Archive content of the magazine is available below.
Issue: Working together to tackle diabetes
Section: Health delivery
Health for all: Universal health coverage essential for all people with diabetes
Interview with Dr Svetlana Axelrod, WHO Assistant Director-General for Noncommunicable Diseases and Mental Health
How big is the problem of diabetes worldwide? What does universal health coverage mean for people at risk of, or living with diabetes?
Diabetes is one of four priority noncommunicable diseases (NCDs) targeted for action by world leaders. The threat to human lives and to economic and social development posed by diabetes, cardiovascular and lung diseases and cancer was recognized when countries agreed to set target 3.4 of the Sustainable Development Goals (SDGs): reducing premature mortality from NCDs by one third by 2030.1
It is the less advantaged that are disproportionally affected by NCDs. Over the past decade, diabetes prevalence has risen faster in low- and middle-income countries than in high-income countries.2 Of course, it is those same countries that tend to lack access to the basic technologies needed both to diagnose the disease and to help people with diabetes manage it properly. People are being forced into poverty because of the catastrophic cost of diabetes care, combined with losing their family income owing to disability. Lack of care results in complications and premature death. It should not be like this. As WHO Director-General Dr Tedros Adhanom Ghebreyesus has said, “No one should have to choose between death and financial hardship. No one should have to choose between buying medicine and buying food.”
Although diabetes is a chronic, progressive, lifetime disease, people with it can live long and healthy lives. The way forward is universal health coverage, whereby everyone can get the health services they need, when and where they need them, without facing financial hardship. Universal health coverage can provide people living with diabetes those services many of us take for granted, including early diagnosis and proper management of the condition without pushing people into poverty. Never has there been as much political momentum for universal health coverage as there is right now. And never has there been greater need for commitment to health as a human right to be enjoyed by all, rather than as a privilege of the wealthy few.
Recognizing the importance of the health-related SDG targets, WHO’s new general programme of work 2019–2023 is based on delivering them, and is relevant to all countries, at all income levels.3 It articulates WHO’s mission – to promote health, keep the world safe and serve vulnerable people – and lays out three strategic priorities, each with an ambitious target: by 2023, one billion more people to benefit from universal health coverage, one billion to be better protected from health emergencies and one billion to enjoy better health and well-being. Each is relevant to the fight against NCDs and each requires health systems oriented towards delivering universal health coverage.
What is most needed today to stop the global epidemic of NCDs, including diabetes and heart disease?
The big gap is not medical: knowledge on diagnosis, treatment and management is growing all the time. What is needed is a recognition that many NCDs are largely avoidable, followed by public and political commitment to make preventing and controlling them a priority. Four main NCDs – cardiovascular and lung diseases, cancer and diabetes – are mostly preventable by tackling major risk factors: tobacco use, harmful use of alcohol, physical inactivity, unhealthy diets, obesity and environmental factors.
Governments need to prioritize the collective implementation of recognized cost-effective NCD interventions – the so-called NCD “best buys” and other recommended interventions4 – which have been shown to prevent and control major NCDs and their risk factors. These include taxing tobacco, alcohol and sugar, making health risks clear by introducing health warnings on tobacco packaging and front-of-pack labelling on foods to show their nutritional value. Governments need to create healthy environments for their citizens where healthy choices are default choices. They can do this by eliminating exposure to second-hand smoke, providing reformulated food low in salt and sugar with no trans fats, restricting availability to alcohol, banning advertising and promotion of tobacco and alcohol, and providing enabling environments for people to be physically active and breathe clean air.
Good management helps to prevent complications in people with NCDs, reduces the need for hospitalization and avoids costly high-technology interventions and premature deaths. Providing drug therapy and counselling for people with NCDs is critical to enabling them to live longer and better-quality lives. The WHO Package of essential NCD interventions (WHO PEN) includes interventions for detection, prevention, treatment and care of NCDs including diabetes and cardiovascular diseases through primary health care.5 Fully aligned with WHO PEN, the HEARTS technical package provides a strategic approach to improving cardiovascular health by strengthening the management of risk factors for heart disease and stroke in primary health care.6
Are there successful examples of improving access to high-quality services and providing financial protection for people at risk of diabetes or living with it?
Given the scale of the challenge, the interventions which make most difference are those that transform services at the primary care level and that have become affordable and accessible for all.
In the Republic of Moldova, one in eight adults has diabetes or glucose intolerance. Mandatory health insurance was introduced in 2004, improving financial access to care. For people with diabetes, one crucial issue was how to improve their access to medicines, particularly insulin, which had hitherto been very uncertain. In 2013 changes were made in the procurement of insulin, with a move from a national tender programme to decentralized procurement by pharmacies. All Moldovan citizens are now entitled to free access to oral medicines for diabetes and insulin.7
Thailand tells a similar story. In 2002 Thailand moved away from a system of out-of-pocket payments to one funded by a mix of taxes and insurance contributions. Thais who have diabetes are now offered free treatment and have ready access to the medicines they need not only to survive but also to stave off complications.8
What can the NCD community do to inspire, motivate and guide governments and policy-makers to make commitments to universal health coverage?
Universal health coverage is an investment in human capital and a driver of economic growth and development. Reaching universal health coverage by 2030 is an ambitious goal, and the NCD community is leading the way. It has long been stressing the importance of moving away from the compartmentalization of health services towards integrated services, incorporating the management of various NCDs, mental health and in some settings tuberculosis and HIV/AIDS into primary care. This advances universal health coverage by increasing the efficiency and effectiveness of service delivery.
Many healthcare systems are not organized to manage the morbidity shift towards NCDs. The presence of lifelong or long-term conditions requires not just a rethinking of services but also a reorientation of the entire health system to rise to the challenge of joint management of diabetes and other diseases. Expanding universal health coverage and access to integrated, people-centred health services makes this more feasible. Resource constraints mean that countries cannot provide all health services, but all countries should be able to ensure coverage of essential health services.
Heads of state and government will come together later in 2018 at the Third United Nations General Assembly High-level Meeting on NCDs in New York to assess the progress of the global fight against NCDs and decide how to accelerate future efforts. Among the commitments it is hoped governments will make is the integration of the NCD “best buys” into national universal health coverage benefit packages provided by the public sector, including access to essential NCD medicines and technologies. As a part of the preparatory process, WHO is mobilizing various groups of stakeholders to provide their input to the outcome document of the Meeting. The WHO Independent High-level Commission on NCDs and the WHO Civil Society Working Group are two examples of platforms the NCD community can use to highlight the importance of universal health coverage for tackling NCDs and for achieving health for all.
Experience has illustrated, time and again, that universal health coverage is achieved when political will is strong, and the NCD community makes an essential contribution to forging that political will.
The theme of World Health Day is “Universal health coverage: everyone, everywhere”. What communications activities will WHO be conducting to mark the day?
The Organization will maintain a high-profile focus on universal health coverage via a series of events starting on World Health Day on 7 April, with global and local conversations about ways to achieve health for all.9 Posters, infographics and social media squares are available to download with a campaign package to help everyone, including political parties, civil society, professionals and communities, to focus on health for all. This will continue throughout 2018.
Each of the six WHO regional offices will contribute their own analyses, reports and conferences – not to mention quizzes and videos – on universal health coverage. WHO and its partners will share examples of steps to take to get there through a series of events and conversations held at multiple levels. The aim is to inspire, motivate and guide, sharing examples of what is being done and what can further be done, and inviting policy-makers to be part of the change.
1. Sustainable Development Goals [website]. New York: United Nations; 2018. (http://www.un.org/sustainabledevelopment/sustainable-development-goals/, accessed 16 March 2018).
2. Global report on diabetes. Geneva: World Health Organization; 2016. (http://www.who.int/diabetes/global-report/en/, accessed 16 March 2018).
3. Draft thirteenth general programme of work 2019−2023. In: World Health Organization [website]. Geneva: World Health Organization; 2018. (http://www.who.int/about/what-we-do/gpw-thirteen-consultation/en/, accessed 16 March 2018).
4. "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017. (http://www.who.int/ncds/management/best-buys/en/, accessed 16 March 2018).
5. Tools for implementing WHO PEN (Package of essential noncommunicable disease interventions). In: World Health Organization [website]. Geneva: World Health Organization; 2018. (http://www.who.int/ncds/management/pen_tools/en /, accessed 16 March 2018).
6. HEARTS technical package. In: World Health Organization [website]. Geneva: World Health Organization; 2018. (http://www.who.int/cardiovascular_diseases/hearts/en/, accessed 16 March 2018).
7. Republic of Moldova: improving access to insulin and oral medicines for diabetes. In: WHO/Europe [website]. Copenhagen: WHO Regional Office for Europe; 2018. (http://www.euro.who.int/en/health-topics/noncommunicable-diseases/diabetes/activities/country-level-diabetes-efforts/republic-of-moldova-improving-access-to-insulin-and-oral-medicines-for-diabetes, accessed 16 March 2018).
8. In Thailand, universal health care eases the impact of diabetes. In: World Health Organization [website]. Geneva: World Health Organization; 2016. (http://www.who.int/features/2016/thailand-eases-diabetes/en/, accessed 16 March 2018).
9. World Health Day – 7 April 2018. In: World Health Organization [website]. Geneva: World Health Organization; 2018. (http://www.who.int/campaigns/world-health-day/2018/en/, accessed 16 March 2018).