By Tonny Odokonyero, Economic Policy Research Centre
Many countries, most especially in the developing world are grappling to attain the crucial health goal of Universal Health Coverage (UHC). The imperative driving the UHC agenda and its advocacy is the lack of basic health care for a significant number of people (about 1 billion) across the globe – implying inadequate healthcare coverage. This is in addition due to problems of inequity in healthcare and poor quality of essential healthcare services.
The need to attain sustained progress towards UHC from a global standpoint is enshrined in the global development agenda – Sustainable Development Goal #3 where the world aspires to achieve healthy lives and promote well-being for all at all ages. In Uganda’s policy context, overall guidance is provided by the second National Development Plan (NDPII 2015/16-2019/20) and the Health Sector Development Plan (HSDP 2015/16-2019/20). NDP II puts emphasis on the need to work towards achieving UHC and this is designed to be operationalized by the HSDP with the overall goal of accelerating movement towards UHC. To achieve this, the HSDP lays down detailed strategies to accelerate movement towards UHC.
However, it is important to note that the philosophy of the HSDP alone can’t fix all the problems that need to be resolved in order to sustain any UHC progress. Particularly, policy makers and practitioners need to understand or be reminded that acceleration of movement towards UHC is not only going to be achieved through a strategy that focuses on just one policy level – i.e. through implementation of the HSDP alone. Rather, to realize sustained progress towards UHC acceleration, concerted effort at several policy levels is required for increased effectiveness towards this cause. Indeed the UHC agenda requires a vertical policy approach with reinforcing and/or synergistic strategies from different sector policy angles. Consequently, this calls for the need to tackle key determinants of health (usually referred to as Social Determinants of Health (SDH)), in a comprehensive manner. Addressing SDH with the intention of accelerating universal coverage requires all sectors or stakeholders to work as an interdependent system aiming at improving health and reducing health hazards.
SDH are factors threatening, promoting or protecting health. Different sector policy interventions should synergistically aim at breaking the cycle for factors threatening health and boosting those that promote and protect health. These factors influence health at four different layers of influence namely: general socio-economic, cultural, and environmental conditions; living and working conditions; social and community networks; and individual lifestyle factors. The structuring of the four levels of influence actually confirms the need for concerted effort from several sector policy angles.
On the basis of health economic thinking, four sets of policy considerations are necessary for such a multi-sectoral approach in addressing SDH and pushing forward the agenda of UHC. These policy considerations (derived from the four layers of influence on health) are aimed at providing signals and prompting different sector players (especially policy makers and practitioners) to judge their relevance in the UHC discourse and highlight how they can make a contribution(s) to the SDH and UHC agenda.
The first layer of influence relates to structural issues in the economy. These call for policies that can generate long term structural changes of the economy for instance among others; macroeconomic strategies that include innovative tax policies capable of significantly financing healthcare to drive UHC goal. The second layer requires policies to improve living and working conditions through healthy public or business strategies within a multi-sectoral framework. Such policies should cover; welfare benefit via social security, adequate and quality healthcare services through the health sector, food and nutrition through agriculture sector, employment through the labour sector, water and sanitation through the water and sanitation/environment sector, and education. All these are aimed at enhancing the material and social conditions in which people live and work. The third layer of influence requires policies for strengthening social and community support to individuals, families or households. The mandate of the Ministry of Gender, Labour and Social Development covers many of these. The policy interventions here should use strategies capable of recognizing intrinsic strengths within families, relatives, friends, volunteer organizations and communities; rather than looking at individuals working in isolation. Accordingly, this layer places emphasis on how people can come together for mutual support to ultimately protect against health hazards. Lastly, the fourth layer requires policy interventions which influence individual lifestyles and attitudes towards healthy living (e.g. individual eating habits). This layer should place emphasis on areas where individuals have a certain degree of choice such as; health education and support for groups of individuals with unhealthiest lifestyles.
The four different levels of policy consideration at each layer of influence on health clearly demonstrates the need for concerted effort to address SDH as the country strives to drive the agenda of UHC. It is therefore important that all sectors or stakeholders assess the seemingly obvious but complex layers of influence and the corresponding policy considerations to gauge their relevance in the UHC discourse and how they can contribute in addressing SDH and ultimately driving the agenda of UHC in the country.
The author is works Economic Policy Research Centre and a member on the SPEED for Universal Health Coverage team