By Marlee Tichenor
“[What] the world has promised in 1948, Health For All, when WHO was constituted, is true today. But still, half of our population doesn’t have access to healthcare and universal health coverage. Not only in 1948, in 1978, [we] have also recommitted, and now in 2015 with the SDGs, another commitment. I think it’s time to walk our talk, and the world is asking for that. Health is a rights issue. An end in itself. And also, health as a means to development. It’s not actually a waste – it’s the smartest thing to invest in. [That’s why] all roads should lead to universal health coverage. [And] when you say universal health coverage, it’s addressing the financial barrier. It’s addressing the challenge we are facing with regard to access to drugs. Addressing the barriers to equality, access to quality of care and diagnosis.” (Dr. Tedros Adhanom, 24 May 2017)
After he won World Health Organization’s Director General position, Dr. Tedros Adhanom asserted that universal health coverage would be the central political concept of his tenure. He reminded his audience that the human right to health was built into the fabric of WHO since the organization’s establishment in 1948 and that this right was reaffirmed at the International Conference on Primary Health Care in Alma-Ata in the former Soviet Union in 1978. Arguing that the Sustainable Development Goals (SDGs) are a recommitment to that right to health, Dr. Tedros – like Dr. Margaret Chan before him – defines health in this context largely on the individual level, with accessible, affordable clinical health care as the central method to making progress toward the goal of “health for all.”
This is the way that universal health coverage has been framed by SDGs, as well. As I discussed in an earlier blog post, the SDG related to universal health coverage has two components: coverage of quality health services and protection from financial risk. The quality of health services is tracked by measuring coverage of certain “tracer interventions” that are to be defined by country-level authorities’ priorities and definitions of “essential health services.” These are separated into four key areas: (1) reproductive, maternal, newborn and child health, (2) infectious diseases, (3) noncommunicable diseases, and (4) service capacity and access. The quality of services within each of these areas is assessed by quantifying service coverage for the general population as well as for the disadvantaged population, for those who are understood to be covered by certain clinical structures. For example, this institutionalized version of UHC currently defines quality antenatal care by 4+ visits before childbirth and delivery care as an institutional delivery and measures, ideally, the coverage of these services by determining the proportion of the population that is actually receiving these services.
These tracer indicators then define and are used to measure the “quality health services” part of the 3.8 SDG on universal health coverage. These tracer indicators have been, like many of the measurement indicators for the SDGs, subject to serious debate. WHO’s document, 100 Core Health Indicators, has served as the foundation for the list of services that individual countries can use to prioritize which are essential and which are not. The exhaustive nature of the SDGs’ list of tracer indicators and the others that consultants added has made the overall 3.8.1 indicator on coverage of quality health services, as the Central Statistical Office of Poland put it, “so general and capacious that it is difficult to consider it to be inappropriate.” Along with determining the coverage of quality health care, tracking UHC requires pairing this measurement of quality with that of financial risk, structured by WHO and the World Bank’s universal health coverage index.
For the SDG version of universal health coverage, this accessible, individual-based clinical care – this Health For All – is defined by quantified metrics, which mirrors the recent rise in management science for measuring the quality of care in the US and Europe. Centrally crucial to the debate on SDG tracer indicators has been the fact that many data systems do not exist or are not equipped to deal with tracking the indicators as they have been framed. This raises important questions about who currently funds, produces, and uses global health data, and about the nature of data production systems that will be put into place and structured by the SDGs. Because SDGs comprise an unprecedented level of complexity when it comes to the standardized measurement of development progress, it will be important to analyze the impacts of health management science on conceptualizations of community and individual health, in-country and global governance, and health funding mechanisms.
For example, some have argued that the concept of universal health coverage promoted by WHO, the World Bank, and others has the potential to undermine efforts to extend and strengthen public health systems because of this narrowing of care down to individual, curative health care away from population-based public health interventions or preventative treatment. Harald Schmidt, Lawrence Gostin, and Ezekiel Emanuel have argued that focusing narrowly on universal health coverage may lead the global health community to neglect the “equitable improvement of health outcomes through action across all relevant sectors – especially public health interventions.” These scholars and others emphasize the importance of attending to the social determinants of health, or the fact that individual and community health is determined by social, political, and economic conditions outside of one’s access to clinical care, and the important role of the government in approaching health development holistically.
After his victory speech, Dr. Tedros fielded a question about the political role of WHO and whether the organization should advocate for countries to invest more in public health systems rather than promote schemes that can diminish the financial and political role of the government in the health of its citizenry. In response, Dr. Tedros emphasized that the goal – universal health coverage – is the crucial part and that the means to get there are less important, and that countries may take a public approach, a private one, or a mixture of both. As private approaches to UHC have come under increased scrutiny – including the World Bank Group’s Health for Africa initiative that supports private hospitals out of reach of the most vulnerable populations – this question is a foundational one, as well as how the concept of universal health coverage bends or shifts to meet the means that constitute it as the goal.