Introduction: In 1978, the Alma Ata Declaration pledged global solidarity towards the progressive realisation of the right to health for all by the year 2000. The strategy was to be achieved using the principles of Primary Health Care, such as the promotion of equitable access to health, through an intersectoral lens with the active engagement of communities. This target was not achieved, due to the lack of political commitment. In 2015 seventeen new Sustainable Development Goals (SDGs) were established to reduce global inequities by 2030. We need to learn lessons from the past and focus on creating a more just global health system. The COVID 19 pandemic will have long term economic and social consequences, which could reduce health system resources and capacity. However, promoting the right to health could lead to a more equitable and peaceful global society. Ensuring timely access to essential effective health care services is a key priority for the third Sustainable Development Goal, with Universal Health Coverage as a specific target.
Aim: The aim of this research was to present the significant contribution of original knowledge that the selected published works contributed to global health policy discourse, on the factors required for improving timely access to health services, especially in fragile contexts. There were three research questions answered: what are the factors needed to improve timely health service utilisation in fragile contexts? Is Universal Health Coverage the same as the right to health, as set out in the Alma Ata? Can Social Health Insurance alone achieve Universal Health Coverage to meet Sustainable Development Goal three?
The literature: Nine peer reviewed published papers were selected, covering publications from 2008 to 2018. All papers were reviewed by academic and professional peers, along with organisational or journal editors. Six papers resulted from primary research, published by either the contracting organisation, or a peer reviewed journal. One paper was a scholarly comment published in a peer reviewed journal and one publication was the result of a scoping review, published by Save the Children.
Methodology and theoretical framework: A mixed method participatory action approach was used for seven of the nine papers. These seven published research papers combined secondary data collection and analysis, with the collection of primary qualitative research. The former was analysed through excel files and the qualitative findings were analysed through thematic analysis and workshops with participants. One briefing report resulted from a scoping review or peer reviewed material and health financing grey papers. All research was carried out with a critical enquiry approach using evidence to reduce health inequities. An adapted theoretical framework approach was used to analyse the publications to support the overall commentary. The framework utilised merged the Primary Health Care principles of equity, voice and governance through an intersectoral lens with Gaventa’s four expressions of power. This adapted framework captured the critical enquiry approach of the collective evidence, to support change in health policy and practice. Evidenced based health and nutrition advocacy can strengthen the power with and to those with unequal access to health. Each publication was published at key moments, to encourage change.
Findings: The original research demonstrated that Universal Health Coverage is not the same as the right to health, as health requires concurrent investment in multiple sectors such as social protection, food security, nutrition, water and sanitation and quality education. However, it could be an effective stepping stone for the progressive realisation of the right to health. The research found no evidence to support Social Health Insurance alone could achieve Universal Health Coverage. Where it was implemented successfully it used public taxation funds to cover health for the poorest. Even in these situations the co-payments led to delays in timely health seeking. Overall, four factors were identified as essential to ensure timely health service utilisation, especially in fragile contexts: (i) Health services provided free at the point of access, through publicly funded taxation, were more equitable than social health insurance or user changes. (ii) Concurrent investment in social protection, food security, nutrition, water and sanitation and quality education with community health services, could prevent 2.5 million under five-year-old child deaths annually. (iii) Services are more effective when there is active engagement with communities. (iv) Good governance has resulted in reductions in under five morality rates, however, the lack of financial support for the World Health Organisation has resulted in fragmented global health governance, which must be urgently addressed.