Here is a discussion on the tension between health promotion and treatment of disease.
We are returning to the very lively discussion we held in the past on the need and challenges faced by health systems in attaining the correct balance between maintaining inborn population health through health promotion, community participation and disease prevention on the one hand and treatment of diseases and illness on the other hand. I am also inspired by what happened in my country Uganda on 8 July 2018 when President Y K Museveni walked 10 kilometers around Kampala streets accompanied by thousands of citizens including political and professional leaders during the National Physical Fitness Day and delivered a number of health promoting messages.
Further, during the 71st World Health Assembly, May, 2018, there were several debates on what the face of UHC will look like. Will it be health financing and health insurance for treatment of disease or will it be health promotion that ensures that people do not lose their inborn health and delay the need for health care for as long as possible? Surely it has to be both and UHC will need to be successful in both. The WHO definition of UHC is balanced and addresses health promotion, disease prevention and treatment of illness and mentions the need for money to achieve all aspects of UHC.
It states: “Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. WHO has also developed a Framework for Integrated People-Centered Health Services that includes both health promotion and treatment of diseases.
However, when we examine the current SDG Targets and Indicators on UHC that have been selected to monitor implementation and level of achievement, it is evident that health promotion has taken a back seat. Below are extracts from the Tier Classification of the SDGs from the UN SDG website dated December, 2017.
Target 3.8 “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” There are only two indicators to monitor this target as follows:
Indicator 3.8.1 “Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged population)”
Indicator 3.8.2 “Proportion of population with large household expenditures on health as a share of total household expenditure or income”
It is evident from the above that there is no current SDG indicator that explicitly and specifically monitors the UHC call for “all people and communities can use the promotive, preventive services….”
The framers of these indicators have fallen into the usual trap in health system design; namely that the pressures to society and governments to pay more attention to repairing and restoring lost and broken individual and community health are stronger than those to promote and protect existing health. For example injuries need immediate attention, obstructed labor that threatens the life of mother and child cannot wait as the baby must be born now, a child is convulsing and the sight is intolerable, an infectious disease outbreak in one country puts the whole world at risk and international alert is declared.
The drama of providing health care to restore damaged individual and community health is easily the more visible face of the health system and accordingly receiving more attention and more resources than health promotion that focuses on needs that may not be immediately visible and do not demand immediate action. The essential services listed in indicator 3.8.1 do not mention health promotion or disease prevention. To get the balance right is a challenge to all health systems and calls for exceptionally focused and strong stewardship and leadership to achieve a balanced response.
The last WHA heard many statements from Dr. Tedros the WHO Director General that illustrated that he understands the need for this balance. He is an eloquent advocate for healthy lives, health security and UHC. WHO has produced elaborate documents around the Framework for Integrated People-Centered Primary Health Services. That is why it is critical to have an explicit SDG indicator on health promotion and disease prevention if we are to ensure that these essential aspects of health system development get implemented in all countries and that SDG 3 and UHC as defined are achieved.
I am informed that at the UN, the SDG indicators are regularly reviewed and that the next review will take place in 2020. I want to call for the inclusion of the at least one explicit indicator on health promotion in the UN SDG Indicator Classification. This should be be taken up urgently and led by WHO member states, CSOs and the new WHO leadership.
Suggestions for such indicators include the following among others: “Levels awareness of the population of risk factors for NCDs” or “Proportion of school curricular containing examinable health seeking behavior content”, “Number of national health promotion activities led by Heads of State or high level citizens”.
I invite you all to comment on this issue and to make more and better suggestions.