Service on Health Issues (Oct20/04)
Geneva, 9 Oct (Kanaga Raja) – The COVID-19 pandemic has brought home the importance of basic public health, and strong health systems and emergency preparedness, lending ever greater urgency to the quest for universal health coverage (UHC).
This is one of the main conclusions highlighted by the UN Secretary-General in a Policy Brief on COVID-19 and Universal Health Coverage.
According to the Policy Brief, with universal health coverage in place, countries could more effectively and efficiently address the three ways in which the COVID-19 crisis is directly and indirectly causing morbidity and mortality: the first is due to the virus itself, the second is due to the inability of health systems to provide ongoing essential health services, and the third is linked to its socioeconomic impact.
Coming out of the COVID-19 pandemic will require a whole-of-government, whole-of-society and a global coordinated approach, it said.
“The lessons learned call for universal health coverage that ensures equal access to quality health care without financial risks for everyone and that effectively protects societies from another health crisis with its devastating effects on lives and livelihoods,” it added.
According to the Policy Brief, the pandemic has laid bare long-ignored risks, including inadequate health systems, gaps in social protection and structural inequalities.
“It has also brought home the importance of basic public health, and strong health systems and emergency preparedness, as well as the resilience of a population in the face of a new virus or pandemic, lending ever greater urgency to the quest for universal health coverage (UHC).”
Health is a fundamental human right, and universal health coverage is a critical tool for achieving health for all, it said.
Universal health coverage is defined as a situation where all individuals and communities receive the health services they need without undue financial hardship.
However, at least half of the world’s population still do not have full coverage of essential health services, and over 800 million people spend at least 10 per cent of their household budgets to pay for health.
It will be important to remove as much as possible financial barriers to accessing health services, the report said.
Within just nine months, COVID-19 has spread to more than 190 countries. By the end of September 2020, the world had recorded over 30 million cases, and over 1 million people had lost their lives, the report noted.
Depending on the age structure of the population, about 5 to 15 per cent of COVID-19 patients will develop critical complications that require mechanical ventilation, and 15 to 20 per cent of patients will have severe symptoms that require oxygen therapy or other in-patient interventions.
COVID-19 often hits hardest those who can least afford it: the old, those with chronic disease, or those in poor living conditions, said the report.
Older persons in long-term care facilities have high morbidity and mortality rates as well as high rates of staff absence due to COVID-19. In several European Union countries, deaths among residents have accounted for over half of all COVID-19-related deaths.
Persons living in confined living spaces, whether in crowded settlements, refugees, migrants, or prisons, are also at high risk.
Healthcare workers are at high risk of COVID-19 infection because of more frequent contact with COVID-19 cases. Frontline workers in essential occupations, such as in public transport, food production, law enforcement, also face greater exposure.
The additional patient load caused by COVID-19 threatens the ability of health systems to provide other essential health services, said the report.
On a local scale, this may mean the cancellation of elective surgeries and other non-urgent procedures, but may also lead to wider effects owing to the restriction of travel, interruption of supply chains and redeployment of staff.
On a global scale, the effects may seriously impair or reverse progress towards the Sustainable Development Goals (SDGs), said the report.
For example, coverage reductions of 9.8 to 18.5 per cent of reproductive, maternal and child health interventions, such as immunization, and a wasting increase of 10 per cent, could lead to more than 250,000 additional child deaths and 12,000 maternal deaths over six months in 118 countries.
Furthermore, 47 million women may not be able to access modern contraceptives, 7 million unintended pregnancies may occur and 31 million additional cases of gender-based violence can be expected to occur if lockdowns continue for at least six months in 114 low- and middle-income countries.
A suspension of planned insecticide-treated nets distributions in 2020, and reduced access to effective anti-malarial treatment could lead to an estimated 769,000 malaria deaths by the end of 2020.
“A global reduction of 25 per cent in expected tuberculosis detection for 3 months could increase tuberculosis deaths by 13 per cent, bringing us back to the levels of tuberculosis mortality that we had 5 years ago,” said the Secretary-General.
A six-month disruption of antiretroviral therapy could lead to more than 500,000 extra deaths from AIDS-related illnesses in sub-Saharan Africa in 2020-2021. In 2018, an estimated 470,000 people died of AIDS-related illnesses in the region.
COVID-19 can negatively affect outcomes in people with noncommunicable diseases through delays in diagnosis of noncommunicable diseases, such as cancers and heart disease among others, resulting in more advanced stages of disease, said the report.
To minimize morbidity and mortality, countries need to identify essential health services that will be prioritized for continuation during the acute phase of the COVID-19 pandemic, it emphasized.
The report noted that various measures used to limit the spread of COVID-19, and ease the strain on health care systems, have reduced travel, consumption and investment, as well as restricted labour supply and production, causing huge socio-economic impacts, especially for the most vulnerable.
The IMF and the World Bank are supporting the Debt Service Suspension Initiative in which borrowers can use freed-up resources to increase social, health, or economic spending.
“This is critical for universal health coverage in particular, as progress requires public funding,” said the report.
Despite these fiscal stimulus interventions, advanced economies are expected to experience a 7 per cent drop in output, while emerging market and developing economies will mark their first output contraction in more than 50 years.
The pandemic is costing the global economy $375 billion a month and 500 million jobs since the beginning of the crisis.
It will be vital to address the root cause of the economic crisis – which is the COVID-19 disease – by prioritizing health investments now, said the report.
“The financial costs for a comprehensive public health response to the pandemic will be small compared with those of a prolonged global recession,” it added.
Health financing policies need to prioritize public financing for health and remove financial barriers to accessing services.
The global recession is projected to lead to the first rise in global extreme poverty since 1998. It is estimated that COVID-19 could push an additional 70 to 100 million people into extreme poverty in 2020, effectively wiping out progress made since 2017.
The consequences for human health are potentially serious, with each health-related SDG target likely to go backwards, said the report.
Those most influenced by a poverty indicator will likely be most affected (e.g. tuberculosis will be less likely to be treated, skilled delivery rates reduced).
A large share of the new extreme poor will be concentrated in countries that are already struggling with high poverty rates and numbers of poor, said the report.
Almost half of the projected new poor will be in South Asia, and more than a third in Sub-Saharan Africa. The increase in world poverty threatens the ability of the most vulnerable to access health services, said the report.
The incidence of catastrophic health expenditure increased continuously between 2000 and 2015, and its incidence may increase further due to the COVID-19 pandemic, it added.
“We are now at a critical juncture of the COVID-19 pandemic. After initial success in suppressing transmission, many countries are now experiencing a resurgence of cases after easing some restrictions,” said the Secretary-General.
“Safe and effective vaccines, diagnostics and therapeutics will be vital for ending the pandemic and accelerating the global recovery.”
But these life-saving tools will only be effective if they are available for the most vulnerable equitably and simultaneously in all countries – essentially, to make these tools global public goods, said the report.
“The Access to COVID-19 Tools Accelerator (ACT-Accelerator) is the best global solution for speeding up the development of the tools we need to save lives as fast as possible, and to make them available for as many as possible as equitably as possible,” it added.
IMPORTANCE OF UNIVERSAL HEALTH COVERAGE
According to the Policy Brief, to respond to the pandemic efficiently and effectively, and build the foundations for a better future, governments need to expand their investments in core health system functions that are fundamental to protecting and promoting health and well-being, called “common goods for health”.
In human-rights terms, this means committing the maximum available resources towards meeting the minimum core obligations under the right to health.
These include access to essential medicines and the equitable distribution of all health facilities, goods and services.
“These functions are integral to the commitments that all Member States made in the International Health Regulations, as well as the Political Declaration on Universal Health Coverage in 2019.”
The COVID-19 experience has brought home the reality that the health systems of many countries were not adequately prepared to fully protect the health of their populations, said the report.
“Strong health systems based on primary health care are the foundation of an effective response to COVID-19 as well as for universal health coverage,” it said.
In some countries the emergency response has focused more on expanding intensive care beds than primary care. Both are needed, it added.
Facility-based services need to be delivered remotely, with personal protective equipment and ventilators, while primary care services that would routinely be delivered across multiple visits need to be integrated when possible.
In-patient admission processes may need to be adapted, as the risks and benefits associated with hospital-based care may change.
Alternative approaches to making essential medicines and services available should be urgently introduced when facility-based services are restricted, said the report.
For example, telemedicine for key information and delivery of medicines by post, self-care interventions and task-sharing for outreach workers are all mechanisms that can increase access to essential health services when facility-based care is not possible.
The report also said that effective communication and community engagement are essential to maintaining public trust, and participation in and access to health information and education are essential for the full enjoyment of the right to health.
Removal of financial barriers to accessing health services is a vital step to ensuring greater public health, said the report.
“This is challenging during an economic recession, but COVID-19 has shown that effective epidemic control benefits the economy,” it added.
COVID-19 reinforces the need to remove financial barriers from individuals’ decisions about whether to seek care.
Ideally, patients do not pay user fees (co-payments) at the point of care for essential services during the COVID- 19 pandemic since the expectation of payment may pose a substantial barrier to seeking and receiving needed care.
The experience with COVID-19 also reinforces messages about health financing for universal health coverage.
In particular, where health coverage is linked to employment, an economic shock that leads to a loss of formal sector jobs also has negative consequences for health coverage. “This is at odds with universal health coverage – the right to health coverage is not a mere employee benefit.”
Therefore, in countries that historically have relied on contributory, employment-linked coverage, it has been essential to inject general budget revenues into the system, both to reduce the vulnerability of the system to job losses and to ensure that the essential actions needed to respond to COVID-19 can be implemented.
“Universal health coverage embodies the goals of equity in the use of needed, effective services with financial protection, and progress towards these goals assessed at the level of entire populations,” said the report.
Systems that are organized to sustain progress towards universal health coverage are better organized to respond to a disease outbreak if they are people-centered and rights-based.
Coming out of the COVID-19 pandemic will require a whole-of-government, whole-of-society and a global coordinated approach, said the report. “Pandemic preparedness can be seen as a global public good with commensurate global and national-level investments.”
Public health systems need to evolve towards a more holistic focus on universal health coverage and primary health care and social protection. It is important that responses to the pandemic avoid locking in inequalities or even worsening them, said the report.
COVID-19 is a human tragedy but has also created a generational opportunity to build back a more equitable and sustainable world.
“For the health sector of each country, this means that the value of getting the right policies in place to enable progress towards universal health coverage is more important than ever,” the report concluded.