Leaving nobody outside our healthcare systems—in Europe or elsewhere

On 23 September 2019, the United Nations (UN) General Assembly held the first high-level meeting dedicated to universal health coverage (UHC), under the theme of Moving Together to Build a Healthier World”. In the resulting political declaration, world leaders strongly recommitted to achieving UHC by 2030—a necessary step to reaching the rest of the UN Sustainable Development Goals to make the world a better place. This is the latest in a series of international commitments to improve healthcare access for all, including that of G7 Health Ministers and the co-operation between the European Union and World Health Organization (WHO).

The UN declaration defines UHC as meaning that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, without being exposed to financial hardship. UHC implies a recognition of the fundamental importance of equity and social cohesion, and reiterates the importance to ensure that no one is left behind, especially those who are vulnerable, stigmatized, and/or marginalized. 

This important and welcome commitment is as important in Europe as anywhere else. The UN notes the discrepancy in life expectancy globally of over 30 years between the countries with the shortest and longest life expectancies. A similar discrepancy also exists within the high-income countries of Europe. For example, studies in England and Ireland have reported a median age of death of 42–52 years among homeless people, as compared an estimated life expectancy at birth across the European Union average of 81 years. Indeed, various communities of socially excluded people, including homeless people, people who use drugs, lesbian, gay, bisexual, transgender and intersex (LGBTI) people, prisoners, sex workers and undocumented migrants are at high risk of poor health and yet among the least likely to receive healthcare. These groups face numerous educational, organisational, legal, financial and administrative barriers to accessing healthcare—and in particular commonly face stigma and discrimination.

While the provision of UHC is ultimately the responsibility of national governments, international bodies can also add value. During 2019, a thematic network co-ordinated via the European Commission Health Policy Platform has focused political attention on this issue. The network has been led by the Nobody Left Outside initiative, a collective of organisations representing the aforementioned communities. The name NLO underscores that these groups are not merely at risk of being “left behind,” but to a large degree are already outside of formal healthcare systems.

On 17 October 2019, the NLO Thematic Network published a Joint Statement that calls on the new European Commission and European Parliament, and EU Member States, to take specific actions to help deliver equitable access to healthcare and support services (e.g. social, housing and legal services) to all people in Europe. These include a call to evaluate the implementation of a novel Service Design Checklist, a tool developed by NLO to help key stakeholders tailor health services to marginalized communities. This tool supports the delivery of integrated (co-located or linked) fit-for-purpose healthcare services that are community-based and people-centred. Structured according to the WHO Health Systems Framework, it provides a series of considerations encompassing service design (including accessibility, adaptation and range of services offered), health workforce issues, health information systems, medical products and technologies, financing and leadership and governance. It also resonates with the UN declaration’s commitment to accelerate the implementation of effective, high-impact, people-centred, gender-responsive and evidence-based interventions to ensure universal access to quality health services, including those that meet the needs of vulnerable groups, and its focus on primary healthcare as the foundation for achieving UHC, while strengthening an integrated and/or effective referral system for secondary and tertiary care. 

The NLO Thematic Network Joint statement also encourages the European Commission to support an EU-level knowledge platform to compile and share research and best practices in healthcare access for marginalised, underserved groups. It calls for a joint action to improve access in these groups; healthcare staff training and capacity building via the European Social Fund+, and research to improve access to cancer screening and care among these groups  Lastly, it recommends that the commission should further prioritise a co-ordinated approach to addressing social determinants of health in all policies.

Ultimately, reaching the Sustainable Development Goals and ensuring UHC in all countries, rich and poor, will require governments to ensure that health systems are responsive to the needs of all communities. To achieve this, they will need to actively engage with communities of service users with respect to health service design, assessment, governance, and financing. They will need to remove the various regulatory, and structural barriers that inhibit healthcare access. And while access is paramount, service quality must also be prioritised, since poor quality care in health systems is now responsible for a greater number of deaths than insufficient access to care. While collaborative efforts can facilitate health system improvements, governments must also measure these. Tick, tock—just 10 years to go until 2030…

Jeffrey V. Lazarus is head of the health systems team at the Barcelona Institute for Global Health (ISGlobal) and an Associate Professor at the Faculty of Medicine, University of Barcelona, Barcelona, Spain. @JVLazarus 

Denis Onyango is Programmes Director at the Africa Advocacy Foundation (AAF), London, UK. @ondeni

Freek Spinnewijn is Director of the European Federation of National Organisations Working with the Homeless (FEANTSA) and President of the European Public Health Alliance (EPHA), Brussels, Belgium. @FreekSpinnewijn

Competing interests: The NLO initiative is supported financially by MSD. JVL reports research grants from AbbVie, Gilead and MSD, outside of the work discussed here.

Written on behalf of the NLO initiative. The following organisations are participants in the NLO initiative: Africa Advocacy Foundation (AAF); Barcelona Institute for Global Health (ISGlobal); Correlation European Harm Reduction Network; European AIDS Treatment Group (EATG); European Federation of National Organisations Working with the Homeless (FEANTSA); International Committee on the Rights of Sex Workers in Europe (ICRSE); International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) – Europe; NPS Italia Onlus; and the Platform for International Cooperation on Undocumented Migrants (PICUM).