EditorialGlobal Health

Research for Universal Health Coverage

Science Translational Medicine  21 Aug 2013:
Vol. 5, Issue 199, pp. 199ed13
DOI: 10.1126/scitranslmed.3006971

Christopher Dye

John C. Reeder

Robert F. Terry

CREDIT: Izabela Suder-Dayao

Everyone should have access to the health services they need without risk of financial ruin or impoverishment. That is the essence of universal health coverage. In 2005, all member states of the World Health Organization (WHO) made a commitment to achieve that goal. The commitment was reaffirmed in 2012 through a resolution of the United Nations General Assembly (www.un.org/en/ga/67/resolutions.shtml) promoting universal health coverage, including comprehensive primary health care, social protection, and sustainable financing. The 2012 resolution highlights the importance of universal health coverage in reaching the Millennium Development Goals, in alleviating poverty, and in achieving sustainable development. It recognizes that health depends not only on having access to medical services and a means of paying for these services but also on understanding the links between social factors, the environment, natural disasters, and health. Universal health coverage is central to the question of how health should be represented in the new development agenda that will succeed the Millennium Development Goals in 2015.

Despite the multinational commitment to achieving universal health coverage, it remains unclear exactly how the two principal components—access to high-quality health services and financial risk protection—can be provided to all people in all settings. For instance, despite the existence of affordable and safe antiretroviral treatments for HIV/AIDS, there are many obstacles to negotiate before getting these treatments to the 5 million HIV-positive people who need them. Likewise, a variety of approaches to health financing have been tried and tested, but there are still no guaranteed remedies for the catastrophic health payments incurred by 150 million people worldwide each year.

Making the commitment to universal health coverage raises big questions. A scientific research agenda is needed to provide the answers. This agenda is the subject of WHO’s 2013 World Health Report, Research for Universal Health Coverage, released on 15 August (www.who.int/whr/en/index.html). The report argues that a wide variety of well-designed research studies—ranging from clinical investigations to health policy and systems research—is needed to show how to provide services for prevention, cure, and care. The findings of each new research study have the potential to yield products and processes that improve access to health services, taking a further step toward universal health coverage. The report also describes how to create an environment that stimulates research and innovation.

The case for investing in research is most compelling when the results have the potential to make health services more accessible and affordable, with measurable benefits for health. The 2013 World Health Report gives a series of examples of the power of research to enact change, as a stimulus to scientists, and as a reminder to policy-makers. In one example, a systematic review of survey data from 22 African countries showed that household ownership of at least one insecticide-treated mosquito net was associated with a 13 to 31% reduction in the mortality of children under 5 years of age (1). These findings underline the value of scaling up and maintaining coverage of insecticide-treated nets, now a mainstay of malaria control in all endemic countries. In a second example, clinical trials in Ethiopia, Kenya, Sudan, and Uganda found a combination of the drugs sodium stibogluconate and paromomycin to be an effective treatment for visceral leishmaniasis (2). Treatment with the drug combination is shorter than with sodium stibogluconate alone and is less likely to lead to drug resistance. On this basis, WHO recommended the drug combination as a first-line treatment for visceral leishmaniasis in East Africa. A third example illustrates the way in which specific health interventions can be supported by new ways to finance all health services. A systematic review of evidence from Brazil, Colombia, Honduras, Malawi, Mexico, and Nicaragua found that conditional cash transfers, in which cash payments are made in return for using health services, did indeed increase the use of these services. They led, for example, to an 11 to 20% increase in children being taken to health centers and 23 to 33% more children making visits for preventive health care (3).

These research studies, and others like them, have the potential to benefit millions around the world. But they are more likely to happen within the supportive environment of a national health research system. The 2013 World Heath Report identifies four essential ways in which health systems can support research on health: setting research priorities, building research capacity, defining norms and standards for research, and translating evidence into practice. Much has been written about how to enable each of these functions, but the report pulls together this collective knowledge and makes some important specific points in each area.

First, although generic methods have been developed to identify research priorities, the best documented examples are for specific health topics, such as malaria and tuberculosis control and the reduction of child mortality. More effort in more countries is needed to set national research priorities and to make the results of research widely known. Deliberations about priorities need a broad compass because many of the determinants of health and disease lie outside the health system. For this reason, research needs to investigate, for instance, the way human activities affect health through agricultural practices and changes to the natural environment.

Second, the results of some research studies are widely applicable (for example, the outcomes of clinical trials), but many questions about universal health coverage need local answers (for example, in relation to health-seeking behavior). All nations therefore need to be producers of research as well as consumers. Whereas the growth of research around the world has been uneven, many low- and middle-income countries now have the foundations on which to build effective national health research systems. Indeed, some low-income countries have much more than foundations, they have thriving research communities with a growing number of international collaborations. The people who do research in these communities—whether they be laboratory or field workers, clinicians, or public health specialists—are the greatest asset.

Third, codes of good practice—concerning ethics, study design, the sharing of data, and the registration of clinical trials—are already in use in many countries. The task ahead is to ensure that these are comprehensive and applicable in all countries and to encourage adherence everywhere.

Fourth, achieving universal health coverage depends on research ranging from studies of causation to the smooth operation of health systems. However, because many existing cost-effective interventions are not widely used, there is a particular need for translational studies that turn existing knowledge into practical applications. To help achieve that goal, research should be strengthened not only in academic centers but also in public health programs, close to the supply of, and demand for, health services.

Research for universal health coverage needs national and international backing in order to succeed. Setting up networks of national and global research observatories would provide a mechanism for monitoring research efforts, for coordinating these efforts by sharing information and fostering collaborations, and for raising and distributing funds to service global and national priorities (4, 5). As these observatories are established, it is vital to keep sight of the overarching goal: to promote investigations in which creativity is harnessed by the highest-quality science to deliver affordable, quality health services and better health for everyone.

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