Comment

www.thelancet.com Vol 381 January 19, 2013 179

Universal health coverage: the post-2015 development agenda
The passage of a UN General Assembly resolution on
universal health coverage (UHC) in December, 2012,
underlines how UHC is becoming a key global health
objective.
1
Adopted by consensus, the resolution urged
member states to develop health systems that avoid
substantial direct payments at the point of delivery and
to implement mechanisms for pooling risks to avoid
catastrophic health-care spending and impoverishment.
This resolution sets the stage for UHC to become
a unifying central health goal in the post-2015
Millennium Development Goal framework.
The Millennium Development Goals (MDGs) trans-
formed global health: they galvanised politicians and
citizens, stimulated civil society, encouraged robust
monitoring and evaluation frameworks, motivated
research communities, and created new institutions.
By focusing global communities on a common
agenda, the MDGs conrmed that progress for poor
and marginalised people is possible. Yet the MDGs also
had major shortcomings. They ignored the central
role of health systems, overlooked emerging health
concerns such as non-communicable diseases, tended
to exacerbate fragmented health systems by focusing
on nal health outcomes related to vertical programmes
rather than on building integrated health systems, and
at times contributed to inequities in health.
24
To redress these shortcomings and respond to
new challenges, the global health community should
consider using UHC to frame the health goal from a
system perspective. UHC is dened by WHO as universal
access to needed health services without nancial
hardship in paying for them.
5
UHC allows for a greater
focus on the equitable distribution of access to health
services and demands a universal focus within and
across countries.
6
Moreover, UHC is a goal relevant for
all countries, rich and poor, as illustrated by the broad
support for the UN resolution on UHC.
1

Uniting the health sector around one health goal
focused on UHC with multiple subgoals recognises
that one size does not t all, but that there are a set
of system-level constraints to scaling up access to
health. Challenges such as absorptive capacity, human
resources for health, and health nancing must be
addressed. One global UHC goal would recognise these
similarities in constraints, while giving each country the
opportunity to customise their approach to achieving
this system-level goal.
To achieve sustainable UHC, health systems need
to deliver and measure progress on two inter-related
components: access to coverage for needed health
services (prevention and treatment) and access to
coverage with nancial risk protection. One possible
indicator of the latter is out-of-pocket spending on
health (the share of health spending paid for by the
patient at the point of service). Worldwide, about
150 million people a year face catastrophic health-
care costs because of direct payments such as user
fees, while 100 million are driven below the poverty
line.
5
To the extent that people are covered by a risk-
pooling mechanism, their out-of-pocket expenditure
will not cause nancial hardship. Out-of-pocket
expenditure for health also illuminates inequities in
that richer countriesand richer populations within
those countriestend to have lower out-of-pocket
expenditure.
3
Additional indicators of access are needed
for coverage, and experts at WHO are leading a working
group on this challenging issue.
7

The UN resolution on UHC illustrates the impressive
momentum behind the need to accelerate action
towards UHC as a strategy for improving health and
ameliorating inequities in health. Using the post-
MDG process as a platform to build on the movement
that sees health systems as the backbone of a healthy
population, we hope to ensure that in another 15 years,
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Health Coverage see http://
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universal-health-coverage
Comment
180 www.thelancet.com Vol 381 January 19, 2013
Antibiotic treatment to eradicate chronic Helicobacter
pylori infection has become the mainstay of treatment
for peptic ulcer disease, and reports indicate that
H pylori eradication might also prevent gastric cancer.
1,2

The relative eectiveness of dierent eradication regi-
mens varies between geographical regions, however,
and the determination of whether one regimen will
perform better than another in a particular population has
seemed to require comparative clinical trials. In The Lancet,
Jyh-Ming Liou and colleagues
3
report ndings that lend
support to the idea that the best eradication regimen
can be reliably predicted if the prevalence of antibiotic-
resistant H pylori in the region is known, as has been
previously suggested.
4
The investigators present the results of a well-
executed, randomised, open-label clinical trial that
included 900 Taiwanese adults and compared three
eradication regimens for H pylori: 14 days of triple
therapy (lansoprazole, amoxicillin, and clarithromycin),
14 days of sequential therapy (7 days of lansoprazole
and amoxicillin followed by 7 days of lansoprazole,
clarithromycin, and metronidazole), and 10 days
of sequential therapy (5 days of lansoprazole and
amoxicillin followed by 5 days of lansoprazole,
clarithromycin, and metronidazole).
3
Both of the
metronidazole-containing sequential regi mens were
more eective in eradicating the infection than was the
14-day triple therapy regimen, although only the 14-day
sequential regimen was statistically signicantly more
eective than 14-day triple therapy (907% vs 823%;
p=0003). Similarly, eradication success with the 14-day
sequential group was greater than in the 10-day group
(870%), but not statistically signicantly so.
The most innovative aspects of the study relate to the
eect of antibiotic resistance on treatment outcome;
in logistic regression models, clarithromycin resistance
decreased the eectiveness of all three regimens, and
metronidazole resistance decreased the eectiveness
of both the sequential regimens. A meta-analysis
5
of
earlier studies that assessed 10-day sequential therapy
in southern Europe and parts of Asia had suggested that
the advantage of 10-day sequential therapy over triple
therapy was attributable to its greater success against
clarithromycin-resistant strains of H pylori. However,
this nding was derived from just two studies, which
included only 45 patients with clarithromycin-resistant
infections.
6
The meta-analysis results also suggested
that metronidazole resistance did not diminish the
success of 10-day sequential therapy in the 71 patients
with metronidazole-resistant infections. Thus, Liou
Dening the role of sequential therapy for H pylori infection
all of the worlds people will have access to health at an
aordable cost. The time is ripe to be bold. A system-
level approach working towards UHC could have a
transformative eect in the battle against poverty,
hunger, and disease. If we prioritise health as a human
right, in addition to a healthier population, social and
economic development will ourish. By focusing on
UHC in the post-2015 framework, the international
community has an opportunity to endorse a country-
driven agenda, as well as build and improve upon the
robust legacy of the MDGs.
Jeanette Vega
The Rockefeller Foundation, New York, NY 10018, USA
JVega@rockfound.org
JV is Managing Director of Health for the Rockefeller Foundation. I declare that I
have no conicts of interest.
1 United Nations General Assembly. GA/11326. Adopting consensus text,
General Assembly encourages member states to plan, pursue transition of
national health care systems towards universal coverage. Dec 12, 2012.
http://www.un.org/news/press/docs/2012/ga11326.doc.htm (accessed
Jan 10, 2012).
2 Waage J, Banerji R, Campbell O, et al. The Millennium Development Goals:
a cross-sectoral analysis and principles for goal setting after 2015.
Lancet 2010; 376: 9911023.
3 Schweitzer J, Makinen M, Wilson L, Heymann M, for Results for Development
Institute and Overseas Development Institute. Post-2015 health MDGs.
Washington: Results for Development Institute, 2012.
4 UN System Task Team on the post-2015 development agenda. Health in the
post-2015 UN development agenda. Thematic think piece from UNAIDS,
UNICEF, UNFPA, WHO. May, 2012. http://www.un.org/millenniumgoals/pdf/
think%20pieces/8_health.pdf (accessed Jan 10, 2013).
5 WHO. The world health report 2010. Health systems nancing: the path to
universal coverage. Geneva: World Health Organization, 2010.
6 Chopra M, Sharkey A, Dalmiya N, Anthony D, Binkin N, on behalf of the
UNICEF Equity in Child Survival, Health and Nutrition Analysis Team.
Strategies to improve health coverage and narrow the equity gap in child
survival, health, and nutrition. Lancet 2012; 380: 133140.
7 Boerma T. Measurement of trends and equity in coverage of health
interventions in the context of universal health coverage. Meeting report,
Rockefeller Foundation Center, Bellagio, Sept 1721, 2012. http://www.
worldwewant2015.org/le/279371/download/302866 (accessed
Jan 14, 2012).
Published Online
November 16, 2012
http://dx.doi.org/10.1016/
S0140-6736(12)61849-2
See Articles page 205