The 2030 agenda for sustainable development is an opportunity for governments and
the international community to renew their commitment to improving health as a central
component of development.
1
The accompanying 17 sustainable development goals (SDGs) define the priority areas
of action.
2
Goal 3 (to ensure healthy lives and promote well-being for all at all ages), with
Target 3.8 on universal health coverage (UHC), emphasize the importance of all people
and communities having access to quality health services without risking financial
hardship.
2
These health services include those targeting individuals, such as curative care and
population-based services, such as health promotion.
3
Achieving UHC is an important objective for all countries to attain equitable and
sustainable health outcomes and improve the well-being of individuals and communities.
4
,
5
Health system strengthening is a means to progress towards UHC. A functioning health
system is organized around the people, institutions and resources that are mandated
to improve, maintain or restore the health of a given population. Health system strengthening
refers to significant and purposeful effort to improve the system’s performance.
6
Strengthening is one way to ensure that the system’s performance embodies the intermediary
objectives of most national health policies, plans and strategies – quality, equity,
efficiency, accountability, resilience and sustainability (Box 1).
Box 1
Intermediary objectives of national health policies, plans and strategies
Quality
Health-care quality is the extent to which health services provided to individuals
and patient populations improve desired health outcomes, consistent with current professional
knowledge.
7
Equity
Equity in health is a measure of the degree to which health policies can fairly distribute
well-being in the population. It can also refer to the absence of systematic or remediable
differences in health status or access to health care.
8
Efficiency
Efficiency refers to the capacity to produce maximum output for a given input.
8
Accountability
Accountability results from processes in the health system that ensure health-care
actorsa to take responsibility for what they are obliged to do and are answerable
for their actions.
8
Resilience
Health system resilience is the capacity of health-care actors,a institutions and
populations to prepare for and respond to crises, maintain core functions in time
of crisis; and, informed by lessons learnt during the crisis, reorganize if needed.
9
Sustainability
Sustainability refers to the potential for maintaining beneficial outcomes for an
agreed period of time at an acceptable level of resource commitment.
8
a Health-care actors are individuals or groups with an interest in the health system,
including patients and their families, nurses, physicians, laboratorial technical
staff, and other external entities such as regulators, insurance companies and health-care
organizations.
We argue that UHC contributes to the SDGs in several ways. The impact of health system
strengthening on UHC, and how health system strengthening, through UHC, contributes
to different sustainable development goals is illustrated in Fig. 1.
Fig. 1
How health system strengthening contributes to sustainable development goals through
universal health coverage
SDG: sustainable development goal.
a A health impact can be positive or negative. A positive impact is an effect which
contributes to good health or improvement in health status. A negative impact causes
or contributes to ill health.
8
b Action refers to interventions that aim at strengthening a health system. c Whether
people are healthy or not, is determined by their circumstances and environment. The
determinants of health include the social and economic environment, the physical environment,
and the person’s individual characteristics and behaviours.
10
One way UHC contributes to the SDGs is by promoting global public health security
and it does so by increasing the resilience of health systems to respond to health
threats that spread within as well as across national borders.
6
,
11
The 2012 Middle East Respiratory Syndrome coronavirus, the 2013–2016 Ebola virus disease
and 2015 Zika virus outbreaks prompted the international community of the financial
aftermath many countries faced as a result of protracted health emergencies. The impact
of humanitarian and natural disasters is exacerbated by weak health systems.
12
These recent outbreaks showed that resilience is an important feature of a health
system and its effect on health workers’ ability to adapt and effectively address
complex challenges when responding to emergencies. Resilience should be envisaged
as a critical objective of contemporary health system reforms.
13
When compared to resources spent on emergency responses, it is cost-efficient and
in the long-term sustainable to invest in building resilient and functioning health
systems.
We claim that progress towards UHC will be essential to four specific SDG goals and
the pledge to leave no one behind. First, as adults in poor health are more likely
to be unemployed, when investments are made in improving health outcomes for the entire
population, this can also contribute to SDG 1 (end poverty in all its forms everywhere).
In addition, implementation of social protection systems to address out-of-pocket
health expenditure reduces the incidence of catastrophic or impoverishing household
health spending. Second, given that children and adolescents with good health have
better educational outcomes, health has an important role to play in advancing SDG 4
(ensure inclusive and equitable education and promote lifelong learning opportunities
for all). Third, as women comprise over 75% of the health workforce in many countries,
14
the health system can contribute to advancing SDG 5 (achieve gender equality and empower
all women and girls). Fourth, through the development of health systems that create
fair, trustworthy and responsive social institutions, health system strengthening
directly contributes to SDG 16 (promote inclusive societies for sustainable development,
provide access to justice for all and build effective, accountable and inclusive institutions
for all).
Investments in the health sector to support UHC will boost economic growth in line
with SDG 8 (promote sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all). The WHO report from the High-level
Commission on Health Employment and Economic Growth states that the contribution to
economic growth can happen through six inter-related pathways.
15
The first pathway is through investment in health which contributes to an increase
in life expectancy and healthier workers, contributing to increases in economic productivity.
The Lancet Commission on Investing in Health reported that around one quarter of economic
growth between 2000 and 2011 in low- and middle-income countries resulted from the
value added by improvements in the health of the population. The estimated return
on investment in health from improved economic growth was nine to one.
16
The second pathway is through promoting economic output. The health sector adds direct
economic value by expanding the number of jobs, investing in infrastructure projects
and purchasing supplies needed for health-care delivery. A rapid and unprecedented
growth in global health employment of around 40 million new jobs, mostly in middle-
and high-income countries, is expected by 2030.
15
This growth will happen against a backdrop of 201 million unemployed people in 2014.
By 2020, the number of unemployed may increase and because of technological advances
from the fourth industrial revolution, it is expected that 7.1 million jobs will become
redundant.
17
Given that occupations in the health and social sector are more labour intensive and
less likely to be automated, the health sector will be an even more important source
of employment in the future.
Third is through enhancing social protection. Investing in decent jobs in the health
sector contributes to enhancing social protection systems, for example in case of
sickness, disability, unemployment and old age, as well as financial protection against
loss of income, out-of-pocket payments and catastrophic health expenditures. Social
protection in turn, promotes sustainable pro-poor economic growth.
18
The fourth pathway is linked to social cohesion. Equal societies are more economically
productive societies.
19
Fifth is through promoting innovation and diversification. The production and export
of pharmaceuticals, equipment and medical services has been an important driver of
economic growth in many countries.
15
Scientific and social innovations in this sector are likely to further support economic
growth in the future.
The sixth pathway is by protecting and promoting human security. Strong health systems
perform better in the detection, prevention and control of infectious disease outbreaks,
protecting individual and global health security for peace, development, and economic
growth.
6
The expectation is that the health sector contribution to SDG 8, by protecting and
promoting human security, will be significant.
To deliver its potential, effective UHC development will require financing and leadership.
Even in fragile states and least developed countries, domestic resources contribute
to about 75% of total health spending.
20
However, these domestic resources are often not equitably distributed either geographically
or among various income quintiles, with out-of-pocket expenditures remaining unacceptably
high. In many countries, a narrow fiscal space will not allow a sharp increase in
domestic funding, but it is possible to critically examine and then recast how and
where funding is allocated and expenditures incurred.
To meet the health-related targets and make progress towards sustainable development,
governments will need to use their domestic resources effectively, ensure people's
interests are taken into consideration and that they have access to information and
education. Governments also need to prioritize health prevention and promotion measures.
Numerous challenges currently exist for governments to overcome. In many countries,
funding is disease-oriented with limited coordination among partners and alignment
with national health strategies and plans is poor. Long-term sustainable investments
in health systems have been neglected. Additionally, there are rigidities in the production
and allocation of professional roles, and vested interests in the management of the
health services. The SDGs provide an opportunity to overcome these challenges and
build political commitment to a common health system strengthening agenda. Realizing
progress towards UHC requires some level of guidance to promote a coherent and consolidated
agenda for health system strengthening, which can be applied to country-specific UHC
roadmaps.
While countries pursue their ongoing national efforts to strengthen their health systems,
the same effort is being reinforced at regional and global level. In September 2016,
the Director-General of the World Health Organization announced the establishment
of a global platform, the International Health Partnership for UHC 2030, expanding
the scope of IHP+ to include health system strengthening towards the achievement of
UHC.
21
IHP+ is a group of partners who work together to put international principles for
development cooperation into practice in the health sector.
21
The global platform aims to bring together development partners and governments, to
improve coordination of health system strengthening efforts in countries, to facilitate
multistakeholder policy dialogue, promote accountability and build political momentum
around a shared and global vision of health system strengthening for UHC.