Natxo Oleaga
Researcher
Several decades ago, we began to hear, write and talk about the necessary strengthening of health systems, with the aim of moving towards universal coverage.
Despite undoubted progress in relation to measured outcomes in areas such as maternal and child mortality, immunisations, monitoring and treatment of HIV, malaria and tuberculosis, child education..., and with increased funding available globally until 2019, the COVID pandemic is having disastrous effects in terms of health and the economy, unevenly distributed across different geographical regions and with consequences that are still difficult to quantify.
The Sustainable Development Goals certainly need to be reviewed. The regression in many countries represents decades of unrecoverable effort. This is why the need to strengthen health systems is back on the global agenda. This is not just a technical or financial issue. Perhaps we have not yet learned well enough that the key to the transformation of a complex social system is essentially political. Beyond well-meaning institutional declarations and official commitments which are routinely flouted, national policies rarely set clear objectives for the system that prioritise health for all on an equal basis, universal coverage without differences. It is not a priority, no matter how often similar mantras are repeated over time.
There are restrictions and a certain amount of contradiction between certain objectives ("trade-offs"), but we repeat lists of objectives as if they were all equally achievable at the same time. Rarely is a clear set of priorities established. We remain mired in stupidity, if not lies. The explanation is simple and we know it. Each group of stakeholders prioritises the targets to be achieved according to their own vested interests. Managers and citizens certainly do not have the same priorities. Nor would stakeholders with different ideological orientations draw up the same list. These interests are anchored in the social principles and values of the group they represent or in which they participate.
Thus, the objectives that are actually set are the result of the balance of power held by the different stakeholders. It should not be too difficult to understand that objectives of universal equity are not to the liking of a sufficient majority of stakeholders. It is clear that, if we are to move forward on this path, after many years of similar discourse, we will have to continue to promote political, professional and economic alliances in order to strengthen public services. But there is no reason to believe that the health sector will behave differently from other sectors or from how it has behaved in the past. The market and capital still have other plans - and more power.
The citizenry continue to be the stakeholder that is heralded as fundamental in today's societies, although to date the REAL social participation of the population in the social production of health and its promotion is of little significance.
With regard to the functions of the health system, let us assume for a moment that in a given country there is the political will, sufficiently sustained over time, to guarantee the right to health and to establish a health care system with characteristics such as efficiency, quality, speed, safety, access, quality, results, etc. This is an assumption. In such a case, it would not seem so unrealistic that we might be able to reach agreements regarding tax-based financing if the actors genuinely agreed to prioritise equity over other policy goals. It still sounds a bit like "those who earn the most pay the most and those who need the most use the most". It would be the sign of a policy that is oriented towards social inclusion and equity and that fights against health inequalities. However, this sign is not there. It seems that allocating at least 6% of GDP to public funding for health is a necessary, though not sufficient, condition for achieving coverage of the entire population. Even if this were the case, in low-income countries the amount of money allocated per capita would be ridiculous.
One of the consequences of the COVID pandemic is the recommendation by the WHO and other UN bodies that an additional 1.5% be allocated to primary care (or whatever you prefer to call it). There is no evidence of any opposition to this idea, which does not mean that we are going to see it implemented any time soon, especially in countries with the greatest needs, which happen to be those that have the least resources and have suffered the worst effects of the pandemic.
In any case, the financing approach of Universal Health Coverage will remain the key issue. The WHO and World Bank proposal recommends insurance as the main approach. In practice, what we see is the expansion of coverage through the addition of many different insurances, most obviously in Latin America. In the official understanding of UHC, universality basically corresponds to financial coverage by some type of public or private insurance, distinguished according to economic level or employment relationship, and access to a package of services, distinguished according to ability to pay. In other words, public policy status is given to segmentation, which is a structural deformation of existing health systems, a clear reflection of the social inequality and distributive inequity that trigger its increase.
We have to go back to politics to ask, in each case, whether such proposals have sufficient support in most historical periods or in most countries. Formally, documents and plans with this focus are signed and agreed upon. The practice of political action rarely takes such declarations seriously; hence we must continue to maintain certain old objectives as current simply because... they have not been achieved.
It seems clear that the coronavirus has helped place public health and health care a few positions higher than usual in the collective imagination, in the media and on social networks, in the discourse of professional policy makers, etc. Some reflection on the patchwork of models (often only mental, in many cases) and attempts to explain the production and provision of services: every society aspires to have sufficient capacity in its systems (infrastructure and competencies of professional resources with a focus on competencies that affect the determinants of health), ensuring that local, regional and national agencies have the necessary knowledge and resources to provide public health services, effectively delivering the Essential Functions, on a day-to-day basis and in the event of emergencies or catastrophes. The continuous updating of the portfolio of services is essential for a number of different and, of course, paradoxical reasons. Daily innovations in the field of medicines and diagnostic procedures, with particular emphasis on digitalisation and artificial intelligence, are becoming commonplace. On the other hand, we need to think carefully about restricting (in many cases, out of necessity) the catalogue of benefits to truly effective services, with effective policies aimed at preventing over-diagnosis and over-treatment. The area ranging from basic services to precision medicine is too wide to be able to generalise. Some countries and certain stakeholders fantasise about the rapid personalisation of medicine within the reach of a few, while others are able to list the services available to their population on a single page. The gap will continue to grow. Another structural issue related to the provision of health systems is institutional and organisational fragmentation. Health organisations belonging to the various institutions that make up a health system coexist with little or no coordination, complementarity or collaboration: public services of the ministries of health, social security (privatised and non-privatised), private services with varying levels of capital concentration, religious, community, philanthropic, armed forces, etc., all with different levels of efficiency, information, management capacity and resources in place. They usually gain (almost) nothing by collaborating more or more effectively.
This fragmentation, which is a consequence, but also a cause, of the weakness of PHC, is one of the factors behind the lack of continuity and comprehensiveness of care, which in turn leads to low quality of care and the squandering of resources. The experience of more than thirty years with PHC motivated PAHO/WHO to promote the creation of integrated health services networks (IHSN) in 2007 in order to overcome fragmentation. The IHSNs would assume responsibility for the comprehensive healthcare system for the population in a given territory, and would establish a relationship of collaboration and coordination between the various organisations and levels of care existing in a given territory-population. However, there are very few IHSNs in operation, and it does not seem that there will be sufficient numbers in the short term.
With or without these networks, there is sufficient information to argue for the successful deployment of PHC as a gateway to the system, with multidisciplinary teams, a focus on chronic conditions and good nursing services. Historical experience has shown us that only health systems with strong comprehensive PHC can ensure UHC, equitable access to services and the efficiency and quality of the health system. Only health systems with a strong and largely public financial base can ensure the right to health.
Without well-trained human resources, in sufficient numbers and in the right combinations for each situation, there is little chance of a system performing with any degree of success. Studies on their numerical availability, geographical distribution, professional migration, quality of training and delusions of competence do not encourage us to raise our hopes for the future.
With some informed pessimism, there is no doubt that there is a greater need than ever to further strengthen health systems. And there will continue to be. We need to keep pounding away at the same problem, albeit with a different hammer.