Universal health coverage post-2015: putting people first

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

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.

David Evans: putting universal health coverage on the agenda

Universal Health Coverage as a Distinct Sustainable Development Goals Target: Dispelling Doubts and Underlining Implications.

Non-communicable diseases: what now?

Youth demand action on the shared global challenge of access to medicines

Universal health coverage: good health, good economics

Universal health coverage and universal access

Universal Health Coverage and Essential Packages of Care

Progress towards universal health coverage in Myanmar.

Universal health coverage is at the centre of current efforts to strengthen health systems and to improve the level and distribution of health services. It is high on the global and national agendas of many countries, many of which have already made significant progress.1–4 The compelling case for universal health coverage derives principally from the values of fairness and equity, and these values are also critical on the path to that goal. If universal coverage cannot be attained immediately, making progress fairly and equitably should be the main concern. Motivated by this insight, the World Health Organization (WHO) in 2012 set up a Consultative Group on Equity and Universal Health Coverage. This initiative was also part of the response to the more than 50 countries that had requested related policy support and technical advice from WHO. The consultative group was unusual in that it consisted of philosophers, economists, health-policy experts and clinical doctors, spanning 13 nationalities. Such a composition helped the group address fundamental normative issues and difficult trade-offs in an unconventional way. The final report, entitled Making fair choices on the path to universal health coverage, was launched in London on 1 May 2014.5 The report addresses and clarifies the key issues of fairness and equity that arise on the path to universal coverage and recommends ways in which countries can manage them. No country starts from zero coverage, and there is no single path towards universal coverage that every country should follow. At the same time, to achieve universal coverage, countries must advance in at least three dimensions. They must expand priority services, include more people and reduce out-of-pocket payments. The consultative group analysed how countries repeatedly face critical choices in each of these dimensions: Which services to expand first, whom to include first, and how to shift from out-of-pocket payment towards prepayment. To help countries make choices, the consultative group suggested the following three-part strategy for fair progressive realization of universal health coverage. First, categorize services into priority classes. Relevant criteria include those related to cost–effectiveness, priority to the worse off, and financial risk protection. Second, expand coverage for high-priority services to everyone. This includes eliminating out-of-pocket payments while increasing mandatory, progressive prepayment with pooling of funds. Third, ensure that disadvantaged groups are not left behind. These will often include low-income groups and rural populations. The consultative group identified several trade-offs that would not usually be acceptable when pursuing universal health coverage. One would be to expand coverage for low- or medium-priority services before near-universal coverage exists for high-priority services. For example, it would normally be unacceptable to expand coverage for coronary bypass surgery before securing universal coverage for skilled birth attendance and services for fatal childhood diseases that are easily preventable or treatable. Several mechanisms and institutions can support the fair and progressive attainment of universal health coverage. In particular, effective public accountability and participation mechanisms can facilitate reasonable decisions and expedite the implementation of these decisions. The consultative group suggested that these mechanisms should be institutionalized, for example, through a national standing committee on priority setting and that the accountability for reasonableness framework can guide the design of such institutions.6 A strong monitoring and evaluation system is also essential.7 The findings and recommendations of the consultative group are highly relevant to everyone involved in pursuing universal health coverage. The guidance offered should be particularly helpful to governments. In addition, the analysis should stimulate further debate and reflection in the global health community about the choices and trade-offs that appear on the path to universal health coverage.

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

Primary health care for the 21st century, universal health coverage, and the Sustainable Development Goals

Universal health coverage means every person has access to quality health care without suffering financial hardships. The basis of universal health coverage lies in the primary health care concept, which was envisioned way back in 1978, as mentioned in Alma Ata Declaration1. The "World Health Report" published by the World Health Organization (WHO) in 2008 structures primary health care reforms in four groups. One of the crucial reforms was universal coverage reform to improve health equity2. WHO and UNICEF in 2018 documented how primary health care will be in the 21st century? The approach was towards universal health coverage and sustainable development goals. Sustainable development goals were to be achieved by 2030, and they were a continuation of millennium development goals 2000–20153. The resolution on Transforming our world: the 2030 Agenda for Sustainable Development adopted the target of universal health coverage by 2030, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all4. Currently, many developing nations do not have access to health services. About 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health. To make health for all, we need individuals and communities to have high-quality health services to take care of their families health. Skilled health workers providing quality, people-centred care and policy-makers should be committed to investing in universal health coverage. Universal health coverage should be based on intense, people-centred primary health care. Good health systems are rooted in the communities they serve. They focus not only on preventing and treating disease and illness but also on helping to improve well-being and quality of life5. Pakistan, the developing country, is struggling to provide good quality health services, mostly availed from the out-of-pocket expenditure.
 Both private and public sector hospitals were trying to deliver health services, but poor people failed to have access to many services due to poverty. To overcome this obstacle and address indicator 3.8 of SDGs, the current government developed a five-year program to improve the targeted population's health by increasing their access to quality health services. The initiative will also reduce poverty, as the government will cover most of their health budget through the "Sehat Sahulat Program". The program was part of the National vision to ensure Universal Health Coverage (UHC) for all Pakistani families. No one is denied quality healthcare services only because of financial constraints. Initially, it was piloted in selected four districts of Khyber Pakhtunkhwa, which was later extended to all over the province. Currently, 7.2 million families are getting free in-patient health care services, and the program's annual cost is 18 billion. It was a bold initiative of the current government, which helped improve access to UHC, thus addressing one of the sustainable development goals6,7.

Achieving universal health coverage in low-income settings