Monday, November 1, 2021

Towards comprehensive UHC: Moving quality along with coverage – Express Healthcare

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In the run up to December 12, International Universal Health Coverage Day 2020, Shikha Rana and Shubham Gupta, Sambodhi Research & Communications explain how with the COVID-19 looming, the priority for this year is to end this crisis, take the learnings for building an adaptive health system and build a safer and healthier future by investing in health systems that protect us all

A fundamental human right, health is considered as the foundation for people, societies, and nations to thrive and realise their full potential. The global health agenda has showcased universal health care at the forefront of promoting better health, with the setting of SDGs reaffirming the achievement of universal health coverage (UHC) by 2030. Universal Health Care means that all individuals and communities should have comprehensible and high-quality health services including promotion, prevention, treatment, rehabilitation, and palliative care without economic hardship.

While there have been multiple commitments as the key asks from the UHC movement, the progress towards UHC has been largely seen through coverage of essential health services and financial risk protection. But it has largely missed out on the essential ask of upholding quality of care. A recent book published by National academies of Science, Engineering and Medicine suggests that simply ensuring access to care and protection from financial risks would be insufficient to achieve UHC.

For effective universal health care, focus on all key dimensions of quality of care (defined by WHO as safety, person-centeredness, effectiveness, timeliness/accessibility, efficiency, integrated, and equity) would be critical. Health systems across countries, while providing access to essential health services have been unable to provide high quality services, making it difficult to achieve the targeted health outcomes.

Despite the significant gains over the past decades, increasing incidences of war induced displacement, migration, modern slavery, climate change, and disease outbreaks have added to the burden on health systems, thus risking the UHC achievement. In the past, outbreaks such as Ebola have served as reminders for specific and focused commitments to quality UHC. Recently COVID-19 pandemic has put the spotlight on how well the health systems have fared on upholding quality and reinforced its importance in achieving health goals.

Data from the India’s Health Management Information System (HMIS) indicates that there has been a dip in both coverage and quality indicators during COVID-19. For instance, Antenatal Care (ANC) registration against estimated pregnancy has fallen by 3.5 per cent in the first quarter of 2020-21 compared to the same quarter of 2019-20. However, the data for quality indicators for the same timeframe have shown a much higher dip, wherein there were dips of 20.3 per cent for 4 or more ANC checkups and 19.3 per cent for 4 or more haemoglobin tests during pregnancy.

Additionally, the stillbirth rate for India has also increased from 12.5 to 15.3 in this quarter, potentially indicating a disruption in quality of care at the facility level along with other factors like restrictive mobility, conversion of facilities to COVID treatment centers, apprehension of beneficiaries to deliver in public facilities due to the fear of COVID-19.

To tackle these challenges, a collective and sustained effort is required. COVID-19 has also provided learnings for building an adaptive health system and one such learning is considering frontline workers as a key piece of UHC.

Frontline workers (FLWs) are one of the fundamental elements of equitable health systems and influence access, equity, and acceptability of the health services. The role of FLWs was also found to be vital in the COVID response efforts. During the lockdown, FLWs acted as live links to communities and delivered routine outreach services, providing COVID-19 specific counselling, tracking and reporting active cases and migrant families, and assisting community members to avail emergency services.

However, it is necessary to enhance the working conditions for the existing frontline workforce (permanent paid positions instead of voluntary, recurrent training, continued supervision and education, inclusion in feedback loops and policy building) and more importantly to realise the need to expand the onus for community health care beyond the frontline workers.

This shift includes encouraging multi-stakeholder engagement including civil society organisations and the public in decision-making. Such multisectoral support integrated into health plans and policies can help in reducing health inequities, particularly in the context of factors outside the health sector that could influence disease burdens and barriers to access. In addition to this, technology-based solution can be utilised as a facilitator in effective health service deliveries along with robust quality monitoring framework for UHC. Furthermore, there should be a focus on broadening the scope of UHC at local and national level to incorporate dimensions of person-centric and inclusive health in the existing care models.

Lastly, a strong political will and financial commitment are needed to build resilient health system. This system would not only address supply-side hurdles in providing quality health services to all but would also absorb further shocks to health system.

(The authors work at Sambodhi Research & Communications, a multidisciplinary research organisation offering data driven insights to national and global social development organisations)

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