The World Health Organisation (WHO) has urged nations to build a fairer, healthier world post-Covid-19. The Covid-19 pandemic has unfairly impacted many people more harshly than others, exacerbating existing inequities in health and welfare within and between countries. For World Health Day, April 7, 2021, and the 73rd Founding Anniversary of WHO, the agency has issued a call for urgent action to improve health and well-being.
The World Health Day is celebrated on April 7 every year to mark the anniversary of the World Health Organisation’s founding in 1948. Each year, a theme is selected to highlight a priority area of public health concern. On World Health Day 2021, WHO invites the global community to join a new campaign to build a fairer, healthier world. World leaders are called upon to ensure that everyone has living and working conditions that are conducive to good health. WHO urges world leaders to monitor health inequities and ensure that all people can access quality health services when and where they need them.
WHO: Covid-19 widens health inequities
The Covid-19 pandemic has exasperated health inequities. Within countries, illness and death from Covid-19 have been higher among groups that are already vulnerable, face discrimination, poverty, social exclusion, and adverse daily living and working conditions including humanitarian crises. The pandemic is estimated to have driven between 119 and 124 million more people into extreme poverty last year.
There is convincing evidence that the pandemic has widened the gender gap in employment with women exiting the labour force in more significant numbers than men in the last 12 months. According to the Periodic Labour Force Survey (PLFS) data for 2017-18, there has been a fall of 7% in work participation rates (WPR) among rural women, declining from 24.8% to 17.5% in India. The pandemic has further reduced the girl child’s opportunities for education and empowerment. Covid-19 school closures around the world will hit girls hardest. India alone has affected nearly 290 million children’s education, causing many children to leave their studies.
The structural determinants of inequities in people’s living conditions, health services, and access to power, money and resources are longstanding. Under-5 mortality rates among children from the poorest households are double that of children from the wealthiest households. Child malnutrition and maternal malnutrition are significant determinants for these deaths and should be accorded the highest priority for corrective action. With malnutrition being a leading risk factor for child death, maternal nutrition during pregnancy needs to be prioritised. We have the technical capacity to track every pregnant woman and every new-born effectively to reduce child deaths in India substantially. A renewed political will is what is needed.
Life expectancy for people in low-income countries is 16 years lower than for people in high-income countries. For example, 9 out of 10 deaths globally from cervical cancer occur in low- and middle-income countries. The life expectancy of an Indian varies widely depending on where you live — which state, rural or urban area, and what your gender is. The average rural male in Chhattisgarh will live less than 63 years, while an urban female’s average life expectancy in Himachal Pradesh is nearly 81, a difference of 18 years.
As countries continue to fight the pandemic, a unique opportunity emerges to build back better for a fairer, healthier world by implementing existing commitments, resolutions, and agreements while also making new and bold commitments. “The Covid-19 pandemic has thrived amid the inequalities in our societies and the gaps in our health systems,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It is vital for all governments to invest in strengthening their health services and to remove the barriers that prevent so many people from using them, so more people have the chance to live healthy lives.”
The inequities could be mended in our lifetime. The post Covid-19 reconstruction provides an opportunity to address the health inequities. WHO is, therefore, issuing five calls for action.
WHO calls for equitable access to Covid-19 technologies
Safe and effective vaccines have been developed and approved at a record speed. The challenge now is to ensure that they are available to everyone who needs them. Key here will be an additional support to COVAX, the vaccine pillar in the ACT-Accelerator, which hopes to have reached 100 countries and economies in the coming days.
Vaccines alone will not overcome Covid-19. Commodities such as medical oxygen and personal protective equipment (PPE) and reliable diagnostic tests and medicines are also vital. So are robust mechanisms to fairly distribute all these products within national borders. The ACT-Accelerator aims to establish testing and treatments for hundreds of millions of people in low and middle-income countries who would otherwise miss out. Nevertheless, it still requires $22.1 billion to deliver these vital tools where they are so desperately needed.
WHO must take leadership to ensure that global trade agreements must not hamper access to affordable Covid-19 vaccines and commodities. South Africa and India are leading a demand to expand Covid-19 vaccine production by temporarily relaxing the Global Agreement on Trade and Tariff (GATT), the international trade rules protecting intellectual property rights. While more than two-thirds of the WTO members support the proposal, a few developing countries are taking a different stand.
Investment in primary healthcare key
At least half of the world’s population still lacks access to essential health services. More than 800 million people spend at least 10% of their household income on healthcare, and out of pocket expenses drive almost 100 million people into poverty each year. As countries move forward, it will be vital to avoid cuts in public spending on health and other social sectors. Such cuts are likely to increase hardship among already disadvantaged groups, weaken health system performance, increase health risks, add to fiscal pressure in the future and undermine development gains.
Instead, governments should meet WHO’s recommended target of spending an additional 1% of GDP on primary healthcare (PHC). Evidence reveals that PHC-oriented health systems have consistently produced better health outcomes, enhanced equity, and improved efficiency. Scaling up PHC interventions across low- and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030.
In a NITI Aayog study on Catastrophic Health Spending (CHS) and impoverishment of households while seeking hospitalised treatment of children (0-4 Years) in India, based on the data from the 75th round of the (2017-18) National Sample Survey (NSS) of hospitalised children (N= 4,564). The households experienced CHS nearly four times higher (37%) in private hospitals than public hospitals (10%) due to high out of pocket payments. More than half of the households (52%) experienced CHS when treatment was taken for children 1-2 years in private hospitals. Nearly two-thirds of the households belong to the most impoverished communities experienced CHS, whereas 27% of the wealthiest communities experienced CHS in private hospitals.
Households experienced CHS in private health facilities were higher in almost all the states (except Delhi) compared to the households that experienced CHS in public health facilities. Almost all the households experienced CHS while taking treatment in private health facilities in the states of Arunachal Pradesh (100 per cent), Goa (91 per cent) and Lakshadweep (91 per cent). Among the states, a significant number of households (75 per cent) in Goa have experienced CHS, while more than half of the households in Andhra Pradesh (53 per cent) have experienced CHS in both the health facilities (public and private).
Governments must also reduce the global shortfall of 18 million health workers needed to achieve universal health coverage (UHC) by 2030. This includes creating at least 10 million full-time jobs globally and strengthening gender equality efforts. Women deliver most of the world’s health and social care, representing up to 70% of all healthcare workers, but they are denied equal opportunities to lead it. Critical solutions include equal pay to reduce the gender pay gap, support for maternal care, child support and recognising unpaid healthcare work by women.
Recognising the dedication and sacrifice of the millions of health and care workers at the forefront of the Covid-19 pandemic, the 73rd World Health Assembly unanimously designated 2021 as the International Year of Health and Care Workers (YHCW). While efforts are being made to address the shortfall of healthcare workers in developed countries, that should not be at the expense of developing countries.
The international migration of health workers is increasing. There has been a 60% rise in migrant doctors and nurses working in OECD countries over the last decade. Future projections point to a continuing acceleration in health workers’ international migration with an escalating mismatch between the supply of and economic demand for health workers. One key element is establishing a supportive working and living environment and opportunities for professional growth so that health workers are less likely to migrate. Another is to implement the 2010 Code of Practice on the International Recruitment of Health Personnel.
Prioritise health and social protection
In many countries, the socio-economic impact of COVID-19 through loss of jobs, increase in poverty, disruption to education, and threats to nutrition have exceeded the virus’s public health impact. Some countries have already expanded social protection schemes to mitigate the impact of wider social hardship and started a dialogue on how to continue providing support to the communities and people in the future.
However, many face challenges in finding the resources for concrete action. It will be vital to ensure that these precious investments have the most significant impact on those in greatest need and that disadvantaged communities are engaged in planning and implementing programmes.
Build safe, healthy and inclusive neighbourhoods
City leaders have often been powerful champions for improving health through improving the transport systems and water and sanitation facilities. However, too often, the lack of essential social services for some communities traps them in a spiral of sickness and insecurity. Access to healthy housing in safe neighbourhoods with adequate educational and recreational amenities is key to achieving health for all.
Meanwhile, 80% of the world’s population living in extreme poverty are in rural areas. Today, 8 out of 10 people who lack essential drinking water services live in rural areas, as do 7 out of 10 people who lack essential sanitation services. It will be essential to intensify efforts to reach rural communities with health and other essential social services (including water and sanitation). These communities also urgently need increased economic investment in sustainable livelihoods and better access to digital technologies. Efforts to reduce air pollution’s health impact are essential in building safe, healthy and inclusive neighbourhoods.
Strengthen data and health information systems
Information systems can improve cost control, increase the timeliness and accuracy of patient care and administration information, increase service capacity, reduce personnel costs and inventory levels, and improve patient care quality. Increasing the availability of timely, high-quality data disaggregated by sex, wealth, education, ethnicity, race, gender, and residence place is key to working out where inequities exist and addressing them. Health inequality monitoring should be an integral part of all national health information systems.
“Now is the time to invest in health as a motor of development,” said Dr Tedros. “We do not need to choose between improving public health, building sustainable societies, ensuring food security and adequate nutrition, tackling climate change and having thriving local economies. All these vital outcomes go hand in hand.”
A recent WHO global assessment shows that only 51% of countries have included data disaggregation in their published national health statistics reports. The health status of these diverse groups is often masked when national averages are used. Moreover, it is often made vulnerable, needy or discriminated against, who are the most likely to be missing from the data entirely. Reconstruction of post-Covid-19 society must ensure a health-first approach. Investment in health is essentially investment for economic and social benefits.
(Dr Joe Thomas is associate dean, faculty of sustainability studies, and head, School of Public Health, MIT World Peace University, Pune.)