Universal access to health care across the life course

Abstract

It is an important moment: we are now halfway through the period allotted for the Sustainable Development Goals (SDGs; 2015–30). This is a useful juncture to evaluate our progress and, if necessary, alter course. In global health, a particular focus is SDG 3: “To ensure healthy lives and promote well-being for all at all ages”. Are we on course to ensure good health at all ages? During the last 30 years, investments in impactful interventions—such as vaccines or skilled birth attendance—and improved access to adequate nutrition, safe water and sanitation have substantially reduced child mortality. In a previous issue, we published an estimation of the trend in mortality of under-5s between 1990 and 2019. In this period, under-5 mortality decreased from 93 deaths per 1000 livebirths to 38 deaths per 1000 livebirths: a heartening 59% reduction. Progress has slowed in the SDG era but, nonetheless, target 3.2—ending preventable deaths of children younger than 5 (defined as <25 deaths per 1000 livebirths)—could be achievable. These outcomes are the clear result of smart investments, and they deserve celebration. Unfortunately, similar improvements have not been realised across the life course. In our last issue, a study reported the changes in health-care access and quality (HAQ) over 1990–2019. This study used mortality-to-incidence ratio and risk-standardised rates for 32 causes of death that should not occur with timely and high-quality health care, to determine a HAQ index score for each country, across age groups and social development indices, with higher scores corresponding to higher HAQ. The analysis found a 66% improvement in HAQ in people aged 0–14 years, versus only 51% improvement in those aged 15–64 years and 46% in those aged 65–74 years. Improvements in HAQ among the youngest group were concentrated in low-income countries (LICs). But improvements were muted in the other age groups, particularly in LICs: notably, the disparity between HAQ in high-income countries (HICs) and LICs increased, especially in the oldest group. To achieve equal access to quality care, we must ensure that health improvements in adults catch up to those in children. But why is progress slower after childhood? The HAQ analysis posits a pragmatic reason: averting premature deaths among older people is more complex and costly. Non-communicable diseases (NCDs) such as cardiovascular disease and diabetes are key contributors to illnesses and deaths in adulthood. Preventing and treating NCDs often requires a very broad approach: within the health sector, this will often be investment in disease prevention and screening, but the greatest impact on the NCDs is made outside the health sector—in education, social inclusion and employment, a built environment that enables physical activity, regulation of harmful products (such as tobacco and alcohol), and beyond. A WHO report published in November, Systems for health, stresses the need to take a more holistic view of health systems, investing in horizontal programmes and primary care to improve the long-term health of entire populations. The report argues that health systems need to be resilient: COVID-19 tested their resilience to acute shocks, but they also need to tolerate long-term challenges, such as the increasing burden of NCDs that will accompany ageing populations. Two of the recommendations in Systems for health stand out. First, commonalities across global health initiatives should guide the directions of funders and researchers, to reduce fragmentation of efforts. This principle was a key focus of a Series that we published in 2021, Clinical Trials in Global Health. We strongly support this recommendation: collaboration across work on different diseases that have similar upstream contributors or making use of existing programmes to deliver additional care are fantastic ways to reduce research and resource waste. Second, the report recommends building trust between national governments and those implementing health programmes, to allow more localised control over when funds are deployed and to what, with minimal restrictions. In the second half of the SDG era, it is crucial that we ensure that everyone has access to quality care, irrespective of age and birthplace. The economic climate makes this a tough time to summon political will for long-term investments in health, but the opportunity could soon be lost as chronic disease becomes established in populations. We must invest at the broadest level, maximising synergies and addressing social and political determinants of health, to halt the still widening health disparities at older ages between those in HICs and those in LICs.