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Ala Alwan ¹

¹Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

EMHJ, 2013, 19(8):685-686

This editorial is based on a speech delivered at the Ministerial Conference on Universal Health Coverage, 27-28 June, 2013, Istanbul, Turkey.

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The right to health is a fundamental human right [1,2]. Universal health coverage (UHC) is a central strategy to achieving that right. UHC has three dimensions: coverage for all people; coverage with all essential services, prevention, promotion, treatment and rehabilitation services; and financial risk protection so service users are not exposed to financial hardship. Progressing towards UHC requires a country to have a strong, efficient, well-staffed and affordable health system accessible to all. Attainment of UHC poses additional challenges in countries affected by humanitarian crises and emergencies.

Humanitarian crises, whether natural or man-made, unfortunately occur with relentless regularity. Between 2001 and 2010, there were on average over 700 natural and man-made emergencies occurring globally every year, affecting approximately 270 million people and causing over 130 000 deaths annually [3]. About a quarter of the world’s population currently lives in countries affected by violent conflicts [4].

In the WHO’s Eastern Mediterranean Region, 13 of the Region’s 23 countries are currently experiencing complex humanitarian emergencies (many of them prolonged), affecting over 40 million people, and more than 55% of the world’s refugees originate from this Region [5].

Emergencies cause enormous loss of life and suffering. They also invariably result in destruction of infrastructure and huge financial losses. From the health perspective, there may be extensive disruption of health services due to reduced supplies at a time of greater need leading to shortages of medicines and other essential equipment. Furthermore, the functioning of the health system may be severely curtailed because of power and water shortages or interruptions.

Emergencies can thus severely impede UHC and may destroy years of developmental gains in the health sector. A report by the United Nations Economic and Social Commission for Western Asia estimates that the current conflict in Syria has resulted in a decline in the country’s Human Development Index level which is now lower than that of 2005; in other words, the country may have lost nearly 10 years of human development achievements [6]. Hence ensuring that health care reaches all people affected by emergencies is a great challenge to global health today.

In 2005 the United Nations (UN) General Assembly endorsed reforms in the management of the emergency humanitarian assistance based on universally accepted humanitarian principles [7]. These principles are intersectoral action, neutrality, solidarity, equity and social justice; participation; accountability and reliability; and the fundamental right to health for all.

In major or protracted emergencies, the humanitarian health relief has three pillars: strengthening of health systems; predictable and reliable financing; and strengthened partnerships and coordination through the establishment of the health cluster which includes national and international players, with WHO as the Cluster Lead. In addition to the provision of essential health care in coordination with the government, the health cluster has the responsibility to provide key public health functions and to set the scene for early recovery.

Based on the above, it is clear that the UHC principle of equal access to essential services and financial risk protection is entirely consistent with the humanitarian principles and UHC is a prerequisite for effective humanitarian health relief. Furthermore, the building blocks for a well-functioning health system are as crucial to emergency management as they are to the achievement of UHC.

Therefore, UHC during emergencies can be achieved if the humanitarian principles are adhered to by national and international actors and effective emergency management is put in place and implemented on the ground. Unfortunately, this is not usually the case during real life emergencies. There are often major gaps and obstacles to effective management of emergencies and hence provision of UHC.

First and foremost is that most countries are not adequately prepared for crises and emergencies and they frequently lack plans and capacity on risk and vulnerability assessment and preparedness at the level of communities and countries at risk. Second is lack of security, which may result not only in destruction of infrastructure, but also in lack of access to health facilities due to hostilities, inability of health professionals to reach people in need, lack of transport and a host of other related issues. Third are other causes of inaccessibility. Despite humanitarian principles, the cost of obtaining treatment may actually rise during emergencies. People may have to compete to access available medical services and supplies, user fees may be imposed and closure of government facilities may force people to resort to the private sector and make them vulnerable to exploitation. Fourth is funding. If adequate preparedness and planning are not in place, a state will not be in a position to implement mitigation and early response measures and may need the international community to help support the emergency response. While funding mechanisms for immediate international response may be available, the longer an emergency continues, the more need there is for a sustainable means of funding and donor fatigue may be a major limiting factor. Fifth is lack of medical supplies and essential medicines. Although emergency health kits are normally provided during acute crises, life-saving medicines and supplies for chronic diseases, maternal and child health care and mental health are often forgotten or inaccessible.

These impediments require action by countries and the international community. Countries need to be better prepared for emergencies and to invest in strengthening the resilience of their health systems. Vulnerable communities also need to consider international experience and lessons learned in order to address gaps. At the global level, the international community should establish stronger coordination and learn from experiences, particularly in the last 8 years since the implementation of the UN humanitarian reforms.

In the Eastern Mediterranean Region, Member States have endorsed a strategic vision aimed at increasing the resilience of countries to crises and ensuring effective public health response to risks and threats. This includes the development of clear policies and legislation based on an all‐hazard, multisectoral and “whole health” approach, paying special attention to safeguarding health facilities and the health workforce during emergencies. However, translating the vision into concrete action is a challenge. Key readiness measures that are given priority by the Regional Office include maintaining regional emergency stockpiles, training a cadre of response experts and encouraging the establishment of intercountry mutual support and solidarity arrangements and agreements in times of crisis. We also aim to strengthen the evidence base for health emergency and disaster risk management by reviewing lessons learnt, best practices and economic assessments.

The ultimate goal is to promote country and regional self‐reliance in emergency management and thereby maintain UHC in times of crisis: risk reduction and emergency preparedness at the community level is the safeguard against the collapse of UHC at the onset of a major emergency; an early and well-organized emergency response will help ensure that the vital elements of UHC are maintained to benefit the affected populations; and early recovery measures using humanitarian resources will lead to prompt and efficient re-establishment of UHC.

References

1. World Health Organization. Constitution of the World Health Organization (http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf, accessed 17 July 2013).
2. United Nations. The Universal Declaration of Human Rights http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf, accessed 17 July 2013).
3. World Health Organization. Investing in the World Health Organization. Taking steps towards a fully-funded Programme Budget 2014–2015 (http://www.who.int/mediacentre/events/2013/financing_brochure_20130620.pdf, accessed 17 July 2013).
4. WDR 2011: conflict, security, and development. Washington DC, The International Bank for Reconstruction and Development/The World Bank, 2011.
5. Displacement. The new 21st century challenge. Global Trends Report, 2012. Geneva, United Nations High Commissioner for Refugees, 2013 (http://unhcr.org/globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%202012_V05.pdf, accessed 17 July 2013).
6. United Nations Economic and Social Commission for Western Asia. The National Agenda for the Future of Syria Programme. The Syrian crisis: political, economic and social impact and responses, unpublished report, December 2012.
7. UN General Assembly, Sixtieth session. Resolution A/RES/60/124. Strengthening of the coordination of emergency humanitarian assistance of the United Nations (http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/60/124, accessed 17 July 2013).