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本文為世界衛(wèi)生組織總干事陳馮富珍博士與世衛(wèi)組織前總干事及The Elders副主席Gro Harlem Brundtland博士聯(lián)合發(fā)布的評論文章。

“可持續(xù)發(fā)展目標(biāo)”包括橫跨不同領(lǐng)域的一系列廣泛目標(biāo)。但其中一個目標(biāo)尤其引人注目，堪稱建立更健康世界的希望之燈——實現(xiàn)全民健康覆蓋（UHC）。全民健康覆蓋是基于所有人和社區(qū)無需承受經(jīng)濟(jì)困難即可獲得所需高質(zhì)量衛(wèi)生服務(wù)這一原則之上。

國際和國家政策制定者和基層積極分子都應(yīng)認(rèn)識到實現(xiàn)全民健康覆蓋的時機(jī)已經(jīng)到來。著名印度經(jīng)濟(jì)學(xué)家阿瑪?shù)賮啞どf過，這是“負(fù)擔(dān)得起的夢想”。經(jīng)濟(jì)學(xué)站在我們這一邊。多年來我們知道良好的健康支持經(jīng)濟(jì)增長。衛(wèi)生就業(yè)和經(jīng)濟(jì)增長問題委員會在去年九月份發(fā)布的報告中表明，衛(wèi)生領(lǐng)域的投資不僅促進(jìn)人口健康，還創(chuàng)造就業(yè)，刺激經(jīng)濟(jì)增長。

全民健康覆蓋不僅保護(hù)個人與社區(qū)的健康與福祉，還有利于創(chuàng)建公平、穩(wěn)定和團(tuán)結(jié)的社會。實現(xiàn)全民健康覆蓋可提供尤其是針對女性和年輕人的就業(yè)與經(jīng)濟(jì)機(jī)會，同時進(jìn)一步推進(jìn)結(jié)束貧困的總目標(biāo)。世衛(wèi)組織估計每年約有1億人由于自費支付衛(wèi)生服務(wù)而陷入貧困。實現(xiàn)全民健康覆蓋有利于消除貧困。

有人可能認(rèn)為全民健康覆蓋的目標(biāo)是理想化和不可實現(xiàn)的。雖然沒有國家能負(fù)擔(dān)每個人可想到的每一項衛(wèi)生服務(wù)，但是所有國家都能取得進(jìn)展。近幾年很多國家已通過擴(kuò)大關(guān)鍵服務(wù)的覆蓋面以及加大對人群獲取衛(wèi)生服務(wù)的財政支持證實了這一點。

比如日本、摩爾多瓦、秘魯、斯里蘭卡、泰國和土耳其等國已經(jīng)通過能帶來實質(zhì)性的衛(wèi)生、經(jīng)濟(jì)及政治益處的醫(yī)療體系改革在實現(xiàn)全民健康覆蓋方面取得顯著進(jìn)展。

但是，很多國家仍落后于其伙伴國家，或進(jìn)展緩慢，或忽視弱勢群體。這些國家似乎缺乏下一代改革，以動員公民支持全民健康覆蓋，表達(dá)他們的需求，并讓各國政府和所有利益攸關(guān)者建立起政治上的勢頭并作出承諾。

正如世衛(wèi)組織在2010年世界衛(wèi)生報告中所說，衛(wèi)生籌資改革對全民健康覆蓋至關(guān)重要。大多數(shù)國家需要減少對私人籌資方法的依賴，比如使用者付費和自愿醫(yī)療保險；取而代之建立主要依靠公共籌資的體系，比如包括強(qiáng)制繳納社會保險等多種形式的征稅，從而在使用時減少經(jīng)濟(jì)阻礙。

各國都正意識到自由市場形式的醫(yī)療保健體系，即醫(yī)療服務(wù)像其他商品一樣被人們購買與出售，永遠(yuǎn)不可能實現(xiàn)全民健康覆蓋。在該種體系下，只有富人能獲得足夠的健康服務(wù)而窮人則會被排除在外。

增加國內(nèi)公共籌資很關(guān)鍵。外國援助金額不足且不可持續(xù)。所以動員社會各界的力量支持全民健康覆蓋對于國內(nèi)籌資和改革成功很重要，雖然這常會受到既得利益者的反對。

證據(jù)清晰地表明只要執(zhí)行正確的政策，擴(kuò)大公共衛(wèi)生支出就能減少對人們自費醫(yī)療支出的依賴。這是一些財力不足的較弱經(jīng)濟(jì)體在顯著擴(kuò)大公共財政時面臨的主要挑戰(zhàn)。對于這些國家而言，加強(qiáng)本國稅制以及打擊國際避稅是向全民健康覆蓋努力的關(guān)鍵，但是必須承認(rèn)最貧窮的國家至少在短期或中期繼續(xù)需要外援。

實現(xiàn)全民健康覆蓋和其他與健康相關(guān)的可持續(xù)發(fā)展目標(biāo)并不僅僅是更多支出。政府需要確保公平有效地利用資源以擴(kuò)大面向所有人的高質(zhì)量衛(wèi)生服務(wù)，配備足夠數(shù)量訓(xùn)練有素、有積極性的衛(wèi)生工作者，改革衛(wèi)生系統(tǒng)以強(qiáng)調(diào)人們的需求而不僅僅是疾病本身?？梢詫崿F(xiàn)上述目標(biāo)的衛(wèi)生體系不僅可以實現(xiàn)更好的衛(wèi)生成果，還能為個人、家庭以及整個國家節(jié)省開支。

所以我們建議國家執(zhí)行可以幫助快速、公平實現(xiàn)全民健康覆蓋的醫(yī)改戰(zhàn)略；而關(guān)鍵的第一步就是擴(kuò)大基層醫(yī)療衛(wèi)生服務(wù)，重視弱勢群體的需求，比如窮人、婦女、女童和青少年，以及殘障人群和老年人。為了覆蓋到每一個人，應(yīng)免費提供基層醫(yī)療服務(wù)。

強(qiáng)大的基層衛(wèi)生是每一個衛(wèi)生體系的生命線，沒有國家或社區(qū)能脫離基層衛(wèi)生而實現(xiàn)全民健康覆蓋?；鶎有l(wèi)生是抗擊傳染病暴發(fā)以及應(yīng)對非傳染性疾病的第一道關(guān)鍵防線，也對于女性和兒童等主要使用者的健康至關(guān)重要。

當(dāng)然，國家如果想實現(xiàn)全民健康覆蓋，必須具備相應(yīng)的評估能力。通過監(jiān)測獲取基本衛(wèi)生服務(wù)的家庭所占比例和醫(yī)療衛(wèi)生支出占家庭收入25%以上的家庭所占比例是已被各國認(rèn)同的兩大關(guān)鍵指標(biāo)，以追蹤實現(xiàn)全民健康覆蓋的進(jìn)展。好消息是很多國家已有上述數(shù)據(jù)，甚至根據(jù)自身需求開發(fā)了更多具體的評估標(biāo)準(zhǔn)；但另一些國家并沒有。世衛(wèi)組織和其合作伙伴正和各國一起合作以加強(qiáng)其衛(wèi)生信息系統(tǒng)。

全民健康覆蓋被納入可持續(xù)發(fā)展目標(biāo)作為其子目標(biāo)之一為實現(xiàn)其他所有健康目標(biāo)提供了平臺，并通過提供預(yù)防為主、以人為本、具備經(jīng)濟(jì)保護(hù)的全面終身服務(wù)來實現(xiàn)這些目標(biāo)。全民健康覆蓋是公平的最終表述，也是所有政策選擇最有力的社會均衡器之一。

Universal Health Coverage: an affordable goal for all

Joint commentary by 

Dr Margaret Chan, Director-General of WHO, and

Dr Gro Harlem Brundtland, Former Director-General of WHO and Deputy Chair of the Elders

When all 193 member states of the United Nations agreed on the Sustainable Development Goals in New York in 2015, they set out an ambitious agenda for a safer, fairer and healthier world by 2030.

The goals include a broad array of targets across different sectors. But one target in particular stood out as a beacon of hope for a healthier world: To achieve universal health coverage (UHC). UHC is based on the principle that all individuals and communities should receive the quality health services they need without suffering financial hardship.

International and national policymakers and grassroots activists alike recognize that UHC is an idea whose time has come. In the words of Amartya Sen, the renowned Indian economist, it is an "affordable dream". And economics is on our side. We have known for many years that good health supports economic growth. The Commission on Health Employment and Economic Growth, in its report delivered in September 2016, showed that investments in the health sector don’t only result in healthier populations; they create jobs and stimulate economic growth.

UHC goes beyond safeguarding the health and well-being of individuals and communities. It also helps build fair, stable, and cohesive societies. Delivering on UHC offers employment and economic opportunities, particularly for women and youth while furthering the overarching objective of ending poverty. WHO estimates that out-of-pocket expenditures on health services push 100 million people into poverty every year. Implementing UHC would help to eliminate this impoverishment.

Some people may regard the goal of UHC as being utopian and unattainable. While it’s true that no country can afford to provide every conceivable health service to every person, all countries can make progress. This has been demonstrated by the many countries in recent years that have extended coverage of vital services and improved financial protection for the population when accessing healthcare.

Japan, Moldova, Peru, Sri Lanka, Thailand and Turkey, for example, show that countries can make dramatic progress towards UHC through health system reforms that can deliver substantial health, economic and political benefits.

However, a number of countries are lagging behind their peers and are either making slow progress or leaving vulnerable groups behind. What appears to be lacking in these countries is the next generation of reforms that mobilize citizens to advocate for UHC, articulate their needs and build political momentum and commitment from governments and all stakeholders.

As WHO demonstrated in its World Health Report of 2010, health financing reforms are crucial for UHC. Most countries need to reduce reliance on private financing methods like user fees and voluntary health insurance, and instead move towards a system that is funded predominantly from public sources (i.e. various forms of taxation including compulsory social insurance contributions) that enable financial barriers to be reduced at the point of use.

Across the world, countries are realising that a free market in healthcare, with people buying and selling medical services like other commodities, will never result in UHC. In such a system, only the rich will receive adequate coverage and the poor and vulnerable will be excluded.

Increasing domestic public financing is essential. Foreign aid alone is not sufficient or sustainable. Mobilizing all segments of society to advocate for UHC is therefore vital to raise domestic financing and deliver successful reforms, often in the face of opposition from vested interests.

The evidence clearly shows that, with the right policies in place, greater public spending on health is associated with less dependence on out-of-pocket payments. This is a major challenge for some weaker economies with inadequate fiscal capacity to expand public finance significantly. For these countries in particular, strengthening domestic tax systems and cracking down on international tax evasion are essential to progress towards UHC, even as it must be recognized that the poorest countries will continue to need external aid at least for the short or medium term.

Achieving UHC and the other health-related SDG targets isn’t just about spending more money. Governments need to ensure these resources are used efficiently and fairly to scale-up the supply of quality health services for everyone, with enough well-trained and motivated health workers, and to transform health systems to address the needs of people, not diseases. Health systems that achieve this don’t just have better health outcomes; they also save money for individuals, households and entire countries.

We therefore recommend that countries implement health reform strategies that move swiftly towards full population coverage in an equitable way. The vital first step is to scale up primary health care services, focussing on meeting the needs of vulnerable groups such as the poor, women, girls and adolescents, as well as the disabled and older populations. To reach everyone, essential health services need to be free at the point of delivery.

Strong primary care is the lifeblood of every health system, and no country or community can achieve UHC without it. Primary care is a vital first line of defence against infectious disease outbreaks as well as tackling the slow march of non-communicable diseases, and is particularly important for the health of women and children, who are its main users.

Of course, if countries are to achieve UHC, they must be able to measure it. Monitoring both the proportion of the population with access to essential health services and the proportion of households that spend more than 25% of their income on health are the two critical indicators that have been agreed on to track progress towards UHC. The good news is that many countries already have data on both and even have more specific measures tailored to their needs, but others don’t. WHO and its partners are working with countries to strengthen their health information systems.

The inclusion of UHC as one of the targets in the Sustainable Development Goals provides the platform for moving towards all other health targets through the delivery of integrated, people-centred services that span the life course, bring prevention to the fore, and protect against financial hardship. UHC is the ultimate expression of fairness and one of the most powerful social equalizers among all policy options.