Universal health coverage (UHC) is increasingly seen by global civil society as a key component of the framework for sustainable development after the Millennium Development Goals (MDGs), and of shaping the kinds of system that promote equity, access, and human rights. Our European network Action for Global Health, together with other international organisations, recently launched a civil society call for UHC—a movement that is gaining momentum with signatories from four continents acting together to demand that there is greater political support.
The multicentre, open-label, randomised controlled trial by Surya Biere and colleagues shows a lower incidence of pulmonary infections in the first 2 weeks after minimally invasive oesophagectomy than after open oesophagectomy. This is an interesting finding of great relevance to clinicians. However, the data reported do not allow for a balanced interpretation of the risk of postoperative pulmonary complications, potentially hindering a direct comparison between the two groups.
Certain concepts resonate so naturally with the innate sense of dignity and justice within the hearts of men and women that they seem an insuppressible right. That health care should be accessible to all is surely one such concept. Yet in the past, this notion has struggled against barriers of self-interest and poor understanding. Building on several previous Lancet Series that have examined health and health systems in Mexico, China, India, southeast Asia, Brazil, and Japan, today we try to challenge those barriers with a collection of papers that make the ethical, political, economic, and health arguments in favour of universal health coverage (UHC), and which will be presented in New York on Sept 26, to coincide with the UN General Assembly.
Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people.
Good news about the Global Fund to Fight AIDS, Tuberculosis and Malaria has been sorely lacking these past few years as the organisation has faced corruption allegations, financial woes, and internal reform. Yet, despite these challenging times, the Fund remains operational and continues its important work. Last week, it announced that its Board had approved 45 new 2 year grants, from 37 countries, totalling US$419·2 million.
We were extremely encouraged by the results of the trial by Maria Goya and colleagues (May 12, p 1800)—ie, that a cervical pessary can prevent preterm birth.
Circumcision of newborn boys has been medically documented since ancient times. It is primarily elective, is sometimes done by religious scholars, and is considered sacred to the Jewish and Muslim faiths. Yet many today consider it to be a human-rights violation. The global debate over religious circumcision erupted anew in June, 2012, when the German city of Cologne banned the procedure, and charged a Rabbi with inflicting “physical harm” on an infant after he did the operation.
[Articles] Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies
The results of this systematic review confirm that children with disabilities are more likely to be victims of violence than are their peers who are not disabled. However, the continued scarcity of robust evidence, due to a lack of well designed research studies, poor standards of measurement of disability and violence, and insufficient assessment of whether violence precedes the development of disability, leaves gaps in knowledge that need to be addressed.
As the world's nations gather for the UN meetings in September, 2012, real momentum on achievement of universal health coverage—aimed at giving everyone the health services they need without causing financial hardship—is no longer a distant dream. The 25 wealthiest nations all now have some form of universal coverage (apart from the USA, where political opposition remains strong, despite a recent supportive Supreme Court decision). Several middle-income countries, including Brazil, Mexico, and Thailand do as well.
The US Food and Drug Administration has approved Stribild, a once-daily “quad” combination pill (elvitegravir, cobicistat, emtricitabine, and tenofovir) for treatment of HIV-1 infection in adults who have had no previous treatment. The decision was made on the basis of the outcome of two randomised trials that compared the new pill with existing daily regimens.
Underpinning the trends examined in The Lancet's Series on universal health coverage are several points that deserve deeper appreciation. Call them EPIC—a fitting acronym, in view of the epic transition now underway as the world moves towards universal coverage.
In an important proof-of-concept trial, Surya Biere and colleagues report a significantly reduced rate of pulmonary infections (9–12%) in patients who received minimally invasive versus open oesophagectomy (29–34%). These numbers are substantially lower than those of previous studies used for power calculations (29% and 57%, respectively). Since both groups received preoperative treatment, including regular consultations by a physiotherapist (lasting 6–8 weeks) and since evidence is increasing that prehabilitation before surgery (eg, different types of respiratory and physical therapies) can reduce the incidence of postoperative pulmonary complications (by contrast with postoperative respiratory physical therapy), it is of utmost interest to know which types of preoperative exercise were done.
The recent Rio+20 United Nations Conference on Sustainable Development, in Rio de Janeiro, Brazil, took place 20 years after the first global conference on the environment and development and 10 years after the World Summit on Sustainable Development. Although much of the discussion focused on the environment, poverty reduction, and sustaining economic growth, the resultant resolution contained an important paragraph for the global health community:
We are perplexed by Maria Goya and colleagues' report, which showed that the Arabin pessary significantly reduced birth before 34 weeks in women with a cervical length of less than 25 mm at 18–22 weeks. The 27% preterm birth rate (birth before 36 weeks) in the control group was extremely high compared with the general rate of 8% in Spain. Previous studies have shown that, in high-risk singleton pregnancies with a cervical length of 25 mm or less at 15–24 weeks' gestation, birth rate before 34–35 weeks was between 6% and 30%, whereas that in low-risk women was only 4·3%.
The effort to increase access of patients with HIV to universal care including antiretroviral therapy (ART) has achieved remarkable success. This achievement has been aided by a specific UN declaration; the establishment of powerful funding agencies; and the availability of cheap, reliable generic antiretroviral drugs in fixed-dose combinations.
Quilty S, Anderson K, Hewitt J, Fahy R, Clothier T, Roseby R. Deprivation in the desert: a case report from central Australia. Lancet 2006; 368: 890—In this Case Report (Sept 2, 2006), the third author's name should have been Jacqueline Hewitt. This correction has been made to the online version as of Sept 7, 2012.
Researchers have long acknowledged the seemingly increased rates of abuse and maltreatment in individuals with disabilities. with disabilities, and high rates of lifetime victimisation. Lisa Jones and colleagues’ meta-analysis of violence against children with disabilities in The Lancet contributes greatly to the scientific knowledge about this group. The authors report pooled estimates of the prevalence of violence against children with disabilities of 26·7% (95% CI 13·8–42·1), with estimates for physical violence and sexual violence of 20·4% (13·4–28·5) and 13·7% (9·2–18·9), respectively.
A 71-year-old man hospitalised with tracheobronchitis, complained of hand discolouration. His hands showed the three-phases of skin colour changes (white, blue, and red) and a diagnosis of Raynaud's syndrome was established. When questioned about the first time he had these symptoms, the patient noted that they had been recurrent for about 20 years. He had relatively short fingers, particularly of the thumbs, and no bone was palpable in most of the distal phalanges (). Radiography of his hands showed bone resorption of almost all terminal phalanges of both hands, so-called acro-osteolysis ().
The Netherlands is one of the few places in the world where euthanasia and physician-assisted suicide are legal under specific circumstances. In The Lancet, Bregje Onwuteaka-Philipsen and colleagues present the findings from their analysis of trends in euthanasia and physician-assisted suicide before and after the 2002 enactment of the euthanasia law in the Netherlands—the most recent rigorously designed, empirical study done in the country to date. By sampling all deaths in the Netherlands, the investigators were able to analyse trends and report some reassuring findings, but they also identified cases that raise ethical concerns.
The goal of universal health coverage is deeply embedded in politics, ethics, and international law. Article 25 of the 1948 Universal Declaration of Human Rights states that everyone has the right to a standard of living adequate for health, including medical care, and the right to security in the event of sickness or disability. Motherhood and childhood are to be afforded special care and assistance. In the same year, the Constitution of the World Health Organization came into force, declaring that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
Following the Australian Government's landmark victory against the tobacco industry on the issue of plain cigarette packaging, the cause of global public health has been dealt a blow by the US Court of Appeals. Legislation by the US Food and Drug Administration mandating graphic health warnings to be printed on all cigarette packages sold in the USA has been deemed unconstitutional. In delivering the ruling, Justice Janice Rogers Brown alluded to the lack of evidence that graphic health warnings would reduce smoking.
The results of the randomised trial by Surya Biere and colleagues are of huge interest, but some qualifications need to be made about their robustness and reliability.
Georges Canguilhem's Writings on Medicine, translated by Stefanos Geroulanos and Todd Meyers (and published by Fordham University Press), is a short book that every dean of every medical school and every school of public health should consider as required reading for their students. The book might also prompt serious discussions among those of us long past our student days. Canguilhem was born on June 4, 1904. He died on Sept 11, 1995. Between those dates, he was variously a doctor, a professor of philosophy at the Sorbonne, and a mentor to some of the best known (and most controversial) French philosophers of the 20th century.
In interpreting the differences in postoperative pulmonary complication rates between minimally invasive and open oesophagectomy, Surya Biere and colleagues concluded that the minimally invasive procedure was superior to the open procedure with regard to short-term outcomes.
While the passing of the Affordable Care Act was met with a backlash in many US states, Vermont took a different approach, with a push for a more public health-care system. Carrie Arnold reports.
[Correspondence] Minimally invasive versus open oesophagectomy for oesophageal cancer – Authors' reply
Stephen Swisher and colleagues criticise the in-hospital pneumonia rate in the open oesophagectomy group in our trial (34% vs 12% in the minimally invasive group). They refer to the 23% chest complication rate in the trial by Burmeister and colleagues. Our reading of this paper is different: major pulmonary complications occurred in 25 (20%) of 128 patients in the neoadjuvant group and 36 (28%) of 128 in the surgery-alone group; the total surgery-related death rate was 5% (11 of 215). These results are surely comparable with those of the open group in our trial.
The Indian Government has vowed to make drugs free for all ahead of the next election but this is not a new pledge, just its latest attempt to realise an old one. Amelia Shepherd-Smith reports.
We were impressed that Maria Goya and colleagues managed to recruit 380 participants (190 per group) into the analysis dataset of their PECEP trial, having, according to the published version of the paper, planned for precisely this sample size. 385 women were initially randomised, and five (two pessary and three controls) were lost to follow up, leaving the exact sample size planned. It was also good, given the open nature of the trial, that the primary endpoint was predefined in the trial registration document.
Canada's public health system has changed very little since its inception but the country's rapidly ageing population and burgeoning costs are now forcing reform. Paul C Webster reports.
In our trial, both groups of patients were managed exactly the same. Cervical and vaginal swabs were taken every month and patients were appropriately treated when cultures were positive. In the past, the pessary has been suspected of causing vaginal infections and chorioamnionitis; consequently, we were interested in showing that the pessary does not increase the rates of these infections, although vaginal discharge was present in 100% of all the women in the Arabin pessary group. Joan Melendez and Manish Gupta's proposal to combine the cervical pessary and prophylactic antibiotics should be studied in a future randomised controlled trial.
As I made my way to the Jewish Museum London, I passed several Olympic and Paralympic signposts in the streets, complete with the London 2012 logo and, of course, the curious mascots Wenlock and Mandeville running, jumping, lunging, and generally being active all over the place. I found myself pondering the origin of the mascots' names, especially Mandeville, the Paralympic mascot.
Meng Q, Xu L, Zhang Y, et al. Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. Lancet 2012; 379: 805–14—In this Article (March 3), the correspondence author should have been Dr Qun Meng, Centre for Health Statistics Information, Ministry of Health, People's Republic of China; [email protected] This correction has been made to the online version as of Sept 7, 2012.
At a time when the Paralympics have had their highest ever media and public profile, and the achievements of disabled athletes are being widely celebrated, it is worth remembering that many people who live with a disability are more likely to be treated as scapegoats than heroes. In the UK alone some recent cases stand out. Kevin Davies, a young man with epilepsy, was kept in a shed and tortured until he died. Fiona Pilkington and her disabled daughter Francesca Hardwick were victims of abuse by their neighbours for many years.
[Articles] Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial
Expansion of primary-care nurses' roles to include ART initiation and represcription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality.
[Articles] Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey
Our study provides insight in consequences of regulating euthanasia and physician-assisted suicide within the broader context of end-of-life practices. In the Netherlands the euthanasia law resulted in a relatively transparent practice. Although translating these results to other countries is not straightforward, they can inform the debate on legalisation of assisted dying in other countries.
I work in a government-funded health-care system that is the envy of many countries. The dismal state of indigenous health notwithstanding, Australia typically features at the “good” end of graphs that depict important health-care statistics. Yet at the teaching hospital where I work, each day of my oncology and internal medicine service starts with a reminder of just how tight the bed status is and how important it is to consider who really needs to remain in hospital. Ward rounds must start early; discharge scripts must be punctual; transport must be booked speedily.
Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people.
[Series] Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia
We analyse nine low-income and lower-middle-income countries in Africa and Asia that have implemented national health insurance reforms designed to move towards universal health coverage. Using the functions-of-health-systems framework, we describe these countries' approaches to raising prepaid revenues, pooling risk, and purchasing services. Then, using the coverage-box framework, we assess their progress across three dimensions of coverage: who, what services, and what proportion of health costs are covered.
We commend Surya Biere and colleagues (May 19, p 1887) on their randomised, multicentre trial comparing minimally invasive with open oesophagectomy. We have several concerns, however.
In August, 2011, a 38-year-old man presented to his local doctor in Qingyuan, Guangdong Province, China, with generalised fatigue. He had had fever for 2 weeks, a non-productive cough, and a 5 kg weight loss. He was treated with antibiotics for 3 days, but the fever continued. He fainted twice at work, falling to the ground. He was taken to the local hospital by his coworkers. Because he admitted to having had unprotected sex with commercial sex workers, an HIV test was done. HIV ELISA was positive, and he went to the local Centre for Disease Control and Prevention clinic for a confirmatory Western blot.