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      Health systems strengthening, universal health coverage, health security and resilience

      editorial
      a , , a
      Bulletin of the World Health Organization
      World Health Organization

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          Abstract

          Global and national initiatives focused on health systems strengthening, universal health coverage, health security, and resilience suffer when these terms are not well understood or believed to be different ways of saying the same thing. Here we aim to facilitate understanding and highlight key policy considerations by identifying critical attributes of each concept and emphasizing the distinction between ends and means in health policy. Set within the political and institutional framework of a country, a health system is “the ensemble of all public and private organizations, institutions, and resources mandated to improve, maintain or restore health.” 1 This definition, along with efforts to more concretely specify the “functions”, “building blocks”, or “control knobs” of a health system, focus on the characteristics or policy instruments of the system itself. 2 – 4 Strengthening health systems involves “a significant, purposeful effort to improve performance.” 4 This goes beyond merely investing in inputs; it means reforming how the health system actually operates. 5 Universal health coverage means that all people are able to receive needed health services of sufficient quality to be effective, without fear that the use of those services would expose the user to financial hardship. 6 Based on this definition, universal health coverage comprises a set of objectives – equity in service use, quality, and financial protection – towards which all countries strive. Progress is assessed at population scale, rather than only those served by specific schemes or programmes. 7 Non-discrimination is a core principle; policies that exclude certain individuals or groups are inconsistent with universal health coverage. 8 Because people need individual and public health services, ensuring that both are delivered effectively falls within the scope of universal health coverage. Criticizing the universal health coverage concept by arguing that public health services are excluded 9 is wrong, though in practice this argument may have validity. Finally, universal health coverage is globally relevant; all countries can do something to reduce the gap between the need for and the use of quality health services. 6 Health system strengthening comprises the means (the policy instruments), while universal health coverage is a way of framing the objectives of policy. Without this distinction, there is a risk that instruments of reform become the objective, with the perception that “the problem” to be solved is the absence or presence of a particular policy instrument. When this occurs, policy dialogue shifts quickly away from where it needs to be – getting to consensus about the nature and causes of underperformance relative to universal health coverage goals – to what is often an ideologically polarized debate about the inherent merits or flaws of particular reform instruments. In health financing, for example, this has been observed in the debate on social or community-based health insurance, performance-based financing and user fees. Similarly, simply calling something a “universal health coverage reform” does not convey any meaning as to the actual content of what is being planned or implemented. Beyond the objectives embedded in universal health coverage, it entails individual health security 10 the intrinsic value of protection against risk. 11 Individuals are better off when they are secure in the knowledge that if something should happen they will be able to obtain quality health services without becoming impoverished as a result. Collective health security10 – reducing the vulnerability of societies to health threats that spread across national borders – is a goal that extends beyond the definition of universal health coverage.  But there is a clear link, because health systems that progress towards universal health coverage also contribute to collective health security. Therefore, health systems strengthening is needed to make progress towards universal health coverage and health security. The resilience of a health system refers to its ability to absorb disturbance, to adapt and respond with the provision of needed services. 12 Thus, resilience is not an action to be implemented but rather a dynamic objective of investments and reforms. In the case of Ebola-affected countries, for example, this has required efforts to not only restore how the system functioned before the crisis but to transform and fundamentally improve the health system. Conceptual clarity is essential for a systematic approach to policy-making. Confusion and inefficiency arise when health system strengthening is defined as an objective and also when universal health coverage, health security or resilience are described as separate programmes to be implemented. So here is a simple guide: health system strengthening is what we do; universal health coverage, health security and resilience are what we want.

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          Why differentiating between health system support and health system strengthening is needed

          There is increasing recognition that efforts to improve global health cannot be achieved without stronger health systems. Interpretation of health system strengthening (HSS) has varied widely however, with much of the focus to-date on alleviating input constraints, whereas less attention has been given to other performance drivers. It is important to distinguish activities that support the health system, from ones that strengthen the health system. Supporting the health system can include any activity that improves services, from distributing mosquito nets to procuring medicines. These activities improve outcomes primarily by increasing inputs. Strengthening the health system is accomplished by more comprehensive changes to performance drivers such as policies and regulations, organizational structures, and relationships across the health system to motivate changes in behavior and/or allow more effective use of resources to improve multiple health services. Even organizations that have made significant investments in health systems have not provided guidance on what HSS entails. While both supporting and strengthening are important and necessary, it is nonetheless important to make a distinction. If activities fail to produce improvements in system performance because they were incorrectly labeled as system strengthening, the value of HSS investments could quickly be discredited. Not distinguishing supportive activities from strengthening ones will lead to unmet expectations of stronger health systems, as well as neglect of critical system strengthening activities. Distinguishing between these two types of activities will improve programming impact. Copyright © 2012 John Wiley & Sons, Ltd.
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            Human security and universal health insurance

            Human security is a multidimensional concept that has been a cornerstone of Japanese development co-operation for more than a decade. At the heart of security is the idea of protection or insurance against downside risk.1, 2 Three distinct questions arise from the concept of human security. First, protection of what? Second, insurance against what? And, third, security for whom? The first question relates to the specification of what is to be protected. The definition of human security offered by the Commission on Human Security 3 is: “to protect the vital core of all human lives in ways that enhance human freedoms and human fulfilment”. The core of a person's life is closely concerned with the person's wellbeing and agency, which is best viewed in terms of his or her “capability” to achieve alternative “beings and doings”. 4 In this context, health assumes central importance for two reasons: it is directly constitutive of a person's wellbeing; and it enables a person to function as an agent—that is, to pursue the various goals and projects in life that he or she has reason to value. This view deploys the notion of well-functioning, but it is not grounded in notions of economic welfare that are based on utility or income. It is, rather, an agency-centred view of a person, for whom ill health restricts the scope of human agency. Since our ability to do things typically depends on our being alive, the capability to lead a long and healthy life must itself be regarded as a basic capability. The second question related to human security is insurance against what. Here the concern is to insure against falling below an adequate threshold of human capabilities—in the case of a person's health, a minimum acceptable level. The probability of falling below a minimum threshold depends on both how vulnerable a person is—the degree of downside risk the person faces—and how much above the threshold he or she is in the relevant dimension. 1 The extreme case of insecurity is certainty of being below a specified threshold, and the absence of any chance of avoiding that fate. Threats to human security can arise, for example, from natural disasters and environmental catastrophes—such as the 2011 earthquake and tsunami in Japan, and the consequent leakage of radioactive material from the Fukushima Daiichi nuclear plant. They can arise from disease outbreaks such as HIV/AIDS, severe acute respiratory syndrome and drug-resistant tuberculosis; from personal accidents and illness; from economic downturns as in the Asian financial crisis of 1997–98; and from various other hazards that people face.3, 5, 6 The vulnerability of a person to such risks will depend on his or her individual circumstances—including location, epidemiological environment, health status, and economic position. A person's health is affected by health care and various other determinants—eg, socioeconomic, behavioural, occupational, and dietary. But access to appropriate health care is also a vital factor in protecting a person from the risk of ill health, and especially of catastrophic ill health. Comprehensive health care is thus important both in promotion of health and in response to health crises. Without health insurance, a severe medical crisis that threatens survival, for example, can have disastrous financial implications—that can affect human security in many other dimensions. The third question concerns security for whom—the entire population or a subset of it? Universalism can be defended through a variety of different approaches, which all invoke equity, fairness, or impartiality in some form or other. For instance, we can appeal to impartiality through the device of Rawls's “veil of ignorance” in the “original position”. 7 Behind the veil of ignorance, I do not know who I will turn out to be and what serious illness or health threat I might encounter, which could require extensive medical attention. Given this uncertainty, the institutional arrangement for health care I am likely to favour is one that ensures comprehensive coverage for all. The concept of human security has wide reach and includes multiple concerns. A major concern is protection of people's health, for which comprehensive health coverage for all is an essential requirement. Universal health insurance thus contributes directly to furthering human security. This implication is as valid for Japan as for other countries in the world. The tragic events of, and responses to, the earthquake of 2011 are a powerful reminder of Japan's concern for human security. In the past, several distinguished politicians, civil servants, and academics in Japan have drawn on and developed the concept of human security—including former Prime Minister Keizo Obuchi, Japan International Cooperation Agency President Sadako Ogata, global health expert Keizo Takemi, and Japan Center for International Exchange President Tadashi Yamamoto.3, 8, 9, 10, 11 Indeed, universal health coverage in Japan, now in existence for 50 years, is indicative of the priority that Japan accords to human security. Over the decades, Japan has also undertaken policies to advance human security in other dimensions, such as basic education, social protection, and economic safety nets. Internationally, Japan has used the concept of human security to guide assistance to developing countries through bilateral aid and multilateral policies. The range and reach of the idea of human security are extensive, as Japanese actions have shown. A central manifestation of these actions is the country's commitment to universal health insurance. © 2012 Reuters 2012 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              Author and article information

              Journal
              Bull World Health Organ
              Bull. World Health Organ
              BLT
              Bulletin of the World Health Organization
              World Health Organization
              0042-9686
              1564-0604
              01 January 2016
              01 January 2016
              : 94
              : 1
              : 2
              Affiliations
              [a ]World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
              Author notes
              Correspondence to Joseph Kutzin (email: kutzinj@ 123456who.int ).
              Article
              BLT.15.165050
              10.2471/BLT.15.165050
              4709803
              ff01e854-79d6-46da-929a-ac9e2a76068b
              (c) 2016 The authors; licensee World Health Organization.

              This is an open access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

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