Achieving Universal Health Coverage Requires Investing in Health Systems

Fundamentally, universal health coverage requires a well-functioning health system. But one only has to look at the scale of the current Ebola outbreak in West Africa to understand that underlying health systems in the poorest countries are weak and fragile.
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In discussions at the United Nations in New York, there is now a growing consensus that the next set of global, sustainable development goals to cover the years from 2015 to 2030 need to include the achievement of universal health coverage. This means that all people will have access to high-quality health care services, regardless of their ability to pay.

Fundamentally, universal health coverage requires a well-functioning health system. But one only has to look at the scale of the current Ebola outbreak in West Africa to understand that underlying health systems in the poorest countries are weak and fragile. Those countries need to build and sustain their health systems, and that will take considerable time and large-scale resources. How can developing countries, with support from their development partners, achieve universal health coverage in the years to come?

It is clear that the extraordinary growth of global health programs over the last 15 years has saved millions of lives and brought about a dramatic improvement in health in developing countries. The large, existing, bilateral and multilateral global health programs -- such as the U.S. President's Emergency Plan for AIDS Relief, the Global Fund to Fights AIDS, Tuberculosis and Malaria, the Gavi Vaccine Alliance, programs to improve maternal and child health, and many others -- have contributed to building health systems even though that result may be ancillary to their focus on specific conditions and patient populations. But are they structured to build health systems in a world that focuses more than ever on bringing quality healthcare to all?

The Institute of Medicine has just released a report, "Investing in Global Health Systems: Sustaining Gains, Transforming Lives," recommending that more health assistance be directed to building health systems in response to the social, economic, and epidemiological changes taking place in developing countries. Such assistance would complement, and not replace, the existing, more "vertical," global health aid programs. It is not a matter of vertical vs. horizontal approaches to health systems; rather, strengthened health systems will sustain the gains and maximize the impact of all health programs.

A health-systems approach in low- and middle-income countries is designed to address priority needs more systematically, to reach those missed in more narrowly targeted programs, and to support universal health coverage. Efficiency is improved and gaps are reduced when disease-specific programs are integrated with the overall health system.

As vaccinated children become adults, as women safely deliver children and eventually become grandmothers, and as HIV-positive patients on antiretroviral therapy grow older and suffer from other diseases, they all will need quality health care services.

To sustain the gains already achieved through the spectacular successes of vertical approaches and to move toward universal health coverage, now is the time for developing countries and their partners to place greater emphasis on strengthening health systems.

There is no quick fix, but the transformative nature of such interventions has the potential over time to result in clear, positive, measurable health outcomes on a broad range of health concerns, including non-communicable diseases. The Institute of Medicine report states, "Directing foreign assistance to health system improvements is an efficient way for donors to help their partner countries prepare for changing patterns of disease."

This approach in no way underestimates the many challenges to strengthening health systems, particularly in extending and improving health services for rural and marginalized people. But one of the distinct advantages of establishing universal health coverage as a global health target will be much-needed attention, focus, and resources on meeting the needs of the poorest of the poor.

Stronger health systems will also lead to greater global health security. The World Health Organization's universally-accepted International Health Regulations provide the basic framework for countries to strengthen capabilities to confront potential public health emergencies of international concern by building core capacities and networks that can prevent local public health crises from becoming international catastrophes. Implementation of these regulations is an important part of strengthening health systems and will better position governments and international organizations to prevent, detect, and respond to Ebola, pandemic influenza, and other infectious disease outbreaks.

The Ebola outbreak has exposed the weaknesses of health systems in fragile, post-conflict countries such as Liberia. Developing countries and their development partners will need to make major, long-term investments to improve their health systems in order to achieve universal health coverage. Now is the time to increase those investments.

John E. Lange serves as Co-Chair of the Institute of Medicine's Committee on Investing in Health Systems in Low- and Middle-Income Countries.

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