Universal health coverage gains momentum in 2016

Measure-what-matters

WHO definition: Universal Health Coverage (UHC) means everyone can access the quality health services they need without financial hardship.

This year it seems that organisations, governments and citizens everywhere are answering the call to UHC, whose annual awareness day is December 12th.

From this year forward, UHC is seen as central to improving health systems, improving economies, and ensuring global health security. The G7 group countries, the primary source of funding for Low and Middle-Income Countries (LMIC), met in Ise-Shima Japan 2016 and made UHC their umbrella concept. Through this, they seek to improve health systems and global health security.  Of the 17 SDGs agreed by the United Nations, just one is directly health-related but it is “achieving UHC”.

Judith Rodin, (President Rockefeller Foundation, has observed that “25 of the wealthiest nations all have some form of universal coverage, as do some middle-income countries including Brazil, Mexico and Thailand and lower-income nations, such as Ghana, the Philippines, Rwanda and Viet Nam, are working towards achieving UHC.”

Rather than talk about why we need UHC, I thought I’d talk  about what is actually proposed by middle-income and lower-income countries (LMIC) to fulfil UHC and what the NGOs, donors and global health community championing UHC would like it to encompass.

What is UHC?

UHC systems vary from country to country: there is no one size fits all.  It very much depends on the minimum health outcomes a government wants to achieve and how much of its GDP it is prepared to spend. The main variables being the level of care delivered, who delivers it, who receives it and how it is funded. 

UHC of itself does not mean universal access to health services nor care for all diseases. It’s about providing a basic level of health services (“Essential Packages of Health Services”) to as much of the population as possible.

The first UHC system was the UK’s National Health Service set up in 1948.

The USA has a non-universal system of health coverage.

What do LMIC see it as?

Over time,  as far as I can see, these basics for a cost-effective UHC have emerged:

  • government regulation, legislation and taxation
  • primary health care
  • vaccination programmes for children (for LMIC this is organised through GAVI, the Vaccine Alliance)
  • maternal healthcare (pregnancy)
  • health insurance to finance (public tax, private insurance or a mix of both)
  • financial protection: pooled funds to reduce out of pocket payments amongst the poorest and vulnerable  

Much of the information that now follows is derived from  the RSTMH 2016 Chadwick memorial lecture "Neglected Tropical Diseases in the Time of Blue Marble Health and the Anthropocene Epoch", given by  Professor Peter Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine, Texas and President of the Sabin Vaccine Institute. 

 

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Why Latin America is nearer elimination of rabies than Africa

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"World Rabies Day" is September 28th. Copyright: CC, Global Alliance for Rabies Control   
   
Rabies: a contagious and fatal viral disease of dogs and other mammals, transmissible through the saliva to humans and causing madness and convulsions. Rabies is fatal once symptoms appear.

Latin America is doing far better at managing, controlling and ultimately eliminating rabies from the region. Africa is failing to make the same gains and a rethink is required: can the lessons learned in Latin America be  applied or adapted to Africa?

At  the biennial RSTMH meeting “Challenges in Disease Elimination” held in Cambridge [September 12-16th, 2016], Katie Hampson [University of Glasgow] described the Pan American Health Organisation (PAHO)'s surveillance & management framework operating in Mexico and Brazil,  and devised to support the elimination of rabies in 25 PAHO countries. She also described the work of Tanzanian colleagues who have developed a “pragmatic approach to surveillance” for the African setting where resources are constrained.

Current situation of rabies control in Latin America vs Africa

The short answer is that in Latin America, PAHO, which exists to “strengthen national and local health systems and improve the health of the peoples of the Americas”, has concentrated on vaccinating the dog population against rabies and interrupting transmission. African countries have no similar regional support structure for their health ministries and rely on post-exposure prophylaxis (PEP)  of humans bitten by dogs, to achieve a form of control of rabies. PEP vaccination only saves lives if the bitten person has timely access to a well-stocked clinic, and the money to pay for the shots. In remote and rural areas, this can lead to grim choices: which child do you treat if you only have money for one?  We heard at the RSTMH of an African mother with several children bitten by the “family dog”, who having travelled a great distance to reach the vaccine, was then faced with that very choice.

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Health & Wellness: making a drama out of public health

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copyright:iStock


A
great
deal of time and effort these days goes into making TV medical dramas both authentic and technically accurate. But it would appear that an unlooked for bonus of such detail is that these dramas – whilst being mainly entertainment vehicles- unintentionally improve health awareness in the watching public. They do so by providing accurate health information and can cause individuals to take action in regard to their own health or that of their family. In other words, take action to achieve “wellness”. These dramas can thus aid the current shift of focus of governments and public health practitioners to deliver Health & Wellness, aka Health & Wellbeing, (a National Wellness service rather than a National Health service?)  

This shift to Wellness i.e. staying healthy, is in response to the rise of chronic diseases and inequity. The aim is to empower the individual to make healthy choices and to address the social, environmental and economic factors which limit that choice. Health awareness is therefore a prerequisite for wellness.

Call the Midwife, the hit medical TV drama,  works hard to depict accuracy and authenticity 

An essay in April's Journal of the Royal Society of Medicine describes the steps taken by the writers, production team and actors of the hit BBC TV series, Call the Midwife, to ensure the series has sufficient medical accuracy and authenticity [the series is set in the poor Poplar district of East London during the early years of the National Health Service (1950s)]. The series  is viewed by more than 10 million people each week, and sold to almost 200 territories worldwide.

The author  of the essay is the actor Stephen McGann who plays the local community docter [GP], Dr Patrick Turner.

As one would expect, a clinical advisor [a practising midwife and lecturer] oversees childbirth and nursing procedures but this series has gone further. Open-access journals and the Wellcome Trust archive are used as resources by the writer, and relevant health charities are called upon to provide an insight into the health impact of social conditions of the time. McGann himself deliberately chose to make his character a smoker “after reading a BMJ study* [by Richard Doll: Mortality in relation to smoking’: 50 years' observation on male British doctors  BMJ 328 (7455): 1519] which observed the effects of smoking on men over a 50-year period, starting in 1951.  A total of 34,439 smokers took part in the research – all of them doctors.” [*The first publication based on this cohort was in 1954 and is in the Global Health Archive database: ‘The mortality of doctors in relation to their smoking habits.  BMJ 328 (7455): 1529.]

But McGann then goes on to explain that the medical accuracy and authenticity pioneered by ‘Call the Midwife’ has communicated valuable insights to ordinary people into important public health issues …giving them the information to improve their own health.

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Veterinarians Target Next Virus for Eradication

 
Following the recent eradication of rinderpest virus in cattle (see blog), the veterinary profession is contemplating which viral disease of animals should be targeted for eradication next. This is not an easy task considering the vast number of viral diseases that plague livestock animals and have devastating effects on animal health, public health and people’s livelihoods.

Sheep

According to the authors of a scientific editorial (1) and a review article (2) that appeared in the recent issue of Veterinary Record published on 1st July 2011, the next livestock virus targeted for eradication could be peste des petits ruminants (PPR) virus.

Dr Michael Baron and colleagues from the Institute for Animal Health (IAH), Pirbright, UK said in their review that the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE) should focus on PPR virus as the next livestock virus for eradication.

PPR virus affects sheep and goats and is closely related to the recently eradicated rinderpest virus. Cattle can also be infected with PPR virus but they do not show obvious signs of disease. PPR is circulating on the edges of the European Union, on the southern shores of the Mediterranean. Outbreaks were reported in Morocco and Tunisia in 2008 and there is evidence for its presence in Algerian sheep this year. It has also been present in Turkey for many years. PPR is the fastest growing and one of the most economically important diseases of sheep and goats, the animals that play a very important role in sustainable agriculture and development in Africa and Asia. Mortality in infected animals ranges from 10 to 90%, depending on age, breed and secondary infectious agents. Animals that survive become anorexic, their milk yield is reduced, and they are susceptible to secondary infections and abortions.

Baron and colleagues are already working on the development of a “smart” vaccine for PPR, one that leaves an antibody signature different from that created by infection with the virulent virus, so that vaccinated animals can be distinguished from animals that have been infected by virulent virus, and vice versa. They are also working on a "dip stick" test for PPR virus, similar to the one that IAH developed for the rinderpest eradication programme.

There are good reasons to believe that the eradication of PPR is an achievable goal, because the PPR virus shares a number of properties with rinderpest virus that contributed to the successful campaign to eradicate the latter, i.e. there is a safe and reliable vaccine; simple and effective diagnostic tests are available; the virus has a short infectious period, with no carrier/persistent state; transmission occurs only by close contact; and there is an economic incentive to eradicate it.

However, before a massive commitment of national and international resources for a successful eradication campaign, which would require surveillance and monitoring over a long period, a thorough evaluation of the likelihood of success of an eradication campaign, as well as its costs and benefits, is of utmost importance. Potential for eradication of other diseases such as foot and mouth disease (FMD) or rabies virus, for example, also needs to be evaluated.

CAB Direct database offers an excellent source of scientific information and is a very useful tool for evaluating potential for eradication of any viral disease of animals. It comprehensively covers world’s scientific literature from over 150 countries and in over 50 languages on all the viral diseases of animals, including PPR, FMD and rabies. CAB Direct database contains over 17000 records on rabies, over 13000 records on foot-and mouth disease and over 800 records on peste des petits ruminants.

References:

1. Anderson J., Baron MD., Cameron A., Kock R., Jones B., Pfeiffer D., Mariner J., McKeever D., Oura, CAL., Roeder P., Rossiter P. and Taylor W. (2011): Rinderpest eradicated – what next? Veterinary Record, 169: 10-11, doi: 10.1136/vr.d4011.

2. Baron MD., Parida S. and Oura CAL. (2011). Peste des petits ruminants: a suitable case for eradication? Veterinary Record, 169: 16-21 doi: 10.1136/vr.d3947.