Universal health coverage and social determinants of health
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universal health coverage does not mention social determinants of health amid its commendable concern that people should not be impoverished by the cost of health care.6 This situation can be dealt with in two ways: work to include social determinants of health within universal health coverage, or recognise that these are complementary activities, both of which are important for population health. We should do both. For example, economic austerity is bad for health, not only because of its eﬀects on funding of health services,7 but because of adverse eﬀects on housing, income, and employment.8 Universal health coverage is unlikely to direct much attention to action by ministers of ﬁnance to reduce childhood poverty, provision of pre-school education, or community empowerment to negotiate loans to improve housing quality. However, much can be done to improve social determinants of health from within the health sector, including changes in clinical practice, partnership working, advocacy, education and training, and employment conditions of health-sector workers.9 One important way to ensure that social determinants of health remain central to the concerns of those pursuing universal health coverage is to include social determinants in a monitoring framework, which is easy to implement and has two components. First, monitoring of all health and health-care measurements by socioeconomic position, sex, geographical distribution, or other relevant markers of health equity, such as education. If health and
As the global health community embraces universal health coverage, a lesson from the 1978 Declaration of Alma Ata is worth remembering. The Declaration was a landmark in global public health and was the conclusion of one of the most important international conferences on primary health care. But in Alma Ata, it was recognised that there was more to improving population health than primary health care. The Declaration called for resources to be devoted to peaceful aims, “and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share”.1 However, the part of Alma Ata about social determinants—acceleration of social and economic development—was largely forgotten and left out of the international agenda. Improvement of access to primary care is a worthy and necessary goal but, by itself, will not revolutionise global health, nor reduce large health inequalities. For example, the UK has an equitable health service that is free at the point of use, but widening health inequities. Action also needs to be taken to address the social determinants of health: the conditions in which people are born, grow, live, work, and age, and the inequities in power, money, and resources that give rise to them.2 There is a danger of going down the same route again with universal health coverage to the apparent detriment of action on social determinants of health. WHO is clear in its deﬁnition of universal health coverage: all people obtain the health services they need without suﬀering ﬁnancial hardship to pay for them, a well run health system, a system for ﬁnancing, access to essential medicines and technologies, and well trained health workers.3 Universal health coverage is a noble goal, but so too is action on social determinants to achieve health equity. The latter should not be forgotten. Both WHO and the UN declaration on universal health coverage4,5 note the importance of locating universal health coverage in the context of action on social determinants of health. However, these two things are not interchangeable. Health care is just one determinant of population health. Other inputs to health, such as social protection, good employment, and early years care, should not be forgotten, but they have been. For example, a joint WHO and World Bank report on
For more on the Commission on Social Determinants of Health see http://www.who.int/social_ determinants/thecommission/en/
health care are to be universal human rights, then we need to understand how unfair the distribution is of both health status and health services. Second, examination of the equitable distribution of key indicators of social determinants of health. I propose four: early child development at age 5 years; the proportion of young people not in employment, education, or training; an adult poverty measure; and a measure of social isolation or poverty or both in people older than working age. Problems of international comparability will arise, but these are soluble, as shown by the Human Development Reports or regular World Bank reports. Personally, I would not stop there. I would want the monitoring framework to include inequities in power, money, and resources—the structural drivers of health inequity highlighted by the Commission on Social Determinants of Health. For example, in London, UK the eﬀects of the economic downturn on health equity will be monitored by indicators of employment, economic security, housing, and migration. Although these are all important, the four areas I have proposed are eminently doable, and should be done, by any country that is serious not just about ensuring universal coverage of health services but equity in health of its population.
Michael Marmot UCL Institute of Health Equity and Department of Epidemiology and Public Health, University College London, London WC1E 7HB, UK [email protected]
I declare that I have no conﬂicts of interest. 1 2
WHO. Declaration of Alma-Ata. International conference on primary health care; Almaty, Kazakhstan, formerly Alma-Ata, USSR; Sept 6–12, 1978. Commission on the social determinants of health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the commission on social determinants of health. Geneva: World Health Organization, 2008. WHO. Universal health coverage: what is universal health coverage? http:// www.who.int/universal_health_coverage/en/index.html (accessed Sept 4, 2013). WHO. What is universal health coverage? Oct, 2012. http://www.who.int/ features/qa/universal_health_coverage/en/index.html (accessed Sept 9, 2013). United Nations General Assembly. Global health and foreign policy. Dec 6, 2012. http://www.un.org/ga/search/view_doc.asp?symbol=A/67/ L.36&referer=http://www.un.org/en/ga/info/draft/index.shtml&Lang=E (accessed Sept 9, 2013). WHO. WHO/World Bank convene ministerial meeting to discuss best practices for moving forward on universal health coverage 2013. Feb 19, 2013. http://www.who.int/mediacentre/news/statements/2013/ uhc_20130219/en/index.html (accessed Sept 4, 2013). Stuckler D, Basu S. The body economic: why austerity kills. New York: Basic Books, 2013. Bloomer E, Allen J, Donkin A, Findlay G, Gamsu M. The impact of the economic downturn and policy changes on health inequalities in London. Aug 13, 2013. https://www.instituteofhealthequity.org/projects/ demographics-ﬁnance-and-policy-london-2011-15-eﬀects-on-housingemployment-and-income-and-strategies-to-reduce-health-inequalities (accessed Sept 4, 2013). Allen M, Allen J, Hogarth S, Marmot M. Working for health equity: the role of health professionals. March, 2013. http://www.instituteofhealthequity. org/projects/working-for-health-equity-the-role-of-health-professionals (accessed Sept 4, 2013).
A probiotic trial: tipping the balance of evidence? Published Online August 8, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61571-8 See Articles page 1249 Copyright © Daneman. Open Access article distributed under the terms of CC BY-NC-ND
Clostridium diﬃcile is the most burdensome gastrointestinal infection and one of the main infectious causes of morbidity and mortality in industrialised countries.1 Prevention of C diﬃcile infection relies on methods to reduce transmission of the pathogen, through eﬀective hand hygiene, barrier precautions, isolation of patients, and environmental cleaning. Perhaps even more important are attempts to reduce host susceptibility to infection by decreasing unnecessary antibiotic use.2 Antibiotic use disrupts and depletes the normal gastrointestinal ﬂora, allowing C diﬃcile to thrive and generate clinical disease.3 When antibiotic treatment is unavoidable, reinforcement of the colonic ﬂora might be another means to decrease susceptibility of patients to C diﬃcile. Deﬁnitive restoration of the colonic ecosystem through stool transfer has unequivocal beneﬁt in treatment of established C diﬃcile infections and prevention of recurrences.4
A more palatable, or at least less pungent, approach to boost colonic defences is the use of non-pathogenic microbial supplements—known as probiotics. Probiotics have been widely marketed in commercial preparations, and widely studied as a means to prevent C diﬃcile. Two recent meta-analyses have summarised the results of previous trials, detecting large reductions in the risk of antibiotic-associated diarrhoea (AAD) in general (relative risk [RR] 0·58, 95% CI 0·50–0·68)5 and C diﬃcile infections in particular (0·34, 0·24–0·49).6 These impressive eﬀect sizes are motivating many health-care institutions to consider routine probiotic coadministration with antibiotic treatments. However, in The Lancet, Stephen Allen and colleagues7 question the usefulness of routine probiotics. Their PLACIDE trial, done at ﬁve centres in England and Wales, is the largest trial to be reported in this discipline (n=2941). The study is rigorous, with central www.thelancet.com Vol 382 October 12, 2013