A practical approach to universal health coverage

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Given the 400 million people who do not have access to essential health services,1WHOUniversal health coverage.http://www.who.int/mediacentre/factsheets/fs395/enDate: 2015Date accessed: February 12, 2019Google Scholar the UN has included achievement of universal health coverage (UHC) by 2030 in the Sustainable Development Goals.2UNSustainable development goals.http://www.un.org/sustainabledevelopment/sustainable-development-g+oalsDate: 2016Date accessed: February 12, 2019Google Scholar UHC has two fundamental and interconnected commitments: the equitable access to high-quality health services and the promise of financial protection for all.3Boerma T Eozenou P Evans D Evans T Kieny M Wagstaff A Monitoring progress towards universal health coverage at country and global levels.PLoS Med. 2014; 11: e1001731Crossref PubMed Scopus (166) Google Scholar To date, the global movement to achieve UHC has mainly focused on demand-side barriers by encouraging countries to increase their domestic financing for health to provide social health insurance and to decrease out-of-pocket expenditures.4Sachs JD Achieving universal health coverage in low-income settings.Lancet. 2012; 380: 944-947Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 5Yates R Universal health care and the removal of user fees.Lancet. 2009; 373: 2078-2081Summary Full Text Full Text PDF PubMed Scopus (165) Google Scholar Yet, even with increased expenditures and efficiency in domestic financing towards these often-called demand-side barriers, the delivery of care is still hamstrung by insufficient staff, supplies, and infrastructure or so-called supply-side investments.6Kruk ME Gage AD Arsenault C et al.High quality health systems in the Sustainable Development Goals era: time for revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1041) Google Scholar Many countries remain impoverished due to structural factors and still cannot afford to provide quality care to all of those affected by their disproportionately large disease burdens. Even when user fees are removed, health facilities often remain empty. However, despite the insufficiency of health-care systems, the effective implementation of HIV programmes has succeeded in moving towards the once impossible goal of universal coverage of antiretroviral therapy (ART), even in impoverished settings. These advances towards realising full access to HIV care and treatment required a coordinated national-level strategy for care delivery. National programmes linked HIV surveillance data with the supply-side inputs needed to address the entire burden of disease. Projected patient volumes based on epidemiological data and treatment protocols were used to quantify and increase the number of staff for counselling, treatment, and laboratory services. Similarly, the process of estimating patient flow and volume informed the building of infrastructure and procurement of medical products.7The Maximizing Positive Synergies Academic ConsortiumInteractions between global health initiatives and health systems: evidence from countries.http://www.who.int/healthsystems/publications/MPS_academic_case_studies_Book_01.pdfDate: 2009Date accessed: February 12, 2019Google Scholar Due, in large part, to the progressive implementation of these supply-side measures, 21·7 million people across the world were accessing ART in 2017.8Atun R Andrade LOM Almeida G et al.Health system reform and universal health coverage in Latin America.Lancet. 2015; 385: 1230-1247Summary Full Text Full Text PDF PubMed Scopus (341) Google Scholar, 9UNAIDSGlobal HIV & AIDS statistics—2018 fact sheet.http://www.unaids.org/en/resources/fact-sheetDate: 2018Date accessed: February 12, 2019Google Scholar The path to the delivery of care needed to assure UHC is less clear and demands additional planning and resources to establish what interventions will be delivered to what populations. Projection models, such as the WHO OneHealth tool, already exist and the WHO and World Bank have proposed a framework for monitoring a country's progress towards UHC. Yet, although these tools are very useful in elucidating national successes and failures, in most cases such analyses do not make it to the subnational level. There is still a practical need to support the planning and implementation of health interventions at the health-centre level based on linking the disease burden for each specific catchment area with the inputs needed to progressively cover the population's health. Building off of existing UHC measurement methods, the Partners In Health UHC Monitoring and Planning Tool adds specificity for district-level and facility-level planning to allow for scaled expansion and improvement of the delivery of care within the local context by enabling granular forecasting. The user enters demographic inputs regarding the specific unit of analysis and the tool calculates, (1) the burden of disease within a given catchment area, (2) the volume of patient visits that would be expected if 100% of the disease burden was met by standard clinical protocols, and (3) the infrastructure, supplies, and staff needed to cover 100% of the population. In 2006, the Government of Lesotho invited Partners In Health to join its efforts to improve care in seven rural clinics with extremely low overall use. Despite the absence of user fees, antenatal care visits and facility-based deliveries were both exceptionally low, resulting in one of the highest maternal mortality rates in the world.10Hogan M Foreman K Naghavi M et al.Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5.Lancet. 2010; 375: 1609-1623Summary Full Text Full Text PDF PubMed Scopus (1447) Google Scholar Using benchmarks from the UHC tool as a guide, the Partners In Health team increased the required inputs (with financing from The Skoll Foundation and the Government of Lesotho) to ensure that 100% of women could have four antenatal care visits and a facility-based delivery. Based on a national crude birth rate of 3% and the essential service package of four antenatal visits, a 7-day stay in a maternal waiting home for women living more than 2 h from the clinic, and a facility-based delivery for all women in the catchment area, the Partners In Health team estimated the number of delivery tables, waiting home beds, midwives, and delivery packs needed for each clinic. Over 2 years of strengthening the health system, the proportion of facility-based deliveries in the Bobete area rose from 12% to 56%, with no reported maternal deaths in the Bobete clinic (figure).11Satti H Motsamai S Chetane P et al.Comprehensive approach to improving maternal health and achieving MDG 5: report from the mountains of Lesotho.PLoS One. 2012; 7: e42700Crossref PubMed Scopus (25) Google Scholar With clear improvements across all seven clinics, Partners In Health was then asked to support a national reform of primary health-care delivery between 2013 and 2017. The method of aligning staff, drugs, supplies, and infrastructure with the burden of disease was formalised into the Partners In Health UHC Monitoring and Planning Tool and was used to strengthen 70 primary care clinics across Lesotho to ensure the availability of care. Preliminary analyses of the 70 facilities show substantial increases in use over a 2-year period, including a 23-times increase in facility-based deliveries in Mohale's Hoek District, which went from 73 in 2013 to 1742 in 2015. This tool does not address the role of demand-side barriers in the underuse of services. Such barriers are linked to the social determinants of health and cannot be addressed by supply-side inputs alone. Achieving UHC will require substantial improvements in health systems and financing strategies to ensure the availability of effective health services. This tool represents one pragmatic method to advocate for adequate resour

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