What services should be guaranteed in universal health-care systems?

KEYwords: Universal health coverage; primary care; health-care expenditure; pandemic; climate change

In light of the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, a new–old reflection on health-care services and their organisational model is useful. In Italy, the Coronavirus Disease 2019 (COVID-19) pandemic showed that we cannot take for granted the public, universal and equal access health care that is provided through general taxation by the Italian National Health Service. In this article, we would like to focus attention on the type of health services we should invest in, in the future. The authors are two young medical doctors. Kadjo Yves Cedric Adja graduated from the University of Florence and works as a third-year resident physician in epidemiology and public health at the University of Bologna (Italy). Davide Golinelli is a physician specialising in epidemiology and public health, who is now working as a researcher at the University of Bologna.

Over the last decades, demographic transition has put increasing pressure on health-care systems internationally, but we have been reminded that other challenges are also likely. Emerging infectious diseases such as SARS-CoV-2, also known as Coronavirus Disease 2019 (COVID-19), may not be the worst thing that health-care systems might face in the future. Climate change and its consequences are a certainty, bringing acute events such as heat waves, floods, drought and other emerging pathogens that may be even more dangerous than COVID-19, which has challenged the world since January 2020. More subtle threats are pollution and the slow and inexorable accumulation of poisons that, over time, can lead to tumours and other chronic diseases.

An appropriate metaphor may be the fable of the frog being slowly boiled alive. The premise is that if a frog is put suddenly into boiling water, it will jump out, but if the frog is put in warm water, which is then brought to a boil slowly, it will not perceive the danger and will be cooked to death. The story is a metaphor for the inability or unwillingness of people to react to or be aware of threats that arise gradually rather than suddenly. This is what is happening with our health-care systems because of the onset of new risks coming from climate change and population aging.

Although accessible and universal health-care systems will be critical into the future, the COVID-19 pandemic helped to uncover some critical weaknesses in the organisation of these systems, particularly in Italy.¹ Italy’s health expenditures account for ~8.8% of its gross domestic product (GDP), in line with the average of Organisation for Economic Co-operation and Development (OECD) countries.² However, how is this money spent? The latest figures, published in 2019 by the OECD, reveal that hospital inpatient and outpatient services comprise the greatest share of health spending across OECD countries, typically accounting for ~60%,³ with hospital expenses alone accounting for 30–40% of total expenditure. In European Union countries, inpatient and day care services account for at least half of hospital spending.²

Primary health care, including family medicine, community- and home-based services, health promotion and prevention, are vital components of every health-care system, but account for only 13% of health spending across OECD countries. Moreover, although inpatient, outpatient and long-term care spending has grown annually in the period between 2009 and 2013, expenditure for prevention and other health services has decreased.³ This has left primary and public health services with limited resources and a constrained workforce to face the challenges raised by COVID-19, even though primary care and public health non-pharmaceutical interventions have so far proven to be the most effective pandemic management tools. Thus, the COVID-19 pandemic has abruptly reminded us of the importance of primary care, epidemiology, public health and prevention.⁴

The rapid emergence of telehealth prompted by the COVID-19 pandemic has also shown that new ways of health-care access are essential and possible. Health literacy, internet access and technological devices are becoming more and more important in gaining access to health care. Failing to guarantee adequate investment in these amenities for at least the most vulnerable populations, could cause wider access inequalities.

A lesson that we can draw from recent events is that we cannot take universal health care for granted. At the same time, it is fundamental to earmark adequate resources for health care, and even more important to allocate them appropriately. It is time to prioritise primary care and public health and foster the financing of activities that for many years have been neglected. These health-care system components might not give immediate results measured in health outcomes, but in the longer term, they will be of higher value for the health of populations.

To conclude, in preparation for the challenges ahead for health-care services, whether related to pandemics or climate change, we must see investments in new models of care and in health-related workforce. For example, governments should foster the development of health-care professionals able to work in multidisciplinary and multi-professional teams supported by digital technology and proactively engage in preventive care, as recently suggested by the OECD.⁵ We do not know what the future holds, but as physicians and health-care professionals, we must prepare for both acute and gradual change, or suffer the consequences.

The authors declare that they have no competing interests.

This research did not receive any specific funding.