This posting coincides with the 40th Anniversary of the 1978 Alma Ata
Declaration on Health for All. Please read and comment.
I have just arrived at Astana, Kazakhstan for the 40th Anniversary of the “Health for All Declaration” and the Global Conference on Primary Health Care (PHC) 25 – 26 October, 2018. It presents an opportunity for us to reflect on how we will monitor PHC especially
its contribution to our progress towards achievement of health for all, UHC and SDGs.
Let us start by drawing attention to the fact that among the current SDG indicators on UHC, there is no indicator that explicitly monitors household and community participation and action for health. Yet we know that the demand side of UHC is critical for supporting health
promotion, wellbeing and building societies that enable healthy lifestyles, and for influencing the habits of individuals and the behavior of institutions.
The demand side facilitates effective engagement of the people and the community in building strong, resilient and responsive health systems.
This population ownership and engagement cannot be optional because the Declaration state that people have a duty and a right to full participation in influencing their own health and health care.
We know that achieving health outcomes and designing effective health services delivery programs at country level are constantly faced with the challenge of getting the right balance between health promotion and disease prevention on the one hand and treatment of diseases on the other. At the World Health Summit (WHS) in Berlin, 14 – 16
October, 2018 questions were still being asked whether UHC was about providing
health care and not about ensuring the enjoyment of holistic health as
defined in the constitutions of WHO and the Universal Declaration of
There were similar debates during the 71st World Health Assembly in May, 2018, on what the face of our effort on SDGs and UHC ought to look like. Will it be actions to promote healthy living so as to ensure that people do not lose their existing inborn health and that they delay
the need for health care for as long as possible? Will it be health financing and
health insurance for accessing services to treat illness and diseases?
At the WHO Afro Regional Committee in August, 2018 statements by several Health Ministers suggested that establishing National Health Insurance schemes is all that they needed to do to achieve UHC.
This is a matter for concern particularly when Dr. Tedros the Director General of WHO frequently states that “all roads lead to UHC.” The “Global Action Plan for healthy lives and well-being for all” was launched by WHO and eight partner health institutions at the Berlin
WHS where, among others, Dr Tedros stated that “health is made and sustained by families” in their homes and communities.
Surely the face of our effort to achieve SDGs and UHC will need to be the visibility and success on both. The WHO definition of UHC 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”. This language is balanced and addresses health promotion, disease prevention and treatment of illness and the need for financing. The framing of the UHC definition implies that a public health approach
precedes the medical interventions. This is smartly captured in the language of SDG 3; stated as “Ensure healthy lives and promote wellbeing for all at all ages”.
Monitoring and measurement of progress in SDGs and UHC is needed in order to guide, motivate and ensure action, results and accountability at all levels. There is currently one SDG Target and two indicators on UHC as follows:
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 two indicators to monitor this target:
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 is “Proportion of population with large household expenditures on health as a share of total household expenditure or income”. This indicator will measure the cost of treatment of illness and diseases.
The indicator 3.8.2 on household expenditure for access to services for treatment of diseases and other medical interventions including vaccinations for disease prevention is explicit and will monitor the financial implications of UHC to households. However, indicator 3.8.1 is not explicit in calling for specific monitoring and measurement of household and community behavior and actions that enable healthy people to remain healthy through their own participation. Such an
indicator would respond to the call for “all people and communities can use the promotive, preventive services” in the definition of UHC.
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 aimed
to promote, sustain and protect existing health. The drama of providing urgent health care to restore damaged individual and community health is easily the more visible face of the health system and accordingly receives more attention and more resources than health
promotion that focuses on important health needs that may not be immediately visible and do not demand immediate action. Getting the balance right is a challenge to all health systems and will be helped by having an explicit and specific UHC indicator that monitors and
measures health action by households and communities.
A call for correction of this important omission of an explicit indicator on health promotion through community participation has also been published by the BMJ signed by a number of promoters and can be accessed at https://www.bmj.com/content/361/bmj.k1716/rr-0
SDG targets and indicators are regularly reviewed and the next review will take place in 2020. We therefore call for the inclusion of at least one explicit target and indicator on community participation in health promotion and well-being in the official UN SDG Indicator
Classification. The process for this should be taken up urgently, and should be led by Member States, Civil Society and the WHO.
I welcome your suggestions and comments.