Redefining universal health coverage in the age of global health security

Correspondence to Vageesh Jain; [email protected] INTRODUCTION Universal health coverage (UHC) has received a great deal of attention over the past decade, with the WHO spearheading the global advocacy effort. Studies have demonstrated the ability of UHC to reduce mortality, and overcome existing health inequalities to create more equitable systems. 2 However, the role of UHC in preventing, detecting and responding to disease outbreaks as per International Health Regulations (IHR), particularly during public health emergencies of international concern (PHEIC), is less clear. Past epidemics, including Ebola or H1N1 influenza, have not provided the opportunity to assess the impact that UHC may have on global health security. In the Ebola outbreak, the virus was largely limited to the West African region, among countries that all had poorly functioning health systems. The H1N1 virus proved to be too feeble to allow an analysis of how resilient different health systems were (based on UHC), in combating the 2009 pandemic. UHC, in its existing form, has the potential to improve global health security through various mechanisms. First, low financial barriers can stimulate demand for health services and facilitate early case detection, one of the foremost factors in dictating the course of an outbreak. Second, UHC may protect people from financial catastrophe. High healthcare expenditures push people into poverty, further increasing their longterm risk of ill health, particularly through communicable disease. Third, UHC protects against economic downturn, with unemployment associated with a lower mortality in UHC countries compared with those without. This is important in the context of epidemics, as seen in the recent Ebola outbreak, where the World Bank estimates $1.6 billion were foregone in GDP in 2015, due to the economic impact of the outbreak. Aside from the clinical and economic benefits, there also lies a societal benefit in creating a more equitable and just system of health whereby the poor do not bear a disproportionate burden of disease. The high death toll inflicted by Ebola has reinvigorated health system strengthening efforts, to which UHC is fundamental. 6 But what exactly should UHC involve, to improve global health security? The ongoing Zika virus outbreak, raging through the Americas, provides an opportunity to examine the complex relationship between UHC and infectious disease control.