Lancet Commission on synergies between universal health coverage, health security, and health promotion

Abstract

Since 2018, this Lancet Commission has sought to understand how to maximise synergies between the global health agendas of universal health coverage, health security, and health promotion, and what drives dis-synergies. By synergies the Commission is referring to an intervention, institutional capacity, or policy, that positively and substantially contributes to the achievement of two or more of these agendas in the areas where they intersect. We gathered data through desk reviews; case studies at the subnational, national, and global levels; consultation with two subregional bodies; and periodic Commissioner meetings both face to face and online to review, analyse, and synthesise data. Several key findings and implications for action arise from the analysis and the gathered data, particularly the in-depth country case studies, which provided several examples of these issues in action. Fragmentation and dis-synergies between agendas is near universal and undesirable Societies can and should pursue the agendas of universal health coverage, health security, and health promotion synergistically. We note that maximising synergies is important for both infectious and non-infectious diseases, and both endemic and epidemic diseases. However, we observed that, in countries at all income levels, counterproductive competition and fragmented investment are too often present in the implementation of these agendas, undermining the ability of health systems to achieve any of them—what we refer to as dis- synergies. For example, as highlighted by our in-depth country case studies, in some contexts, investments in health security detract from attempts to achieve universal health coverage, or efforts towards universal health coverage miss opportunities to promote healthy lives (ie, health promotion). Such dis-synergies weaken health systems, making them less able to cope with day-to-day and emergency demands, and render people more vulnerable to serious disease, as we saw with the COVID-19 pandemic. COVID-19 has been our warning The COVID-19 pandemic has shown that it makes good sense for all countries, regardless of their income level, to develop comprehensive health systems with synergies between health security, health promotion, and universal health coverage. We explored this in our COVID-19 case study and found that universal health coverage and healthier populations have helped some countries withstand the pandemic by accommodating the surge of patients from COVID-19, minimising stress on health- care facilities; and by minimising the burden and strain of serious COVID-19 disease on health systems because of fewer comorbidities. Drivers of dis-synergies are diverse and multidimensional, including ill-considered national self interests and coloniality Drivers of dis-synergies in subnational, national, and global health are diverse. Drivers include inappropriate laws and policies; imbalanced investments in specific areas of health systems; disregard for context; siloed programmes; inadequate capacities; politically driven interventions not based on evidence; ill-considered national self interests; and coloniality. Coloniality involves frameworks of thinking and doing that lead to misuse of power over others in decision making and implementation, with an assumption of inherent superiority without critical questioning of validity. Centralised decision making, exploitation of power disparities, disregard of context, and failure to critically question the validity of decisions are all manifestations of these drivers. An example of coloniality potentially exacerbating dis-synergies in health systems is when nationally identified health priorities are unsupported by some powerful global-health actors if they are not consistent with their own priorities and concerns, as sometimes occurred in the early stages of Ghana’s national health insurances reforms. The national health insurances reforms, which were an attempt to introduce universal health coverage into interventions and synergise with other health sector interventions, despite resource constraints, had to sometimes contend with opposition from some powerful global funders who saw the reform as inappropriate for a highly indebted poor country. Donor funding for health security investments in resource-constrained settings have been justified as serving the self interests of the donor country. We acknowledge that national self interest will take priority for governments of all countries as they prioritise and allocate funding and make decisions for national or international health objectives, regardless of country income level. However, supporting health security in a manner that is synergistic with universal health coverage and health promotion can help a country better control infectious disease. Thus, we argue that global solidarity in health can be consistent with enlightened self interest. Changes in mindsets, decision making, and accountability are required to advance towards the comprehensive health systems we need to achieve universal health coverage, health security, and health promotion We recognise that pulling together fragmented approaches that have evolved into entrenched systems requires long-term processes of change, which could sometimes take decades. We argue that constructing coherent comprehensive health systems is nevertheless necessary and will require three changes. First is a change in mindset. We urgently need to reframe health in a comprehensive, holistic manner, and to develop shared values and principles to achieve this vision. We need to recognise that all health systems operate with constrained resources, and realising synergies at the intersections between universal health coverage, health security, and health promotion is not only desirable but necessary, rather than promoting any one goal at the cost of the others. Second is a change in decision-making. A decolonised approach would avoid top-down decision making that exploits power disparities within and between countries. We need to shift away from decisions that privilege global or donor priorities over those of implementing countries. We also need to end the wholesale uncritical transfer of interventions, policies, and programmes from the global to the national, or from one country to another. Instead, decisions should be based on evidence and understanding of how and why particular interventions work in context, valorising the knowledge required to make interventions work. Our country case studies show the importance, feasibility, and effect of national health leaders asserting their health priorities. Global health agencies should offer enough flexibility for countries to adapt investments, policies, and programmes to national priorities and contexts. Third is a change in accountability. In our view, national governments retain primary responsibility for the health of their populations, and it is they who should be accountable for maximising synergies in their health systems. Holding governments accountable requires improved methods to measure and track synergies and dis-synergies, resilience, and performance of health systems over time. This change lies beyond the scope of this Commission but could be taken forward as a next step. That said, we recognise that, particularly in countries where development assistance for health has a substantial role, providers of development assistance for health (both funding and technical advice and support) hold considerable power. These powerful countries therefore also bear responsibility and should be accountable for their contributions to dis-synergies or synergies in health systems. There is also ample space to improve synergies between global actors at the international level. Therefore, a monitoring and accountability framework should encompass both national and global actors and could make a small contribution to addressing power disparities between and within them.