Featured Issue: Universal Health Coverage: What immunization advocates should consider

At least half of the world's people do not have access to essential health services. UHC ensures that no one is left behind. Image from UHCday.org

Universal Health Coverage: What immunization advocates should consider

December 12th is worldwide Universal Health Coverage (UHC) day!  Although exceedingly complex in its implementation, the concept behind UHC is simple: All people should benefit from quality health services, medicines and vaccinations, and no one should be put in financial peril to do so.  In recognition of UHC Day 2018, the VoICE team brings you a brief look at the interplay between coverage of immunization and other basic health interventions, and the important role of immunization in protecting against financial risk – both within the context of the Strategic Development Goal Target for UHC.

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Key Points 

  1. Achieving universal coverage of basic health services will require strengthening and expanding current health systems AND new approaches to reaching those who still cannot or do not access health services
  2. The reach of immunization delivery programs can be leveraged to provide other basic services – and increase financial efficiency of health systems – and the reverse is also true: the delivery of other interventions can help to increase the uptake of vaccines.
  3. Achievement of UHC will positively contribute to at least six of the 17 Strategic Development Goals
  4. Immunization can contribute significantly to achieving financial risk protection against health costs

 

Universal Health Coverage and the Strategic Development Goals

December 12th is worldwide Universal Health Coverage (UHC) day!  The aim of drawing attention to this day is to shine the global spotlight on the gaps in achieving health as a human right. Although exceedingly complex in its implementation, the concept behind UHC is simple: All people should benefit from quality health services, medicines and vaccinations, and no one should be put in financial peril to do so.

In 2015, 193 United Nations Member States committed to an ambitious set of 17 “Strategic Development Goals” (SDGs) by 2030. The right to health not only figures prominently as a goal in and of itself – SDG3 is to “Ensure healthy lives and promote well-being for all at all ages” – but is also fundamentally intertwined with goals related to equity, poverty, economic growth and inclusion. (See Figure 1.)

 

Figure 1: The interrelatedness of Universal Health Coverage with other Sustainable Development Goals, and the importance of health systems strengthening

Source: Tracking Universal Health Coverage: 2017 Global Monitoring Report. World Health Organization and International Bank for Reconstruction and Development / The World Bank; 2017. License: CC BY-NC-SA 3.0 IGO. Available here: http://www.who.int/healthinfo/universal_health_coverage/report/2017/en/

 

Embodied in the 8th Target of  SDG3 (SDG 3.8), the pursuit of UHC is supported by the twin indicators of 1) coverage of essential services (including immunization), and 2) financial risk protection from the incurrence of economically burdensome health costs.  In recognition of UHC Day 2018, the VoICE team brings you a brief look at the interplay between coverage of immunization and other basic health interventions, and the important role of immunization in protecting against financial risk – both within the context of SDG 3.8.

 

Building on coverage of vaccines gives UHC a head start, but there is more to do

Equity is at the heart of the Sustainable Development Goal target 3.8, which seeks to achieve universal health coverage and financial risk protection for all.  The coverage indicator for the achievement of UHC tracks the coverage of 14 “tracer interventions”, which together serve as a barometer for access to basic health services. Access to immunization is tracked through the coverage of the third dose of DTP3, one of four maternal and child health tracer interventions. Although DTP3 coverage is evidence of the fact that immunization is one of the most widely available and equitably distributed interventions worldwide, several other important vaccines lag behind the 85% coverage of DTP3 worldwide in 2017.

Specific vaccines notwithstanding, high coverage with some vaccines such as DTP make immunization programs a critical backbone of any universal health coverage strategy. Routine and campaign-based immunization programs reach some children in remote or poverty stricken areas whose families have little other connection to the health system, and as such, offer opportunities to provide additional basic health care services to children and their families, especially interventions associated with maternal and child health. See Figure 2 for some highlights from VoICE of the opportunities for mutual reinforcement between immunization and other programs.

 

Figure 2: Examples of the integration of immunization and other health services.

Basic health services, like Vitamin A delivery, can be integrated into vaccine programs.Vitamin A distribution integrated with polio vaccine campaigns led to increased VitA coverage in several African countries.

School-based HPV vaccine programs for girls can also serve as opportunities to connect boys with health services.Delivery of HPV vaccine to school-age girls in Rwanda provided an opportunity to offer school-age boys a variety of health services at the same time.

Integrated health programs, like immunizations and other health services, have an opportunity for cost-sharing and external funding.Immunization programs provide opportunities for cost-sharing and external funding, when used alongside other health interventions.

The timing of childhood immunizations could be harnessed to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.

 

 

 

Despite the relatively high coverage globally of some vaccines, other critical vaccines have reached only a small fraction of the world’s children. Fully 15% of the world’s children are not reached at all by immunization – a gap whose distribution carries significant inequity – so vaccine coverage successes are very much tied to the achievement of UHC goals and targets for other health services.

Achieving health equity requires providing whatever resources are necessary to help everyone have the same opportunities for health, and thus means giving additional support to those with the least access and coverage of basic health services. This image (from the US State Department) depicts the difference between equity and equality.

The achievement of UHC targets will, however, require significant reform and expansion of existing health systems to address challenges such as missed opportunities to integrate services. For example, a recent study in 14 low- and middle-income countries found an exceedingly high rate of missed opportunities to vaccinate in 8 of the 14 countries, despite families coming into contact with the health system. For these countries, children failed to be vaccinated more than 50% of the time, despite they or their mother having received at least one of 5 other basic health interventions provided through the health system. Additionally, for the millions of families not reached at all by current health systems, barriers may include socio-cultural factors, in addition to geography, education, poverty, etc.

For these families and others with inadequate health services, a truly equity-driven approach is needed. That is, governments, partners, health-providers, and systems will need find ways to provide whatever additional support is needed to help them catch up, not just make the same resources available to everyone.

 

For families, financial barriers to immunization are relatively low, but health and economic returns are high

The second indicator of the universal health coverage target acknowledges that the costs associated with health care – both preventative services and treatment for illness – are a significant barrier for hundreds of millions of people around the world. These costs prevent some people from even trying to access health services, and for those who do seek care they cannot afford, the financial burden of these services can have significant, negative and lasting economic impact. The provision of a basic package of preventative services, including immunization, would thus create a positive, reinforcing cycle of increased health-seeking behavior and improved financial stability for individuals, families and economies.

Immunization is a critical element to success for two reasons. First, thanks to global institutions such as Gavi and UNICEF, immunization is free of charge for a large proportion of families in the world’s middle and low-income nations and financial barriers to access are thus relatively low. However, not all crucial vaccines are yet available through national immunization programs in every country. In some places, lifesaving vaccines against disease such as pneumococcal disease are only available through the private market, carrying a price tag far too high for many families to access. And, as mentioned above, sociocultural factors and other issues are significant drivers of gaps in vaccine coverage and these must be addressed carefully and concertedly.

The second reason immunization is critical to meeting the financial risk protection targets of UHC is much more obvious: the widespread use of vaccines has the power to avert significant costs associated with treatment of infections. The huge economic burden of these infections stems from the costs associated with treating relatively low-cost but frequently occurring infections and complicated infections such as meningitis which are rare but very expensive to treat. These vaccine-preventable episodes of illness are responsible for a large number of families being pushed into poverty each year.

Visit the VoICE tool to find out more about how vaccines can help people avoid economic impoverishment from medical costs. Read our feature on medical impoverishment averted through immunization in 41 low-income nations.

A mother in Nigeria holds her baby as health worker prepares to give the baby a vaccination.

 

The hurdles that remain are high, but health for all awaits on the other side

The road to UHC will be fraught with risk and will require creative new ideas for reaching the unreached. For one, we must ensure that whatever systems are put in place to expand access to basic health interventions will not inadvertently damage immunization coverage, but will reinforce progress that has been made in expanding immunization coverage.

It is also clear that the achievement of UHC goals by 2030, or by any time, will require us to not only expand and improve upon the health systems that already exist, but also to change our approach to these imperfect health systems. Those families who receive no basic health services are called “hard to reach” for a reason. The challenge in devising a system flexible and comprehensive enough to reach everyone is very real, and very worthwhile.

 

 

 

 

A selection of VoICE evidence in this issue

Hinman, A.R., and McKinlay, M.A. 2015. Immunization equity. Vaccine. 33(2015):D72-D77. Chebab, E.T., et al. 2016. Experience of integrating vitamin A supplementation into polio campaigns in the African Region.. Vaccine. 34(43). Torres-Rueda, S., Rulisa, S., Burchett, H.E., et al 2016. HPV vaccine introduction in Rwanda: Impacts on the broader health system. Sexual and Reproductive Healthcare. 7:46-51. Niessen, L., ten Hove, A., Hilderink, H., et al 2009. Comparative impact assessment of child pneumonia interventions. Bulletin of the World Health Organization. 87:472-80. Deoganakar, R., Hutubessy, R., van der Putten, I., et al 2012. Systematic review of studies evaluating the broader economic impact of vaccination in low and middle income countries. BMC Public Health. 12:878. Olusanya, B.O. 2009. Optimising the use of routine immunisation clinics for early childhood development in sub-Saharan Africa. Vaccine. 27:3719-23. Restrepo-Mendez, M.C., Barros, A.J., Wong, K.L.M., et al. 2016. Missed opportunities in full immunization coverage: findings from low- and lower-middle-income countries. Global Health Action. 9(1). Verguet, S., Memirie, S. T., and Norheim, O. F. 2016. Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia. BMC Medicine. 14(1), 164. Chang, A. Y., Riumallo-Herl, C., Perales, N. A., et al. 2018. The equity impact vaccines may have on averting deaths and medical impoverishment in developing countries. Health Affairs. 37(2), 316-324.