Breaking down the barriers to universal health coverage

The 2030 agenda for sustainable development calls on the international community to prioritize the needs and rights of vulnerable populations, so that no one is left behind. (1) The sustainable development goals (SDGs) are supremely ambitious, broad-based in their scope and strongly focused on the root causes of human misery, including the multiple interacting forces that make populations vulnerable to ill-health and premature death. Vulnerability is often associated with poverty, but it is also shaped by political processes and policies, legislation that excludes population groups or criminalizes certain behaviours, and social attitudes that marginalize, stigmatize and discriminate. Vulnerable populations addressed in this issue include remote rural populations and the urban poor, children affected by drought and conflict, people living with the human immunodeficiency virus (HIV) and at risk of tuberculosis, persons with physical disabilities, undocumented migrant workers and gender minorities. The SDG target for universal health coverage requires that the health needs of these and other vulnerable groups be met. As universal health coverage entails social protection against financial hardship caused by health-care costs, it also contributes to the overarching SDG objective of poverty alleviation. Papers in this issue cover a range of practical strategies for reaching vulnerable populations and addressing the multiple social, economic and environmental determinants of health. Research in Ethiopia shows how examining the effects of drought and conflict on the prevalence of wasting in children can guide the design of population-wide interventions. (2) Gavi, the Vaccine Alliance, has developed a tool for monitoring equitable vaccine coverage, using equity benchmarks that reflect the ambitions of the sustainable development agenda. (3) In Thailand, a programme for modifying the homes of people with disabilities proved technically and financially feasible, with support from government subsidies. (4) In Nepal, using peers to contact people living with HIV for tuberculosis screening resulted in a high participation rate and the identification of a considerable number of HIV-positive tuberculosis patients, illustrating one way to break through the barriers of discrimination. (5) Models for extending service coverage stress the importance of education, training and community engagement. Enhanced recruitment, training, supervision, and compensation of community health workers rapidly improved coverage with maternal and child health services in rural areas of Liberia. (6) Brazil has used a package of incentives to recruit physicians to work in remote and deprived areas and to improve the primary health-care infrastructure, leading to better working conditions and better quality of care. (7) Political commitment can be decisive. A paper on the fate of underserved and marginalized populations during donor transition shows how limited political commitment can lead to the persecution of vulnerable groups, pointing to the need to engage key populations in planning, implementing, and monitoring the transition. …