Securing vital health coverage

Kidong Park, World Health Organization representative in Vietnam

All member states of both the World Health Organization (WHO) and the United Nations signed off the 2030 Agenda for Sustainable Development Goals (SDGs) with 17 goals and 169 targets to achieve by 2030. In order to be on track for delivery of the health-related SDG targets, the WHO will focus its work on strategic priorities to reach a trio of goals in the next five years – one billion more people benefiting from universal health coverage; one billion more people better protected from health emergencies; and one billion more people enjoying better wellbeing.

Strengthening primary healthcare (PHC) is the most inclusive, effective, and efficient approach to advance universal healthcare coverage (UHC) and enhance people’s physical and mental health, which was written in the WHO constitution and confirmed by the Declaration of Alma-Ata in 1978.

Last October, leaders of WHO member states gathered in Kazakhstan and renewed their commitment to PHC, as primary care and essential public health functions are the core of integrated health services.

Dr Halfdan Mahler, former WHO director-general who led the PHC initiative in 1978, once said that “a health system based on primary care cannot be realised without support from a network of hospitals,” which was true and more relevant now than ever.

Hospitals at the core

Hospitals provide acute and complex care and contribute to patients’ overall health outcomes. They support other healthcare providers through community outreach, and are also an integral part of health emergency preparedness and response. Hospitals provide settings for education and training for health professionals, while leading clinical research.

The achievement of UHC requires a clear determination of the role of hospitals in service delivery and targeted efforts to optimise their performance. When health facilities perform well, the overall performance of the health system improves. However, many countries are struggling to improve hospital performance as well as overall health performance.

In order to assist member states to improve hospital performance, the WHO in the Western Pacific has developed a regional action framework on improving hospital planning and management in the region, which was approved by the Regional Committee in 2018. This framework provides actions areas and action domains both at facility level and system level.

At the facility level, hospitals can improve their performance by increasing accountability, strengthening sustainability and resilience, improving quality of service and efficiency of day-to-day operations, and ensuring equity.

Hospitals can increase accountability by introducing a clear management structure, compliant to government regulation and performance monitoring. A sustainable and resilient hospital system is based on sound governance practices and is able to adapt to changes in the external environment and mitigate risks.

Quality services at hospitals include clinical governance structure and processes, technical quality, the patient and family experience, continuity of care, and of course patient safety.

Efficiency gain at the facility level could be achieved through effective operational management, including streamlined patient flows, streamlined supply and logistics management and appropriate health staff numbers and competencies. Meanwhile, hospitals can contribute to UHC by ensuring that there is equity in access to health services.

Advances across the board

At the system level, health authorities can use the framework of goal, institutional arrangements, regulation, financing, and feedback as a governance tool to improve hospital performance. First, the health authority should set clear goals on the role of hospitals in a path to UHC. Hospitals must play an important role for countries to achieve this. They may either function as standalone facilities or be affiliated to a network of group of hospitals.

Next, institutional arrangements have three action ­domains of system-level governance, service planning and service delivery architecture. Hospitals could improve their overall performance if they had some autonomy and authority to plan services, manage staff and other resources, and respond flexibly to patient needs. However, governments must retain responsibility to ensure the accountability of hospital operations. This balance can be achieved through various modes of hospital governance, for example, a hospital run as a corporation or state-owned enterprise and supervised by a governing board or committee.

Third, the regulation of facilities and staff is important to ensure equitable access to quality health services.

As for financing, financial incentives drive provider behaviour. All countries must decide what services should be publicly funded, regardless of the maturity of their health financing systems. With budget constraints and emerging new health interventions, countries must make critical decisions on benefit design and resource allocation. Strategic payment methods can improve efficiency, accountability, equity and quality, and reduce financial hardship.

Finally, feedback of relevant information can reinforce hospital accountability by creating communication loops, improving both staff and community participation. Key feedback mechanisms may include quality and patient safety monitoring; access and equity monitoring; efficiency and productive monitoring; and risk monitoring.

As socio-political, economic, and cultural contexts surround the health sector, and as hospitals are different country-to-country, the pathway towards UHC will also be varied. However, a health system based on primary care with support of a network of hospitals is the key to achieve UHC. Every country is moving towards building a healthier world, and the WHO is committed to support its member states and travel together towards UHC.