Future Challenges for Universal Healthcare 

Written by Zara Ahmed

Universal healthcare coverage (UHC) is a sustainable development goal, which ensures adequate healthcare coverage for the entire populace of a country without causing financial hardship (1). There are numerous benefits if this ambition is achieved, both at the individual level – better health – and at the population level – flourishing and economically active communities. Crucially, implementing UHC requires a culturally appropriate approach that takes account of country-specific nuances and contexts. UHC can be funded in myriad ways and this can comprise standalone general taxation and/or insurance-based systems (2). 

Internationally, many countries are making progress towards achieving UHC, which is encouraging, but important challenges remain (1). An example of a country that has achieved a high level UHC is the UK with the National Health Service (NHS). That said, while the NHS has contributed enormously to the accessibility of healthcare, the publication of The Black Report, in 1980, outlined where it continued to fall short, especially in regard to addressing the substantial health inequalities that persist in the UK, such as for refugees and those experiencing homelessness (3). Since then, our understanding of the wider determinants of health have helped inform our understanding of why these issues are so intractable, even in the context of universal healthcare: good health is a subjective state that arises from the complex interaction between intrinsic and extrinsic factors. This highlights that although UHC is an essential foundation for the health of a population, it remains just a starting point. 

Across the globe, there is a pressing need for equitable access to primary healthcare services (4,5). Primary care services have an important role to play in encouraging preventative healthcare measures amongst a community and managing chronic diseases through a biopsychosocial model – a multidisciplinary approach that takes into account the links between biology, psychology and socio-environmental factors. It is estimated that quality primary care services can address as much as 80% of a population’s health issues (6). Care provided must be of high quality, however, which is underpinned by evidence-based medicine (7). The WHO has calculated that by investing 1% of Gross National Product annually into quality primary care services, the life expectancy of a given population can be extended by 3.7 years and 60 million lives can be saved globally by 2030 (6). 

Although universal primary healthcare provision is underdeveloped, other initiatives have been utilised to improve access to primary healthcare. Currently, in some low- and middle-income countries (LMIC), some services are delivered by community healthcare workers (CHWs) (8). These services can be utilised to provide basic healthcare in resource-scarce rural communities, not just in LMICs but also in those countries with stronger, more formal healthcare systems (8). A prominent example of the latter would be Brazil’s family health programme which aims to improve access to primary and public healthcare (9,10,11). 

Historically, the healthcare resources in Brazil have been distributed unevenly, with many specialists concentrated in cities and practising privately, whilst other issues, such as bureaucracy, have hindered expansion of healthcare in rural areas. Primary health services were undervalued, but in 1994, the Family Health Strategy was introduced (13). This aims to provide basic healthcare using multidisciplinary teams, usually consisting of a nurse, physician, and six CHWs, and the teams are then assigned to areas covering 3000-4000 people. The CHWs resolve many basic issues, ensure that patient take medication regularly, and visit families at least once a month, feeding back to nurses and physicians. This programme has seen great success, with the proportion of the population covered by the Family Health Strategy increasing from 7.8% in 2000 to 58.5% in 2016 (11).

The success of UHC hinges upon an adequate supply of well-trained healthcare workers (HCWs). Currently, demand for HCWs far outweighs supply: current projects for 2013-2030, suggest that demand here will increase from 48 million to 80 million with the supply only able to grow from 7 million to 15 million (9). This underscores the value of investing in healthcare education and the training of qualified healthcare personnel to provide the requisite workforce for achieving UHC goals (8,9).

Furthermore, in developed and developing nations alike, healthcare often remains prohibitively expensive for citizens – particularly those who are experiencing poverty (1). Vulnerable subsets of the population, including the homeless, the displaced or those coming from the lowest socioeconomic groups, typically experience the most barriers to accessing healthcare. UHC plans must identify and created mitigating strategies to overcome these barriers if they are to have any hope of success. (5).

Finally, COVID-19 has posed a significant challenge for healthcare systems worldwide, testing the resilience of existing infrastructure for delivering quality care. The pandemic has emphasised the importance of having robust healthcare systems in place to deal with the burden of disease and has underscored the value of UHC. Once this disease has been contained, it will be essential to reflect upon how healthcare infrastructure must adapt to withstand future health threats and the local, epidemic and pandemic level.

References:

  1. Wagstaff A., Neelsen S., A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study. The Lancet Global Health. 2020 Jan 1;8(1):39-49.

  2. Nicholson D., Yates R., Warbuton W., Fontana G., Delivering universal health coverage: a guide for policymakers. Report of the WISH Universal Health Coverage Forum. 2015 Feb.

  3. Gray A.M., Inequalities in health. The Black Report: a summary and comment. International Journal of Health Services. 1982 Jul;12(3):349-80.

  4. Chan M., From primary health care to universal coverage-the affordable dream. World Health Organization. [External Link] Published 2017. Accessed 28th December 2020.  

  5. Bloom G., Katsuma Y., Rao K.D., Makimoto S., Yin J.D., Leung G.M., Next steps towards universal health coverage call for global leadership. BMJ. 2019 May 24;365.

  6. Arredondo A., Recamán A.L., Castrejón B., Universal health coverage in the framework of the 2030 global agenda for sustainable development: agreements and challenges. Journal of Global Health. 2020 Jun;10(1).

  7. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities.

  8. Frenk J., Chen L., Bhutta Z.A., Cohen J., Crisp N., Evans T., Fineburg H., Garcia P., Ke. Y., Kelley P., Kistnasamy B., Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010 Dec 4;376(9756):1923-58.

  9. Sripathy A., Marti J., Patel H., Sheikh J.I., Darzi A.W., Health professional education and universal health coverage: a summary of challenges and selected case studies. Health Affairs. 2017 Nov 1;36(11):1928-36.

  10. Machinko J., Harris M.J., Brazil’s family health strategy—delivering community-based primary care in a universal health system. New England Journal of Medicine. 2015 Jun 4;372(23):2177-81.

  11. Massuda A., Hone T., Lele F.A., de Castro M.C., Atun R., The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Global Health. 2018 Jul 1;3(4).

  12. World Health Organization. Tracking universal health coverage: first global monitoring report. World Health Organization. [External LinkPublished 2015. Accessed 29th December 2020.

  13. Wadge H., Bhatti Y., Carter, et al. Brazil’s Family Health Strategy: Using Community Health Care Workers to Provide Primary Care. The Commonwealth Fund. [External LinkPublished 2016. Accessed 11th Janaury 2021.

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