How Covid-19 changed everything
Just one month ago on December 12, the world celebrated, though within a much-limited space this time, the International Universal Health Coverage Day. Until this year, Universal Health Coverage (UHC) has appeared to be an issue of developing nations practically though it is principally a global matter.
The reason is clear that Covid-19 hits the world’s strongest economies with its utmost effects from both health and economic perspectives. To date, 1.95 million deaths have been reported, of which 27.2% took place in the US, UK, Italy, France, and Spain. Covid-19 even accounted for an economic loss of $375 billion globally every month. While we are struggling with Covid-19 in many countries, particularly in many high-income countries, our thoughts should not be limited within Covid-19 per se, rather be put in the context of emerging infectious diseases (EIDs), the threat of which is eminent.
Emerging infectious diseases (EIDs), in other words, the diseases which newly appeared in a population or have existed but are rapidly increasing in incidence or geographical range, have been considered as a continuous threat for public health.
This inevitable, but unpredictable, appearance of new infectious diseases has been recognized for millennia. Though we observe extraordinary counter-measures (diagnostics, therapeutics, and vaccines) to address such diseases, globalization, including international travels and interdependency across countries, greatly accelerates the risks of infection.
However, while such EIDs had detrimental effects as a health and economic burden for many years, they shocked the world profoundly with the emergence of the most recent EID -- Covid-19.
Meeting the target
UHC is a target within the third goal of the SDGs, indicated by service coverage (indicator 3.8.1) and financial risk protection (3.8.2) while utilizing such services. In such a context, EIDs face the challenges of identifying and/or inventing the appropriate services, which may include preventive, promotive, curative, as well as rehabilitative care, which are included in the concept of defined health services for UHC with sufficient quality.
As we have been observed since the outbreak of Covid-19, the governments of different countries started to work with promotive and preventive measures (diagnostic tests, vaccination), including restrictions/lockdown, immunity enhancing actions like food and drink habits, physical exercise, home-based care, and hospital care (blood-thinner, oxygen, ICU) as well as care after returning home from hospital.
We have observed that many countries, including several high-income ones, faced severe scarcity of health resources, including adequate health staff (like, doctors, nurses). More acute was that any appropriate and effective health care was not known for treating the patients, particularly during the beginning of the pandemic.
A year later
It still remains a challenge after one year has passed. On November 22, 2020, the Guardian reported on concerns that the National Health Services of the UK "are so routinely understaffed patients are at risk of poor care."
In many developing countries, we observed chaotic conditions in society and health system and sometimes lack of adequate political commitments.
Research in Bangladesh found that decision-makers failed to engage the right kind of experts, which resulted in poor pandemic management that included imposing lockdown in periphery areas without arranging patient transport to the centre, declaring certain hospitals as Covid-19 dedicated without preparing the facilities or the staff, and engaging private hospitals in care without allowing them to test the patients for Covid-19 infection.
It was further reported by Al-Zaman: “Bangladesh, a poverty-stricken South Asian country, is losing its battle against the pandemic, but mainly because of its incompetent health care system. The casualties are escalating, and public sufferings are becoming unimaginable. On this backdrop, this perspective piece discusses the health care crisis in Bangladesh during the pandemic. This article also identifies three responsible issues for the country’s deteriorating health care: 1) Poor governance and increased corruption, 2) Inadequate healthcare facilities, and 3) Weak public health communication.”
The situations observed in the UK and Bangladesh are not a dispersed picture but rather a global portrait, might be different in severities across countries. While government and health organizations as well as individuals in different countries engaged resources and efforts on promotive and preventive, one important component, ie, vaccination is still yet to reach many, especially in developing nations. The government of the UK recently published the largest vaccination program in British history, that is, the procedure of providing vaccine against Covid-19 efficiently equitably among the British people.
Similar actions have been observed in the US and European Union countries. The EU has secured around 600 million doses of the Pfizer/BioNTech vaccine for their 380 million people (excluding UK). It is not surprising that Astra-Zeneca-Oxford vaccine and Moderna will additionally be consumed by some EU countries, particularly when Sweden has ownership of the Astra-Zeneca-Oxford vaccine. When the vaccines for high-income countries appear to be overwhelming, the World Health Organization expressed deep concern about bilateral agreement for vaccine purchasing.
An example can be the agreement between Bangladesh (Beximco) and India (Serum Institute), which created huge concerns about actual delivery date due to Indian government’s statement about satisfying the domestic need before transferring to other countries and the agreed high price ($5 while the actual price is %2). However, Bangladeshis saw some hope when Beximco managing director promised lately that the vaccine will be received from India by January 25, 2021.
Sadly, “at least 90% of people in 67 low income countries stand little chance of getting vaccinated against Covid-19 in 2021, because wealthy nations have reserved more than they need and developers will not share their intellectual property, says the People’s Vaccine Alliance, which includes Amnesty International, Frontline AIDS, Global Justice Now, and Oxfam.”
For securing equitable access to the Covid-19 vaccine, a platform called COVAX has been developed with the coordination of Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI) and the WHO to support the research, development, and manufacturing of a wide range of Covid-19 vaccine candidates, and negotiate their pricing. It is intended that all participating countries of COVAX, irrespective of income levels, will have equal access to these vaccines once they are developed.
The initial aim is to have 2 billion doses available by the end of 2021, which should be enough to protect high risk and vulnerable people, as well as frontline health care workers. However, it appears to be a big concern that the disproportionate distribution of vaccines across rich and poor countries and the bilateral agreements of vaccines between countries may distort the aim of COVAX. Such distortions would contribute to inequitable vaccine access and to further challenges to the developing nations towards achieving universal health coverage, while considering the UHC indicator 3.8.1 (service coverage).
If we look into the other indicator of UHC (3.8.2) ie financial risk protection, meaning that no one faces financial hardship for utilizing health care in need, it shows a horrible picture in the countries where general people are supposed to pay from their own pocket for health care. The Hindustan Times reported that it costs Rs20,000-25,000 daily for treating a Covid patient in India, meaning that a 10-day hospitalization costs a patient a minimum of Rs200,000 in total if we ignore the costs before and after hospitalized days, which certainly have a considerable expense.
It is predictable that if several members of a household get infected, the economic pressure gets unbearable for a large number of households in a country with a per capita income of around $2,000. Even in a public hospital, the cost is not remarkably lower in India.
In Bangladesh, just a Covid-19 test costs Tk5,000 and the hospitalization costs vary across hospitals but may not be much different than the Indian scenario. A partial picture, of course, is that some attempts by government in these countries have been undertaken which secured available good quality and low-cost treatment though for a small share of patients.
In the welfare states, like the UK, Sweden, Germany, Australia, and so forth, financial affordability has not been a big concern for individual patients. But to what extent a health system can remain financially sustainable remains as a challenge.
In sum, it is evident that emerging infectious diseases, as experienced by Covid-19, would be a continuous challenge for achieving UHC in both service coverage and financial risk protection dimensions.
Additionally, further economic consequences, though not framed by UHC, in terms of income-loss due to temporary and permanent illness and disabilities, unemployment etc. would contribute to poverty. A strong bond between research communities and policy-makers, a health system that covers the entire population with affordable quality care, and a global integration for meeting EIDs are inevitable to deal with the challenges of emerging infectious diseases in order to achieve universal health coverage.
Dr Jahangir Khan is Senior Health Economist and Associate Professor, University of Gothenburg and Karolinska Institutet, Sweden. This piece is from the platform Health System Improvement Forum, Bangladesh.