 percentage points (5·51–17·2)”.5 Furthermore, Reeves and colleagues’ findings show that how tax revenues are sourced also matters: progressive tax revenues from profits, capital, and income are much more effective in generating public funds for health than are consumption taxes. Also, whereas some indirect taxes (for example on luxury goods) are not likely to affect poor people adversely, and other indirect taxes might help improve health outcomes (for example taxes on tobacco and alcohol), other consumption taxes are highly regressive. Health-care user fees and copayments, for example, represent a consumption tax on the sick that take countries away from UHC and adversely affect health outcomes. Reeves and colleagues5 show that infant mortality rates are strongly associated with consumption taxes that include taxes on health services (0·50%, 95% CI 0·18–0·83).5 In presenting their evidence, the authors highlight shortfalls in the quantity and quality of international data for UHC and health financing indicators. If UHC is to be incorporated into the Sustainable Development Goal for health, it will need to be addressed as a top 228
priority. The ongoing work by the World Bank and WHO to develop an appropriate UHC monitoring framework6 and strengthen health information systems should therefore be welcomed. In using existing data sources, a limitation of Reeves and colleagues’ study5 is that the authors seem to downplay the potential role of compulsory social health insurance (SHI) payments to public health financing. Since these contributions are also, in effect, a progressive tax on incomes, this position is unfortunate and might give the impression that SHI financing systems are inferior to those financed by general taxation. This impression would be misleading, because health financing debates are tending to move beyond comparisons of the merits of pure Beveridge (general taxation) and Bismarck (SHI) models.7 In fact, many low-income and middle-income countries are developing hybrid health financing systems that mix SHI contributions and general taxation revenues.8 In recognising the superiority of progressive, compulsory public financing mechanisms over private voluntary health financing, it would be useful if future research in this area could include SHI contributions too. The findings of Reeves and colleagues,5 similarly to those of the 2012 report Transitions in Health Financing and Policies for Universal Health Coverage,9 have profound implications for health development policy. Both of these papers highlight the importance of public financing reforms in delivering UHC, and recognise that political processes are driving these transitions. As Savedoff and colleagues9 argue: “The clearest explanation for the long-term rise in the pooled share of health spending is the persistence of political demands for universalising health coverage.” With this being the case, and with aid financing potentially crowding out domestic tax financing,10 this argument suggests that development agencies should become much more engaged with the political economy of health financing reforms. As Reeves and colleagues5 propose, this involvement could include helping countries to expand their overall fiscal capacity, but could also require encouraging countries to allocate greater shares of their tax revenues to the health sector. The example given of India is an excellent one, where the share of gross domestic product allocated to public health financing and health coverage indicators are www.thelancet.com Vol 386 July 18, 2015
Comment
some of the lowest in the world.11 Furthermore, in view of the size of India’s economy and the political context of the country,12 external aid financing is unlikely to have much effect on closing coverage gaps in India. In view of the experience of other large middle-income countries,13 only domestic health financing reforms will deliver UHC to the Indian population. Such reforms will also have a beneficial effect on global health security, for which extending effective health coverage might provide the best defence against the threat from epidemics of infectious diseases and the growing burden of non-communicable diseases.14 As the current Ebola epidemic and growing rates of multidrug resistant tuberculosis show, it is in everybody’s interests to reach universal coverage of some health services. If UHC is to be realised globally, health development agencies should therefore be paying a much keener interest in helping countries make the transition to financing their health systems publicly.
2
3
4 5
6
7
8
9
10
11
Robert Yates UHC Policy Forum, Chatham House, London SW1Y 4LE, UK [email protected]
12
I declare no competing interests.
13
Copyright © Yates. Open Access article distributed under the terms of CC BY. 1
United Nations. United Nations General Assembly resolution on global health and foreign policy A/67/L.3: resolution adopted by the General Assembly on 12 December 2012. http://www.un.org/en/ga/search/view_ doc.asp?symbol=A/RES/67/81 (accessed April 24, 2015).
www.thelancet.com Vol 386 July 18, 2015
14
World Health Organization. World Health Report. Health systems financing—the path to universal coverage. Geneva: World Health Organization, 2010. Rottingen JA, Ottersen T, Ablo A, et al. Shared responsibilities for health—a coherent global framework for health financing. Final report of the Centre on Global Health Security Working Group on Health Financing. London: Chatham House, 2014. Moreno-Serra R, Smith PC. Does progress towards universal health coverage improve population health? Lancet 2012; 380: 917–23. Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D. Financing universal health coverage—effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries. Lancet 2015; published online May 15. http://dx.doi.org/10.1016/S0140-6736(15)60574-8. World Bank, World Health Organization. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets, May 2014. Geneva: World Health Organization, 2014. Kutzin J, Ibraimova A, Jakab M, O’Dougherty S. Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan. Bull World Health Organ 2009; 87: 549–54. Maeda A, Cashin C, Harris J, Ikegami N, Reich M. Universal health coverage for inclusive and sustainable development: a synthesis of 11 country case studies. Washington DC: The World Bank, 2014. Savedoff WD, Bitrán R, De Ferranti D, et al. Transitions in health financing and policies for universal health coverage: final report of the transitions in health financing project. Washington DC: Results for Development Institute, 2012. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. Public financing of health in developing countries: a cross-national systematic analysis. Lancet 2010; 375: 1375–87. Reddy KS, Patel V, Jha P, Paul VK, Kumar AKS, Dandona L. Towards achievement of universal health care in India by 2020: a call to action. Lancet 2011; 377: 760–68. Gilligan A. India tells Britain: we don’t want your aid. The Telegraph Feb 4, 2012. http://www.telegraph.co.uk/news/worldnews/asia/india/9061844/ India-tells-Britain-We-dont-want-your-aid.html (accessed May 6, 2015). Evans TG, Chowdhury AMR, Evans DG, et al. Thailand’s universal coverage scheme successes and challenges—an independent assessment of the first 10 years (2001–2011). Nonthaburi, Thailand: Health Insurance System Research Office, 2012. Heymann DL, Chen LC, Takemi K, et al. Global health security: the wider lessons from the Ebola outbreak. Lancet 2015; 385: 1884–901.
229
