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Global Health Security and Universal Health Coverage: from a Marriage of Convenience to a Strategic, Effective Partnership

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Global Health Security and Universal Health Coverage: from a Marriage of Convenience to a Strategic, Effective Partnership Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2018-001145 on 13 January 2019. Downloaded from Global health security and universal health coverage: from a marriage of convenience to a strategic, effective partnership Clare Wenham,1 Rebecca Katz,2 Charles Birungi,3,4 Lisa Boden,5 Mark Eccleston-Turner,6 Lawrence Gostin,7 Renzo Guinto,8 Mark Hellowell,9 Kristine Husøy Onarheim,10 Joshua Hutton,11 Anuj Kapilashrami,12 Emily Mendenhall,13 Alexandra Phelan,14 Marlee Tichenor,15 Devi Sridhar15 To cite: Wenham C, Katz R, ABSTRACT Summary box Birungi C, et al. Global Global health security and universal health coverage have health security and universal been frequently considered as “two sides of the same What is already known about this subject? health coverage: from a coin”. Yet, greater analysis is required as to whether and marriage of convenience ► Universal health coverage (UHC) and global health where these two ideals converge, and what important to a strategic, effective security (GHS) are frequently being used in tandem differences exist. A consequence of ignoring their partnership. BMJ Glob Health by policymakers, recognising that there are syner- individual characteristics is to distort global and local 2019;4:e001145. doi:10.1136/ gies between the two parallel agendas. bmjgh-2018-001145 health priorities in an effort to streamline policymaking and funding activities. This paper examines the areas What are the new findings? Handling editor Seye Abimbola of convergence and divergence between global health ► UHC and GHS goals are in tension. The research security and universal health coverage, both conceptually and practice communities that represent these two Received 30 August 2018 and empirically. We consider analytical concepts of risk streams need to engage so that smart strategies can Revised 19 October 2018 and human rights as fundamental to both goals, but also be identified to improve both aims simultaneously Accepted 28 October 2018 identify differences in priorities between the two ideals. We using codependent, but distinct policy. support the argument that the process of health system ► Risk and human rights are two areas of convergence strengthening provides the most promising mechanism of between UHC and GHS. benefiting both goals. ► Divergence appears in the conceptualisation of risk at the collective or individual level, and the prioritisa- http://gh.bmj.com/ tion of domestic or global activity. What are the recommendations for policy and INTRODUCTION practice? Global health security (GHS) and universal ► Health systems strengthening can be the policy health coverage (UHC) are frequently mechanism which, brings GHS and UHC together, on September 30, 2021 by guest. Protected copyright. regarded as two sides of the same coin,1 or elevating health and mitigating risk for all. more cynically as a marriage of convenience.2 Yet, there has been little consideration of how these ideals interact, with academics and be in conflict. Similarly, while both agendas policymakers assuming that actions for one enshrine human rights and we see conver- will also be advantageous to the other. This gence through the realisation of the right to paper analyses at a macro level where these ideals converge, and where differences lie health, we see distinctions between economic, both conceptually and empirically. We argue cultural and social rights with civil and polit- both GHS and UHC focus on the mitigation ical rights. © Author(s) (or their It is important to address these differences employer(s)) 2019. Re-use of risk and human rights. Mitigating the permitted under CC BY. risk of individuals who face impoverishment before considering the mutual opportunities Published by BMJ. owing to healthcare expenditure is core to offered by their ‘marriage’, to ensure that For numbered affiliations see UHC. For GHS, the risk is transnational and inherent differences are not jettisoned for end of article. emerges from outbreaks with cross-border pragmatic reasons, risking distortion of local health priorities. We support the link that Correspondence to potential. Hence, the bearer of the risk, Dr Clare Wenham; and the appropriate steps to mitigate it, are health system strengthening (HSS) creates c. wenham@ lse. ac. uk different in each agenda and may sometimes opportunity to connect GHS and UHC in a Wenham C, et al. BMJ Glob Health 2019;4:e001145. doi:10.1136/bmjgh-2018-001145 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001145 on 13 January 2019. Downloaded from tangible way, with clear policy pathways that can benefit international organisations and non-governmental stake- both ideals. holders,16 which provides political impetus and interna- tional collaboration to meeting IHR requirements. Defining Global Health Security (GHS) and Universal Health Coverage (UHC) Current intersections between the two concepts We recognise that the definition of UHC can vary in 3 Five key works have sought to connect GHS and UHC. Jain distinct, but convergent ways. A holistic definition is and Alam highlight that UHC can help advance GHS.17 ensuring individuals have access, without discrimination First, low or no financial barriers to accessing healthcare to comprehensive, appropriate and timely, quality health stimulates demand for health services which facilitates services determined at the national level according early infectious disease detection. Second, protecting to needs, as well as access to safe and affordable medi- people from catastrophic financial risk reduces an indi- cines, while ensuring that the use of these services do not vidual’s possibility of falling into poverty, an important expose users to financial difficulties.4 However, for the social determinant of infectious disease spread.18 purpose of this paper, we focus within this definition on Yates, Dhillon and Rannan-Eliya echo Jain and Alam’s the extent to which the costs of healthcare are covered.5 first thesis verbalising “the availability of accessible We recognise that such a definition is not comprehen- and universal healthcare services in all countries is the sive, but we also acknowledge that the two components crucial first line of defence for all against such threats to of UHC (access and risk protection) are in tension when health”.19 Moreover, if people are unable to access health- it comes to decision making about provision, particularly care in their local communities, this increases the likeli- in resource-poor settings, as the goal of access would hood of individuals crossing borders to seek healthcare, lead to prioritisation of the most (cost) effective services, thus increasing the risk of onward transmission interna- whereas a focus on financial protection would favour 19 6 tionally. This work shows how these two concepts are allocation of resources to more expensive interventions. mirrored empirically: suggesting that UHC’s relationship However, in stressing the importance of universal access to effective healthcare, and universal financial protection between financial protection and equitable distribution against the costs of this care, the definition is consistent of risk (which addresses people’s ability to pay, while with the United Nations Sustainable Development protecting the sick), mirrors the relationship between Goals (SDGs), which includes in Goal 3 "ensure healthy donor and recipient states for GHS, whereby wealthy lives and promote well-being for all at all ages" and in states finance outbreak responses in affected states. While particular target (3.8) to “achieve UHC including finan- this risk pooling is not part of the IHR or GHSA mandate, it can be argued that IHR compliance should reflect the cial risk protection, access to quality essential healthcare 19 services and access to safe, effective, quality essential ability to pay while protecting weaker states. 7 Moreover, Yates et al highlight that movements towards medicines and vaccines for all”. 2 19 We define GHS activities as those concerned with UHC build trust. This form of trust may exist between http://gh.bmj.com/ preventing, detecting and responding to infectious governments and populations, between health providers disease threats of international concern to limit any and patients and between financiers and recipients of socioeconomic impact of transborder disease, which health. This trust may foster effective collaboration when mirrors the WHO definition.8 Nevertheless, we recognise an outbreak emerges, improving public compliance 20 21 that GHS is “very much like a chameleon” “essentially with state-led interventions to limit disease spread. contested” and “not adequately defined”.9–12 However, Ooms et al are more sceptical of joining the two on September 30, 2021 by guest. Protected copyright. GHS is underpinned by a legal instrument, the Inter- agendas together, recognising that they are synergistic, 2 national Health Regulations (2005) (IHR).13 The IHR but not self-evidently so. In resource-poor settings, they provide guidance for how states should develop and recognise distinct policy pathways for UHC and GHS; for maintain their national capacities to minimise public example, whether to fund development of surveillance health threats. While there is no binding international capabilities or social health insurance mechanisms, a legal equivalent for UHC, the International Covenant point we would agree with. on Economic, Social and Cultural Rights guarantees Ooms et al further underscore the instrumentalism in the human right to health.
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