Universal Health Coverage (UHC): through the lens of pneumonia

Pictured above: Mother Tiguida Keita looks into the cot where here five-month-old daughter Ami Coulibaly fights the devastating effects of pneumonia. The daily cost of antibiotic treatment for Ami surpasses the money Tiguida spends each day to feed all of her other children combined.

Ten years ago in the pediatric hospital of Mali’s capital city, Bamako, an entire ward of children – some, three to a crib – were fighting life-threatening pneumonia infections, many of which could have been prevented through interventions promoted as part of a Universal Health Coverage (UHC) plan. Mothers like Tiguida Keita scrambled to find the money to buy antibiotics to treat their babies, while hoping to have enough left over to buy food for their other children at home. While some preventive measures encompassed by UHC – such as vaccines –are now available to Malian mothers like Tiguida, many other interventions for pneumonia are effectively out of reach due to cost or low/non-existent availability of these interventions.

(Read more about pneumonia in Mali and other countries in Save the Children’s Fighting for Breath Country Briefings here.)

Mali is not alone. Nearly 40 other countries offer neither free nor universal health coverage, and the majority of these countries bear a heavy burden of poverty, disease and poor health. In terms of pneumonia, none of the four countries with the lowest pneumonia intervention scores featured in IVAC’s 2017 Pneumonia & Diarrhea Progress Report have implemented UHC.

UHC is embodied in Sustainable Development Goal 3.8 which sets out to achieve the following by 2030:

“Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” (https://sustainabledevelopment.un.org/sdg3)

WHO Director General Dr. Tedros further points out that “Universal health coverage is not an end in itself: its goal is to improve the other health-related Sustainable Development Goals.” Given the far-reaching consequences of childhood pneumonia, the strength and coverage of primary care and preventive services necessary to tackle pneumonia in children can be seen as a litmus test for advancement towards UHC goals.

What is UHC?

UHC encompasses “essential” health services that cover the spectrum of care from health promotion, to prevention and treatment.  The package of services can be tailored to suit country-specific goals and budgets.  The WHO has defined key, essential services that are proven effective and provide guidance for resource-constrained countries.  (See the WHO fact sheet on UHC for more information.)

UHC is not only about what services are covered, but also who pays for them, and how they are managed and delivered.  This encompasses a health systems approach, where countries purposefully invest in health service delivery systems, health workforce, and quality assurance, along with health financing.

Why is UHC important?

• At least half of the world’s population does not have access to essential, life-saving health services, and as a result they suffer ill-health and death due to preventable conditions.
• About 100 million people are pushed into “extreme poverty” (defined as living on USD $1.90 or less per day) by health care costs – temporarily, longer-term and/or multiple times
• 12% of the world’s population spends at least 10% of their household budget on health care.

The goal of UHC is better financial risk protection for families from catastrophic health care costs and better health outcomes based on higher quality services.

In the case of pneumonia

Many of the child deaths due to pneumonia are a symptom of underlying health system failures at multiple points that deny children access to basic, quality care.

Pneumonia is the leading cause of death in children under 5—taking the lives of more than 100 children each hour, or nearly a million children per year—and it disproportionately affects those living in the poorest households and in the poorest countries around the world, like Tiguida Keita and her daughter, Ami. (http://data.unicef.org/topic/child-health/pneumonia/)

Much of the morbidity and mortality due to pneumonia represent shortcomings at multiple levels of fragmented health systems that forces families to spend out-of-pocket and without assuring quality care.  Here is a look at some of the basic components of UHC and current health system gaps, as highlighted by the example of pneumonia.

1. Access to essential vaccines: The WHO has articulated “full child immunization” as an essential health service that is proven cost-effective and safe. (WHO.  Universal health coverage. 2017) Yet 2016 global coverage estimates of vaccines that could reduce the burden of common bacterial causes of childhood pneumonia show this coverage to be suboptimal – that is, below the 90% target set out for each vaccine in the Global Vaccine Action Plan:

1. 42% of infants received a 3^rd dose of pneumococcal (PCV) vaccine.
2. 70% received a 3^rd dose of Hib vaccine
3. 86% received a 3^rd dose of pertussis (DTP) vaccine
4. 64% received a 2^nd dose of measles vaccine

Note: these global averages hide wide variability in vaccine coverage based on country, household income and geography. (UNICEF.  State of the World’s Children. 2017.)

2.“Health-seeking behavior for pneumonia” is another essential health indicator as defined by the WHO. Yet globally only 62% of children with pneumonia symptoms were taken to a health care provider, and this proportion dropped to 49% in the least developed countries, and 47% in Sub-Saharan Africa. (UNICEF.  State of the World’s Children. 2017)  Poor families were less likely to seek care compared to wealthier families in the same country as shown in the figure below.

ARI=acute respiratory illness
Source: Save the Children. Fighting for breath: a call to action on childhood pneumonia. 2017.

3. Quality of care with accurate diagnosis and treatment: Even when families seek care, the quality of the health care their children receive may be inadequate. In a national health facility census conducted in Malawi from 2013-2014, only 39% of children between 2-59 months old classified with non-severe pneumonia by Integrated Management of Childhood Illness (IMCI) criteria were prescribed a first-line antibiotic, and 27% of children with pneumonia symptoms were not prescribed an antibiotic at all.[1] In some settings, antibiotics are not available in the correct dosage or form for a child, and additional challenges are presented by antibiotics that must be reconstituted with water, as the water itself may be contaminated.

Overall, roughly only a third of children with symptoms of pneumonia (cough and fast or difficult breathing) received antibiotics, but first-line antibiotics for pneumonia are effective and inexpensive, costing only USD $0.40 for a full course.  (Save the Children.  Fighting for breath: a call to action on childhood pneumonia. 2017. https://www.savethechildren.org.uk/content/dam/global/reports/health-and-nutrition/fighting-for-breath-final-low-res.pdf). It has been estimated that community case management of pneumonia with antibiotic treatment could reduce pneumonia mortality by 70% in children, as over 80% of childhood pneumonia deaths are believed to occur outside the hospital.[2] [3] These figures underscore the importance of building the community-based and primary care capacity to manage and triage sick children appropriately.

The low proportion of children with suspected pneumonia who receive appropriate antibiotic treatment is thus a result of a cascade of circumstances: low health-seeking behaviors—especially among poorer families who may feel they cannot afford treatment – misdiagnosis of pneumonia or misclassification of its severity based on insufficient training and supervision of first-line health providers, and insufficient or inappropriate antibiotic supplies at health facilities.  Implementation of UHC may help to avert these circumstances, in part by ameliorating the differential health-seeking behaviors by household wealth, and strategically planning for and investing in community-based case management.

2. “Basic hospital access” is another essential health service in the WHO UHC package. Without adequate oral antibiotic treatment, children with pneumonia can deteriorate rapidly.  At highest risk are children with weaker immune systems, either due to their young age (neonates), concurrent infections (such as with malaria or viruses) and/or undernutrition.  Basic hospital care consisting of supplemental oxygen therapy, and intramuscular or intravenous antibiotics and fluids are then needed.  These essential hospital-based services are vitally important for the sickest children: it has been reported in a systematic review, that hospital care can reduce neonatal deaths due to pneumonia by 90%.[4]

With a commitment to UHC, there are many opportunities for scaling up effective pneumonia interventions . . .

• Prevention: continued progress on vaccine coverage and reduction of inequities based on wealth and geography
• Health promotion: promote awareness and care-seeking by educating parents and communities on signs and symptoms of pneumonia, when and from whom to seek care, and the importance of timely immunization in protecting young children and their siblings
• Health financing: risk protection to avert catastrophic costs and medical impoverishment incurred by families from having to pay out-of-pocket for all treatment costs
• Improved care-seeking: financial protection to reduce out-of-pocket treatment costs can encourage families, who otherwise might not have access to care or who might go to traditional healers, to seek care from appropriate providers when a child is sick
• Health workforce: supervision and training of community health workers and clinic staff to systematically approach diagnosis, treatment and referral of sick children – three factors which can be the difference between life and death, especially for high risk populations
• Health facility network: planning for and maintenance of a network of community health workers, primary care clinics and referral centers to geographically cover population needs
• Medical supply chain integration: procurement and distribution of essential antibiotics, pulse oximetry and supplemental oxygen equipment (UNICEF and WHO. End preventable deaths: global action plan for prevention and control of pneumonia and diarrhoea.)

References

[1] Johansson EW, Nsona H, et al.  Determinants of Integrated Management of Childhood Illness (IMCI non-severe pneumonia classification and care in Malawi health facilities: analysis of a national facility census.  J Global Health 2017; 7(2): 020408.

[2] Theodoratou E, Al-Jilaihawi S, et al. The effect of case management on childhood pneumonia mortality in developing countries.  Int J Epid 2010; 39: i155-i171.

[3] Nair H, Simoes EA, et al.  Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.  Lancet 2013; 381: 1380-1390.

[4] Zaidi AKM, Ganatra HA, et al.  Effect of case management on neonatal mortality due to sepsis and pneumonia.  BioMed Central Public Health 2011; 11 (Suppl 3): S13.