Knowledge Summary 8: Strive for universal access
Providing universal access to health care is still a challenge for many countries. But they can make significant improvements in three key ways. First, they can ensure entitlements, which link human rights with the resources required to enjoy these rights. Secondly, they can integrate services and packages to promote access and improve outcomes for women and children.Thirdly, they can strengthen and scale up health systems, reaching out to those who are underserved.
What do we know?
Universal access means that all individuals can obtain the health care they need. This would enable women and children around the world to enjoy their fundamental human right to the highest attainable standard of health.
However, many countries face challenges in providing universal access to essential health services. In low- and middle-income countries, people often have to pay for health care out of their own pockets,5 putting it out of the reach of the poorest and most vulnerable.The challenge for these countries is to find ways to modify health financing and delivery systems in order to achieve universal access. Other barriers stem from sociocultural, gender and age differences as well as geographical and transportation challenges that result in women, newborns, children and adolescent girls being discriminated against when trying to access essential health services.
"To improve the health of women and children around the world the answers lie in building our collective resolve to ensure universal access to essential health services."
UN Secretary-General Ban Ki-moon
Reviews of what works in promoting universal access to essential health services identify important interventions and strategies.3,6 These include sustainable financing, improving the quality of care, addressing inequities, removing barriers to access, strengthening participation and accountability, integrating services, and drawing on human rights and advocacy (see Knowledge Summaries 3, 7, 9, 11 and 12).The three key components discussed in this Knowledge Summary are: ensuring entitlements, using a ‘diagonal’ approach to integrate services, and strengthening and scaling up health systems.
Entitlements link human rights with the resources required to enjoy these rights. All individuals have human rights, including the right to the highest attainable standard of health. However, unless they also have the ability and resources to access essential health services, they cannot enjoy this right.
Entitlements = Rights + Resources
The right of women and children to enjoy the highest attainable standard of health is set out in human rights agreements and in related declarations and policies at global, regional and national levels. Providing the required resources depends on three key health financing functions: (1) collection of sufficient and sustainable resources or revenues; (2) pooling of funds to ensure that costs are shared equitably to ensure financial accessibility; (3) purchasing and providing health care services in the most efficient and equitable way.5 Health systems reforms in Mexico illustrate how the concept of entitlements can be used to promote universal access.
A ‘diagonal’ approach to integrating services
Emerging research shows that integration of services and packages across the reproductive, maternal, newborn and child health (RMNCH) continuum has the potential to promote access and improve outcomes for women and children (see Knowledge Summaries 2 and 3).
In Bangladesh, for example, evaluations of the Integrated Management of Childhood Illnesses (IMCI) program show that it resulted in improvements in exclusive breastfeeding rates and a reduction in the prevalence of stunting. A recent review of 185 studies found that creating linkages between sexual and reproductive health and HIV interventions reduced the incidence of HIV and sexually transmitted infections. It also encouraged use of condoms and other contraceptives, and improved uptake of HIV testing and quality of services.
Meanwhile, Egypt, which is one of the few countries on track to achieve both MDGs 4 and 5, has integrated child health and family planning, upgraded maternal health programs and expanded water and sanitation systems. This has happened alongside training of health workers and improving community outreach programs.
Such integration across the RMNCH continuum and between RMNCH and other health and intersectoral issues has the potential to improve outcomes for women and children.
There is an ongoing debate in the global health community about the relative benefits of integrated health programs versus programs that emphasize specific interventions. A systematic review found little hard evidence to support one approach over the other. Instead, the review said that:“The purpose, nature, speed and the extent of integration also vary – in part, dependent on the intervention complexity, the health system characteristics and the contextual factors … creating a rich mosaic of local solutions to address emergent problems.”
Thus, a strategic, context-specific approach is required to integrate services effectively, efficiently and equitably for universal access, which should include identifying and addressing specific barriers. This strategy is referred to as a ‘diagonal approach’ that combines proactive vertical interventions targeting specific problems, with horizontal demand-driven interventions that connect healthcare from homes to hospitals.
Strengthening and scaling up health systems
While consideration has to be given to country-specific contexts, including the burden of disease and health system capacity, the expansion of proven interventions and strengthening of health systems will generally need to be undertaken in a phased manner. Investment in high-impact and cost-effective interventions is a priority (see Knowledge Summary 3). Countries and partners engaged in scaling up will also need to prioritize, reaching out to those who are underserved to ensure equity (see Knowledge Summary 9). Health systems strengthening can then be addressed as part of longer-term strategic plans based on existing systems capacities and current levels of health outcomes. Expanding coverage of interventions, in parallel with health system strengthening, should also address the socio-economic barriers to healthcare access, which influence the success of any health system.
A determination to improve the health of women and children must include a commitment to improving universal access to essential healthcare. Using the synergies that exist between the various health and development programs is an efficient and effective way of delivering services and improving health outcomes. A special effort must be made to reach those who are underserved. Governments, donors and those who manage global initiatives must come together to make this possible.