Public health, universal health coverage, and Sustainable Development Goals: can they coexist?

In her 2012 reconfi rmation speech as WHO DirectorGeneral, Dr Margaret Chan asserted: “universal coverage is the single most powerful concept that public health has to off er. It is our ticket to greater effi ciency and better quality. It is our saviour from the crushing weight of chronic noncommunicable diseases that now engulf the globe”. The UN General Assembly is currently considering proposals for Sustainable Development Goals (SDGs), succeeding the Millennium Development Goals. SDG 3, focusing on health, specifi cally includes universal health coverage (UHC) among its targets. Unquestionably, UHC is timely and fundamentally important. However, its promotion also entails substantial risks. A narrow focus on UHC could emphasise expansion of access to health-care services over equitable improvement of health outcomes through action across all relevant sectors—especially public health interventions, needed to eff ectively address non-communicable diseases (NCDs). WHO fi rst endorsed UHC in its 2005 resolution on sustainable health fi nancing, calling on states to provide “access to [necessary] promotive, preventive, curative and rehabilitative health interventions for all at an aff ordable cost”. The resolution and its UHC concept fi rmly and narrowly centre on health insurance packages fi nanced through pre-payment. This narrow understanding is echoed in major recent reviews of 65 empirical studies on UHC progress. The proposed SDGs also separate population-level public health measures from UHC, addressing the former as distinct targets, not under UHC. Yet, a broader understanding encompassing nonclinical measures can also be found in relevant WHO documents. Independent of UHC’s conceptual indeterminacy, clinical health services are an essential part of UHC, and are likely to dominate post-2015 state health system improvements. In implementing UHC, how can we ensure continued emphasis on the full spectrum of public health interventions? Unmediated, a narrow UHC focus risks that fi ve distinct pressures prioritise expanded curative clinical services at the expense of individual and population-level health promotion, prevention, and action on social determinants of health. The risk is that this focus leads to more health-care services, but worse overall health outcomes, with less equitably distributed benefi ts. First, unbalanced, the introduction of UHC usually increases inequity by disproportionately benefi ting the wealthiest groups. Although there are some exceptions, UHC progress analyses from 11 countries at diff erent levels of development suggest poorer people often lose out initially. UHC expansion generally begins with civil servants or urban formal sector workers; wealthier, well connected urban populations demand and receive clinical services, while poorer and rural populations do not. Some public health interventions—such as nutrition labelling, or information campaigns on behavioural NCD risks—also tend to disproportionately benefi t wealthier groups, raising similar concerns. But other populationlevel measures such as clean air acts or road-safety improvements benefi t the whole population from the outset, ensuring greater equity. Targeted population-level measures can balance temporary or persistent inequities arising from the introduction of UHC. Second, the clinical sector commonly tends to emphasise specialist curative over health promotion or preventive primary care. Interventions such as dialysis, organ transplants, or new cancer therapies—frequently introduced under UHC—often have the irresistible aura of the rule of rescue, enabling the instant saving of otherwise doomed lives. But as the addition of dialysis to the public benefi t package in Thailand illustrates, doing so can entail substantial budgetary opportunity costs with unclear sustainability, and deprioritisation of primary and secondary prevention, undermining benefi ts to far more people than typically benefi t from high-cost curative care. Third, political and societal pressures can skew budgets towards more advanced, costly clinical services at the expense of public health. Such shifts rarely take the form of pure zero-sum situations, in which one sector gains what the other loses, but are embedded in complex allocation decisions. In Thailand, the initial 2002 Universal Coverage Scheme spending formula reserved 20% of the budget for health promotion and prevention at individual and family level (personal communication, Viroj Tangcharoensathien, International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand). With the decision to cover high-cost interventions including antiretroviral therapy in 2004, dialysis and kidney transp lantation in 2008, and to account for other newly covered services, infl ation, and increased outpatient and inpatient service uptake, between 2001 and 2012 the per head budget was increased by 3% per year above infl ation. But with reduced prevention and health promotion unit cost, the share of the ring-fenced budget decreased from the initial 20% to 14% over the past several years (although it has recently been decided to return to previous levels). While the clinical benefi t package was expanded, no new health promotion and prevention services were added in the past decade (personal communication, Viroj Tangcharoensathien). Similarly, Colombia introduced UHC in 1993. Since then, health plan budgets increased annually by 6·4% Published Online June 30, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60244-6