Elsevier

The Lancet

Volume 364, Issue 9444, 23–29 October 2004, Pages 1541-1548
The Lancet

Series
Achieving universal coverage with health interventions

https://doi.org/10.1016/S0140-6736(04)17279-6Get rights and content

Summary

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale—ie, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short.

Section snippets

Choice of priority interventions

In this article we build on the issues raised in preceding reports,1, 2, 3 examining how health programmes known to be effective in low-income countries can be taken to scale. Scale has become a popular word, as evidence mounts that available, affordable, and effective interventions are not reaching many of those who need them.4, 5 As documented in the first article of this series1 and elsewhere,6 people not receiving services are disproportionately from among the poor. Our emphasis will be on

Health delivery issues

A proportion of the failure to achieve adequate and equitable population coverage with good public health programmes can be attributed to weaknesses in health delivery systems. Alternative strategies for strengthening the delivery of interventions have received little attention.19 This lack is largely attributable to the fact that effectiveness studies have often failed to separate the health impact of a specific intervention (eg, a vaccine), from the delivery strategy used to reach the target

Type of programme

The debate between proponents of vertical and horizontal approaches to health delivery is not new.28, 29, 30, 31, 32 Horizontal approaches tend to incorporate several health interventions as part of a comprehensive primary care approach, usually delivered through government health facilities. Vertical programmes, on the other hand, tend to deliver selected interventions, often independently, with specialised management, logistics, and delivery mechanisms. These services could be delivered

Costs

When faced with the issue of going to scale with a given programme, the first question that many policy-makers will ask is how much will it cost? Experts have estimated the costs of going to scale with specified packages of health interventions, as in the 1993 World Development Report35 and the Commission for Macroeconomics and Health.8 The World Bank has estimated the resources needed to achieve the Millennium Development Goals,38 which extend beyond health to include the full range of

Operational opportunities and constraints

Irrespective of the technical issues a substantial rise in expenditure is needed to go to scale. But how money is spent will also determine whether additional spending will be translated into effective coverage, especially among the poor. Furthermore, there may also be limits to the ability of systems to spend additional resources efficiently and effectively, sometimes referred to as difficulties of absorptive capacity (panel 2). Work done for the Commission for Macroeconomics and Health

Conclusions

Known, cost-effective interventions with potential for greatly improving global health are still failing to reach a high proportion of the world's population. We have argued that going to scale with these interventions is essential for improving global health, and that strong health systems are essential for reaching this objective in a sustainable way.

Multitrack approaches are needed that address both the need to achieve short-term universal coverage at high levels of quality, and the

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