Universal Health Coverage and Essential Packages of Care

Affordable treatment and political commitment are crucial to eliminate hepatitis C globally

Global health 2035: a world converging within a generation

Economic Burden of Chronic Ill Health and Injuries for Households in Low- and Middle-Income Countries

Multiple criteria are involved in making decisions and prioritizing health policies (Baltussen and Niessen 2006). Potential trade-offs between efficiency and equity are among these criteria and have long been emphasized in the treatment and prevention of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (for example, Cleary 2010; Kaplan and Merson 2002; Verguet 2013). Notably, several mathematical frameworks, including mathematical programming, have proposed incorporating equity into resource allocation decisions in the public sector (Birch and Gafni 1992; Bleichrodt, Diecidue, and Quiggin 2004; Epstein and others 2007; Segall 1989; Stinnett and Paltiel 1996). The worldwide application of benefit-cost analysis provided for “distributional weights” as early as the 1970s.Protection from financial risks associated with health care expenses is emerging as a critical component of national health strategies in many low- and middle-income countries (LMICs). The World Health Organization’s World Health Reports of 1999 and 2000 included the provision of financial risk protection (FRP) as one criterion of good performance for health systems (WHO 1999, 2000). Reducing these financial risks is one objective of health policy instruments such as universal public finance (UPF), that is, full public finance irrespective of whether services are provided privately or publicly. Indeed, out-of-pocket (OOP) medical payments can lead to impoverishment in many countries, with households choosing from among many coping strategies (borrowing from friends and relatives, selling assets) to manage health-related expenses (Kruk, Goldmann, and Galea 2009; van Doorslaer and others 2006; Xu and others 2003). Absent other financing mechanisms, household medical expenditures can often be catastrophic (Wagstaff 2010; Wagstaff and van Doorslaer 2003), defined as exceeding a certain fraction of total household expenditures. A large literature documents the significance of medical impoverishment, but far less is known about the medical conditions responsible for it. Essue and others (2017), in chapter 6 of this volume, review and extend that literature, and Verguet, Memirie, and Norheim (2016) provide a framework for assessing the global burden of medical impoverishment by cause, applying it to a case study of a systematic categorization by disease in Ethiopia. In the literature on medical impoverishment, attenuating such impoverishment is considered a significant objective of health policy, but surprisingly little analysis has been performed of efficient ways to address the problem. The method of Extended cost-effectiveness analysis (ECEA) was initially developed for DCP3 by Verguet, Laxminarayan, and Jamison (2015).Traditionally, economic evaluations of health interventions (cost-effectiveness analyses [CEAs]) have focused on improvements in health and estimated an intervention cost per health gain in dollar per death averted or dollar per disability-adjusted life year (DALY) averted (Jamison and others 2006). However, arguments have been developed for some time that CEA in health should be extended to explicitly consider the multiple dimensions of outcome. Jamison (2009), for example, argued that CEAs can be extended to include FRP on the outcome side and use of scarce health system capacity on the cost side (figure 8.1). Specific methods for advancing this agenda were first proposed and applied in assessments of the consequences of two alternative policies—public finance and improved access to credit—for extending coverage of tuberculosis treatment in India (Verguet, Laxminarayan, and Jamison 2015). That study and other early ECEAs (Verguet 2013; Verguet, Gauvreau, and others 2015; Verguet, Olson, and others 2015) supplemented traditional economic evaluation with evaluation of nonhealth benefits (such as FRP and equity), with the broad objective of providing valuable guidance in the design of health policies.ECEA in this respect builds on the existing frameworks of cost-benefit analysis and cost-consequence analysis that tabulate disaggregated results (Mauskopf and others 1998) and on analytical frameworks that incorporate equity and FRP concerns into economic evaluations (Asaria and others 2015; Brown and Finkelstein 2008; Cookson, Drummond, and Weatherly 2009; Finkelstein and McKnight 2008; Fleurbaey and others 2013; McClellan and Skinner 2006; Sassi, Archard, and Le Grand 2001; Smith 2007, 2013). It enables the design of benefits packages that quantify both health and nonhealth benefits for a given expenditure on specific health policies, based on the quantitative inclusion of how much nonhealth benefits are being bought as well as how much health benefits are being bought with a given investment in an intervention or policy. In this respect, ECEA can answer some of the policy questions raised by the World Health Reports for 2010 and 2013 (WHO 2010, 2013) regarding how to select and sequence the health services to be provided on the path toward universal health coverage. This chapter first describes the ECEA approach and then summarizes findings of ECEAs undertaken in the context of the third edition of Disease Control Priorities (DCP3; http://www.dcp-3.org ).

Universal health coverage (UHC) continues to receive considerable attention from the global health community. UHC was the main topic of the 2010 World Health Report (WHO 2010), the main topic in 2012 issues of The Lancet (2012) and Health Policy and Planning (McIntyre and Mills 2012), and the theme of the Second Global Symposium on Health Systems Research in Beijing in 2012. Margaret Chan, Director-General of the World Health Organization (WHO), stated that “universal health coverage [is] the single most powerful concept that public health has to offer” (Chan 2012). This continued attention led to the 2013 World Health Report, which discusses the role that research can play in answering important questions about UHC (WHO 2013).Although substantial variation is a hallmark of UHC initiatives, UHC is generally viewed along three dimensions: who is covered, what services are covered, and the proportion of the costs that are covered (WHO 2010). One financing option, universal public finance (UPF), involves the government shouldering the entire cost of specific services, regardless of who receives them. The potential benefits of UPF include improved health outcomes and improved financial risk protection (FRP). However, the evidence available to policy makers is limited with respect to the magnitude and distribution of these benefits.Extended cost-effectiveness analysis (ECEA) (Verguet, Gauvreau, and others 2015; Verguet and Jamison 2015; Verguet, Laxminarayan, and Jamison 2015; Verguet, Olson, and others 2015; Verguet and others 2013) provides a tool with which to gain a more complete understanding of the health and financial benefits associated with different health policies and interventions. ECEA combines the traditional health system perspective of cost-effectiveness analysis (CEA) with the patient perspective, notably through the quantification of the benefits associated with avoiding medical impoverishment and the assessment of the distributional consequences, that is equity, of policies (Verguet, Laxminarayan, and Jamison 2015). This tool helps policy makers make decisions based on the joint benefits and tradeoffs associated with different policies and interventions, specifically in health gains, FRP and equity benefits.In 2013 in Ethiopia, about 60,000 children under age five years died as a result of pneumonia or diarrhea, the fifth-highest absolute level worldwide (IVAC 2013). Studies have associated the incidence of both conditions with socioeconomic status (Fekadu, Terefe, and Alemie 2014; Mihrete, Alemie, and Teferra 2014), suggesting that an evaluation of the impact of prevention and treatment services by income quintile would be suitable.This chapter uses ECEA methods to examine UPF of the prevention and treatment of pneumonia and diarrhea in Ethiopia, with a focus on children under age five years. The combination of prevention and treatment options illustrates health and FRP benefits brought by the different intervention packages available to decision makers. This analysis also examines these benefits by income quintile so that policy makers can better understand how each package affects different segments of the population—a critical element of UHC. A 20 percentage point increase in coverage is modeled. Our purpose is to expose with simplicity the broad implications for policy makers rather than to provide them with definitive estimates, hence the presentation of limited rudimentary sensitivity analyses. After we summarize current child health services in Ethiopia, we outline the methods used in this chapter, which draw from the ECEA methodology (Verguet, Laxminarayan, and Jamison 2015). Then, we present results—both health and financial protection—for the following:Finally, we discuss the implications of the findings and conclude.

BackgroundCountries are recommended to progressively work towards universal health coverage (UHC), and to make explicit choices regarding the expansion of priority services. However, there is little guidance on how to...

When is a country financially ready to implement universal health coverage (UHC), a health policy designed to ensure that all citizens receive the health services they need without financial hardship?...

OPINION article Front. Public Health, 15 October 2015Sec. Public Health Policy Volume 3 - 2015 | https://doi.org/10.3389/fpubh.2015.00238

In this edition of the Bulletin, Marks-Sultan et al.1 propose that the World Health Organization (WHO) should provide capacity-building for drafting health laws in Member States. They highlight that WHO has the authority and credibility to work with countries to make their national laws easier to access, understand, monitor and evaluate. WHO’s new technical support work related to universal health coverage (UHC) laws is a good example of its support for Member States in this important area. Strengthening countries’ legal and regulatory frameworks and engaging in universal health coverage-compliant law reforms has been missing from the universal health coverage agenda. WHO calls on Member States to align their health system policies with universal health coverage goals such as equity, efficiency, health service quality and financial risk protection. Strengthening health systems using health laws and legal frameworks is a pivotal means for attaining these goals2 and achieving sustainable results in health security and resilience. Laws are needed to ensure the equity, quality and safety of health services and financial protection for health system users. A strong legal framework sets the rules for how the health system functions, establishes a legal mandate for access to health services and provides the means by which a national government can implement universal health coverage at a population level. Several governments have already successfully used their health laws in service of their universal health coverage goals. For example, the governments of the Bolivarian Republic of Venezuela, Brazil, Chile, Colombia, Cuba, Mexico, Peru and Uruguay have all legislated a right to health, which entitles their citizens to expanded access to health services. To date, countries’ legal and regulatory frameworks have not been systematically assessed for their compatibility with the goals of universal health coverage. Work on law reform so far has only focused on individual laws rather than on creating a supportive legal environment for universal health coverage. In many countries, information is lacking on the extent to which existing national laws support or block the goals of universal health coverage.3 A different approach is required. WHO thus recommends that countries analyse their existing legal and regulatory frameworks at international, national and local level and assess their compatibility with universal health coverage, with the ultimate aim of ensuring a legal environment that supports the functioning of the entire health system. In practice, the work on universal health coverage law reform is highly technical and political. It involves legal analysis, multi-stakeholder dialogue and policy discussions.4 A government’s capacity to make and enforce laws and its broader political and economic situation, heavily influence whether law reform can happen. Technical law makers alone cannot address these issues. For example, in Turkey, a universal health coverage reform process included policy dialogue and reflection on the necessary supporting legal reform needed and this consultation led to an accelerated universal health coverage reform implementation.5 Turkey’s experience demonstrates the centrality of law-related policy discussions and multi-stakeholder dialogue on law reform and their importance for the ultimate success of UHC reform. WHO’s technical support to Member States on universal health coverage laws should similarly take a systems approach. In response to requests from its Member States, WHO is working to help governments create supportive legal environments for universal health coverage through legal environment assessments, specialist technical support, multi-stakeholder policy dialogue and advice and guidance on law reform.

In November 2022, the World Health Organization (WHO) launched the first Global Oral Health Status Report (GOHSR) that describes the status of oral health care in the 195 member states. In the present editorial, we summarize the key findings of the GOHSR report and discuss the successes and pitfalls of the suggested remedy strategies. The WHO GOHSR report that is available online was used to summarize and discuss in the present editorial. The report highlights that globally close to 3.5 billion people suffer from oral diseases, with South-East Asian and Western Pacific countries having the highest caseloads. Key issues that have led to the unproportionally high-rise in the caseloads include political, socio-economic, familial, and historical experiences of the communities, ever-growing power, and sophistication of targeted commercial advertisements, negligent attitude of the policy planners and insurance companies, and lack of funding in oral health research and instrumentalization of proper surveillance tools. Global strategies for improving dental health needs to be tailored for each country given the logistical and financial challenges with self-care and regular dental hygiene proving to be the most effective factors in preventing dental diseases.

Accelerating action towards universal health coverage by applying a gender lens

Women's rights will drive universal health coverage

Recent improvements in prevention and treatment have led to marked reductions in age-standardized mortality rates from cardiovascular disease (CVD) in low- and middle-income countries (LMICs). However, because of rapid population growth and aging in these countries, the number of fatal and nonfatal cases of CVD continues to rise (Roth and others 2015). This increase in the absolute burden of CVD is accompanied by an increase in the economic impact of CVD that includes financial risks related to accessing treatment (Bloom and others 2011; Jha and others 2013). The findings from a systematic review indicate incidence of catastrophic health expenditure (CHE) of greater than 70 percent in patients with CVD or stroke in China, India, and Tanzania, and 68 percent in patients with cancer (Huffman and others 2011).CVD and its risk factors are frequently distributed across populations in different ways. A popular notion is that CVD is a condition of older, urban males; however, evidence suggests that younger individuals in poorer and rural areas are often disproportionately affected (Gaziano 2009). Furthermore, recent studies have shown that the poorest countries and world regions have the highest incidence and case-fatality ratios from CVD, compared with the wealthiest areas. This observation could be due in part to disparities in access to health services in general and evidence-based interventions in particular (Yusuf and others 2014).Extended cost-effectiveness analysis (ECEA) is a new economic evaluation method developed as part of the Disease Control Priorities Network grant funded by the Bill & Melinda Gates Foundation and the Disease Control Priorities, 3rd edition (DCP3, http://www.dcp-3.org ). The rationale for ECEA is to extend the scope of cost-effectiveness analysis (CEA) to assess health policies more adequately. CEA centers on the summary metric of incremental cost-effectiveness—cost per amount of health gained—and is a key part of health technology assessment.ECEA goes beyond simply measuring health outcomes to estimate incremental gains in nonhealth outcomes that are important to health systems, such as financial risk protection (FRP) and distributional consequences like equity and fairness (Verguet, Laxminarayan, and Jamison 2015). ECEA results are usually presented in “dashboard” format, that is, disaggregated into health and nonhealth outcomes per dollar spent on a particular health policy and estimated separately for different socioeconomic groups. ECEA is well designed to respond to the policy questions posed in the World Health Reports of 2010 and , specifically, how to move efficiently to universal health coverage (UHC) (WHO 2010, 2013).This chapter summarizes lessons learned from three ECEAs that have been conducted on CVD risk factor reduction policies for DCP3. Specifically, it highlights new insights that these ECEAs have provided into the differential impacts of well-established CVD prevention interventions. It also identifies priority issues for future ECEAs to address, and draws some conclusions and implications for public health policy.

The Role of the WFSA in Reaching the Goals of the Lancet Commission on Global Surgery.

In 2020, an estimated 596 million people worldwide had distance vision impairment and a further 510 million had uncorrected near vision impairment.1 Most of these people live in low-income and middle-income countries (LMIC). Eye health is also affected by conditions that do not, at least initially, impair vision. Although these conditions are not currently included in global prevalence estimates, they contribute substantially to the unmet need for eye health services. Vision is important for many aspects of life, and vision impairment can profoundly affect individuals, families, and society. Eye health touches all lives, either directly or indirectly, through its impact on those close to us. The year 2020 marks the culmination of the global initiative to eliminate avoidable blindness, VISION 2020: The Right to Sight (appendix 1 p 7). This initiative provided the framework for national programmes to address eye health over the past 20 years. In 2019, WHO published the World report on vision,2 which was endorsed by the 73rd World Health Assembly in 2020. The report and resolution call for the advancing of eye health as an integral part of universal health coverage, by implementation of integrated people-centred eye care, following the approach outlined in a broader health services framework.3 The Lancet Global Health Commission on Global Eye Health contends that eye health should be part of the mainstream agenda to achieve universal health coverage and sustainable development. We define eye health as the state in which vision, ocular health, and functional ability are maximised, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health can be considered both a process and an outcome. We define eye care services as those that contribute to any of vision, ocular health, or functional ability being maximised. This report broadly divides into two halves. First, we present evidence for the importance of eye health, supporting the case for urgent action. Second, looking beyond 2020, we examine approaches to enable delivery of eye health services within universal health coverage. In section 1 we summarise the visual system, vision impairment, and common conditions. In section 2, we synthesise several reviews done by the Commission on the relevance of eye health to the Sustainable Development Goals (SDGs), as well as its impact on quality of life, general health, and mortality. In section 3, we describe the magnitude and causes of vision impairment in 2020 and projected global and regional trends. We explore service needs of people with non-vision impairing eye conditions. We propose a more standardised approach to reporting population-based eye health surveys and examine the disability weights applied to vision impairment. In section 4, we summarise findings from a systematic review of eye health economics, identifying important areas for future work. We present a new estimate of global lost productivity associated with vision impairment for 2020, and an analysis of the cost-effectiveness ratios for cataract surgery and refractive error services. In section 5, we outline a bibliometric analysis of eye health research since 2000, and report a global Grand Challenges project, highlighting crucial issues for concerted research and action. Lastly, we address the question of how health systems can practically advance towards delivering high quality integrated people-centred eye care within universal health coverage.2 We argue that business as usual will be insufficient, as evidenced by new analysis of effective cataract surgical coverage data. We examine service delivery components: primary eye care and integration with general health services, workforce strengthening, financing, health information systems, indicators, advocacy, and approaches to increase quality and equity. The development of global eye health This Commission views global eye health through the global health framework articulated by Koplan and colleagues.4 Eye health started with an understanding of the anatomy, physiology, diseases of the eye, and the development of clinical ophthalmology, the medical and surgical discipline for diagnosis and treatment of eye diseases. From the mid-20th century onwards (figure 1), there have been major technological advances in microsurgical techniques for cataract and other conditions, and equipment for diagnosis and treatment of major non-communicable eye diseases, resulting in more effective interventions. There has been an enormous demographic transition, with ageing populations and epidemiological changes from infectious diseases and towards non-communicable diseases, requiring accessible and affordable eye services with long-term follow-up. The increase in demand, emphasis on better quality, and higher cost of more sophisticated diagnostic and treatment services is requiring an increase in resources, which presents enormous public health challenges. Open in a separate window Figure 1 The development of global eye health Blue circles indicate major global developments. Red circles indicate major treatments and programmatic developments. WHA=World Health Assembly. IAPB=International Agency for the Prevention of Blindness. RAAB=Rapid Assessment of Avoidable Blindness. RACSS=Rapid Assessment of Cataract Surgical Services.