From universal health coverage to right care for health, by Sabine Kleinert and Richard Horton

sem-tituloThe Lancet, Right Care Series –  Achieving universal health coverage is the most important means to advance health and wellbeing during the next decade. Too many countries—and not only in low-income or middle-income settings—do not have a health system that provides “access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”, as described in Sustainable Development Goal 3.8.1

Even many high-income countries, such as the USA and the UK, see important inequalities in income, life expectancy, and health outcomes,2, 3 and the prevailing political and economic landscapes are not encouraging for a reversal of this trend in the foreseeable future. At the same time, changing demographics in many countries mean that the share of the population with two or more chronic conditions will increase. As a result, the resilience and sustainability of health systems will be put under even more pressure. In a recent report by the Organisation for Economic Co-operation and Development, it is estimated that the proportion of the population in European Union countries aged 65 years or older will increase from 20% in 2015 to 30% by 2060.4 The same report states that in 2013, more than 1·2 million people in European Union countries died from avoidable illnesses and injuries4—people who would not have died had there been more effective public health and prevention policies in place, or more timely and effective health care. Yet all countries are struggling with spiralling costs of health and social care, with the prospect of rationing and restricting services—a strategy that would increase inequality and injustice still further. Failure to provide treatment and preventive care at all remains the unacceptable reality in many low-income and middle-income countries for most of their populations. Clearly, something has to change in our thinking about the provision of health and health care to achieve health and wellbeing for all.

In a Series of papers5, 6, 7, 8 and Comments9, 10 in The Lancet, Vikas Saini and colleagues provide a framework for such a change of thinking. The Right Care Series examines the areas and extent of overuse and underuse of health and medical services around the world. It defines overuse as “the provision of medical services that are more likely to cause harm than good”,5 and underuse as “the failure to use effective and affordable medical interventions”.6 The Series authors argue that both overuse and underuse happen side-by-side in different countries, within countries, among populations, within institutions, and even for a single person. This situation offers an enormous (and currently poorly recognised) opportunity to tackle underuse and overuse together to achieve the right care for health and wellbeing.

What is right care? In its simplest definition it is care that weighs up benefits and harms, is patient-centred (taking individual circumstances, values, and wishes into account), and is informed by evidence, including cost-effectiveness. The Series authors acknowledge that most medical services fall into a grey zone where the benefit and harm ratio for a given individual is unknown. However, an important start is to think about, and aim to influence, the drivers of poor, unnecessary, and harmful care. The authors argue that these drivers fall into three important categories: money, finance, and organisations; knowledge, beliefs, assumptions, bias, and uncertainty; and power and human relationships.

To begin to address each of these levels, the roles of all actors have to be examined closely: patients, community leaders, and civil society; health-care providers and health service organisations; national policy makers and health technology assessment institutions; and global health leaders and professional societies. The best example, where progress is slowly being made, is perhaps that of reduced antibiotic prescribing to combat antibiotic resistance.11 Patients and the public need to be protected from false information for private gain and actively educated, engaged, and empowered to be able to make and accept decisions that are right for them. Clinicians and health-service providers need to examine their knowledge continuously and honestly, taking account of their biases and motives for decision making. Atul Gawande, writing for The New Yorker,12 admits that “as a doctor I am far more concerned about doing too little than doing too much”, and explains how the missed diagnoses and omitted treatments haunt him far more than having caused harm by too much treatment. And doctors and other health-care workers need the right amount of time for each patient to decide what the right care is. Our time-starved, factory-like approach to primary care provision is not conducive to delivering the right care with deleterious and more costly consequences further down the line in a patient’s journey through the health and social care system. National policy makers, regulators, and health technology assessment organisations need to work together to negotiate affordable drug prices, and to publicly fund effective health care and interventions. It is unbelievable that the UK still funds homeopathy, on the one hand,13 and has failed to recognise the outrageously inflated price for phenytoin sodium capsules for patients with epilepsy, on the other.14Professional societies need to work together at a global level to provide strong, unbiased, evidence-based, and relevant treatment guidelines. Global health leaders need to recognise the opportunity to eliminate poor care and provide right care as the answer to truly and sustainably achieve healthy lives and wellbeing for all.

This Series could form the basis for serious discussions about what kind of health system we want for the 21st century as part of our commitment to universal health coverage.

We declare no competing interests.

References

  1. UN. Sustainable Development Goals. https://sustainabledevelopment.un.org/sdgs; 2015. ((accessed Dec 11, 2016).)
  2. Office for National Statistics. Health and life expectancies.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies#publications; 2016. ((accessed Dec 11, 2016).)
  3. Xu, J, Murphy, SL, Kochanek, KD, and Arias, E. Mortality in the United States, 2015. Centers for Disease Control and Prevention. NCHS Data Brief, no 267.http://www.cdc.gov/nchs/data/databriefs/db267.pdf; December 2016. ((accessed Dec 11, 2016).)
  4. OECD. Health at a glance: Europe 2016. State of health in the EU Cycle.http://www.oecd.org/health/health-at-a-glance-europe-23056088.htm; 2016. ((accessed Dec 11, 2016).)
  5. Brownlee, S, Chalkidou, K, Doust, J et al. Evidence for overuse of medical services around the world. Lancet. 2017; (published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)32585-5.
  6. Glasziou, P, Straus, S, Brownlee, S et al. Evidence for underuse of effective medical services around the world. Lancet. 2017; (published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)30946-1.
  7. Saini, V, Garcia-Armesto, S, Klemperer, D et al. Drivers of poor medical care. Lancet. 2017;(published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)30947-3.
  8. Elshaug, AG, Rosenthal, MB, Lavis, JN et al. Levers for addressing medical underuse and overuse: achieving high-value health care. Lancet. 2017; (published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)32586-7.
  9. Saini, V, Brownlee, S, Elshaug, AG, Glasziou, P, and Heath, I. Addressing overuse and underuse around the world. Lancet. 2017; (published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)32573-9.
  10. Berwick, DM. Avoiding overuse—the next quality frontier. Lancet. 2017; (published online Jan 8.)http://dx.doi.org/10.1016/S0140-6736(16)32570-3.
  11. Goff, DA, Kullar, R, Goldstein, EJC et al. A global call from five countries to collaborate in antibiotic stewardship: united we succeed, divided we might fail. Lancet Infect Dis. 2016; (published online Nov 17.)http://dx.doi.org/10/1016/S1473-3099(16)30386-3.
  12. Gawande, A. Overkill. The New Yorker. May 11, 2015;http://www.neworker.com/magazine/2015/05/11/overkill-atul-gawande. ((accessed Dec 5, 2016).)
  13. Fenton, S. NHS has spent more than £1·75m on homeopathy, despite admitting there is “no good-quality evidence it works”. Independent. Aug 7, 2016; http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-spending-funding-homeopathy-homeopathic-treatment-evidence-a7177551.html. ((accessed Dec 11, 2016).)
  14. UK Government Competition and Markets Authority. CMA fines Pfizer and Flynn £90 million for drug price hike to NHS. https://www.gov.uk/government/news/cma-fines-pfizer-and-flynn-90-million-for-drug-price-hike-to-nhs; Dec 7, 2016. ((accessed Dec 11, 2016).)
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