The essay aims to highlight the significance of different health systems frameworks for evaluating health system performance. It will further discuss how primary health care (PHC), universal health coverage (UHC), and sustainable development goals (SDGs) are interrelated, to promote a comprehensive and coherent approach to health. It will highlight the potential challenges of emphasizing UHC.Finally, the paper will discuss the potential usefulness of the HAQ index and OECD international comparisons, for ensuring universal access to quality healthcare.
Recognizing the importance health system strengthening (HSS) agenda, various frameworks have been proposed for measuring health system performance, such as World Health Organization (WHO) Health System Framework [1], Systems Thinking Framework [2], and the Canadian Institute for Health Information (CIHI) Performance Measurement Framework [3]. Each of these frameworks has different illustrations, but they are broadly categorized into three main components, including, health system architecture, instrumental goals, and intrinsic goals. Few frameworks incorporate a wide range of performance dimensions and contextual elements and thereby represent a more comprehensive approach for assessing health system performance. For instance, the four quadrants (inputs, outputs, outcomes, and social determinants) in the CIHI framework are understood within a broader context of demographic, political, economic, and cultural concerns [3]. It is recommended that the frameworks should align with the country’s health needs and reflect priorities set out in comprehensive national health policies and strategies. The directions laid out in all these frameworks are determined by the values and goals outlined in the principles of PHC.
PHC is foundational to achieving the vision of ‘health for all’, as first declared in the Alma-Ata Declaration of 1978, a seminal landmark in global health history [4,5]. In 2018, the Astana Declaration emerged as a major milestone to reaffirm the commitment to PHC [6]. It provides a novel approach to PHC and is vital to achieving SDGs and UHC [6]. The emphasis on PHC is vital for three reasons including, PHC empowers the health system to address complex interactions in a rapidlyevolving world [7], PHC has been recognized as a most effective and efficient approach to respond to the upstream and downstream factors of poor health [8], and UHC and SDGs can only be accomplished with a vital focus on PHC [7]. The provisions under the Canada Health Act reflect that the principles of PHC are consistent with Canadian values; however, there are challenges in organizing and delivering PHC services including, poor emphasis on health promotion, poor continuity of care, lack of care coordination for chronically ill patients and issues with access to care in rural and remote areas [9]. There is an opportunity to implement PHC reforms to ensure HSS in Canada.
The PHC principles serve as a programmatic engine for UHC [5].UHC is the highly influential notion of public health discipline for ensuring access to health services for all people, without suffering from financial hardship [10]. Countries like China, Mexico, Rwanda, and Thailand have made success in achieving UHC because they pivoted their domestic funding towards PHC [8]. As countries move forward on the journey of UHC, they should reflect on three dimensions of coverage including, population coverage, service coverage, and cost coverage [8]. There is no one-size-fits-all model for attaining UHC as each country's path to UHC will vary depending on their historical background, health needs and priorities, and health system learnings and capacities [10]. In Canada, the healthcare model (Medicare) is universal and reflected as “deep public coverage of a narrow basket of services”. There is no cost-sharing for physician visits, hospital in-patient care, and prescription drugs; yet the out-of-pocket payments (OOPs) account for 15% of total health spending. The model faces some important health system and policy challenges including delays in elective care, high OOPs for outpatient prescription drugs, vision, dental and, long term care, and poor health outcomes for indigenous people [9]
Although, UHC is timely and essentially important. Schmidt et al. argue that its advancement also involves considerable risks such as high inequities, high costs of health services, more focus on therapeutic clinical services, lack of a sufficient trained healthcare workforce, and lack of policy vehicles in population-level health targets [10]. UHC is the overarching target [3.8] of SDG-3 and the inclusion of UHC in the SDGs offers an opportunity to take a holistic approach for improving health outcomes [10]. SDG-3 is of interest to health professionals as it aims to ensure healthy lives and promote the wellbeing of populations by providing equitable health outcomes and wellbeing [10]. In Canada, progress on SDG-3 has been significant over the past 20 years as depicted by rate reductions in neonatal mortality, chronic diseases, smoking, and an increase in the number of healthcare workers [11] However, progress on SDG-3 can be best achieved through an emphasis on other SDGs (SDG 1,2, 4, & 5), which target social determinants of health.
An important element of attaining UHC is making sure that all people have access to quality health care. Canada noted, only a 0.3% per year gain in the healthcare access and quality (HAQ) index, between 2000 and 2016 [12]. The stalled gains in recent years indicate that the Canadian health system advances, not keeping pace with population health needs, and thus has major policy implications. International comparisons are also considered valuable for improving the quality of care. The Organization for Economic Co-operation and Development (OECD) international comparisonson six dimensions of care suggests that there is a clear opportunity to improve on patient safety indicators, as Canada lags behind international counterparts [13]. In other dimensions of care, Canada performed relatively well, especially in fruit and vegetable consumption in children, breast cancer screening, admission rates to hospitals for asthma and diabetes, and stroke mortality rates [13]. The banning of the sale of junk food by Canadian schoolscould explain the reason for the increased consumption of fruits and vegetables among children [14].
In conclusion, UHC and SDG-3 can only be arguably accomplished with a robust focus on PHC. PHC reflects the right priorities and is a critical milestone along the road to achieving UHC. However, each country's context is unique, and therefore, strategic policy dialogue is needed to support countries in identifying an essential package of services based on their health priorities.
- WHO (2007) Everybody's business--strengthening health systems to improve health outcomes: WHO's framework for action. World Health Organization.
- De Savigny D, Adam T (2009) Systems thinking for health systems strengthening: World Health Organization.
- Canadian Institute for Health Information (2013) A Performance Measurement Framework for the Canadian Health System (Updated November 2013): Canadian Institute for Health Information.
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- Sanders D, Nandi S, Labonté R, Vance C, Van Damme WJTL (2019) From primary health care to universal health coverage—one step forward and two steps back. Lancet 394: 619-621. [Crossref]
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- WHO (2018) A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. World Health Organization.
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- Kindornay, Shannon. (2019) Progressing National SDG Implementation: An independent assessment of the voluntary national review reports submitted to the United Nations High-level Political Forum in 2018. Ottawa: Canadian Council for International Co-operation.
- Barber RM, Fullman N, Sorensen RJ, Bollyky T, McKee M, et al. (2015) Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 390: 231-266. [Crossref]
- Canadian Institute for Health Information (2020) OECD Interactive Tool: International Comparisons.
- Pellegrini C (2014) Canada ranks low on patient safety in international comparison. Can Med Assoc 186: E12. [Crossref]
