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  • 2019-05
  • Competing pressures for resources across sectors however mea


    Competing pressures for resources across sectors, however, mean that increasing the proportion of resources for health will be difficult. Efficiency gains in the health sector could help to make the case for more investment. Countries need to tackle major sources of inefficiency by doing more of the right things (ie, low-cost, high-effect interventions) in the right settings (ie, at the most appropriate system level) and in the right way (ie, without waste). Domestic resource mobilisation combined with more effective strategic purchasing will become increasingly important, with a financial and programmatic transition away from directly donor-financed service delivery, where such delivery exists. Perhaps the most important message to come from this analysis though is the central importance of progressive universalism—ie, steadily increasing coverage in countries without access to good-quality services, and leaving no one behind. As countries get wealthier, they casein kinase increase the proportion of overall national resources allocated to health. Countries can also ensure that increases in domestic revenues through other reforms, such as tax administration, also translate into proportional increases in health. However, without the right policies and allocation systems in place, there is a natural tendency for expansion to favour rich people, and for inequalities to increase in terms of access to care and services. Policies and actions to counter this tendency require leadership and long-term vision, both at national and local levels. Debates in the USA this year show the dangers of assuming that policies aimed at UHC will always be sustained in the long term.
    Global health estimates are primarily used for global monitoring and priority setting. The estimates for blindness and visual impairment presented in help to monitor the current endorsed by the World Health Assembly in 2013, which aims to reduce visual impairment and its unequal distribution. Bourne and colleagues estimated that global age-standardised blindness prevalence declined from 0·75% (80% UI 0·25–1·41) in 1990 to 0·48% (0·17–0·87) in 2015, and the corresponding decline in moderate and severe visual impairment was from 3·83% (1·66–6·42) to 2·90% (1·31–4·80). As the authors outline, reasons for this decline include socioeconomic development, targeted public health programmes, and improved access to eye health services. However, as most visual impairment occurs in older age, population growth and ageing over the period outstripped declines in prevalence. Consequently, the number of people affected increased—from an estimated 31 million to 36 million for blindness, and from 160 million to 217 million for moderate and severe visual impairment. Alarmingly, the authors predict further increases in the number of people living with blindness and visual impairment: their future projections see a reversal of the downward trend in prevalence, with blindness (0·50%; 80% UI 0·17–0·92) and moderate and severe visual impairment (3·06%; 1·31–5·15) both predicted to increase in 2020 compared with 2015 estimates. The authors acknowledge the limitations of their prevalence projections, but combined with the continued growth and ageing of the population their projections suggest that eye health services must be strengthened for universal eye health to be realised. A further barrier to achieving universal eye health is persistent inequity, confirmed by the ten-times difference in age-standardised blindness prevalence between global regions, and the excess blindness and visual impairment occurring in women compared with men in all regions, even after accounting for women\'s increased life expectancy. Scarcity of data meant that other possible determinants of inequity such as socioeconomic status and place of residence could not be considered. Furthermore, we cannot assess whether gains at the aggregate level over the past 25 years mask increasing inequity within populations, nor whether the projected increase in impairment will disproportionately occur in disadvantaged groups. We urge researchers to expand primary data collection and reporting so that future estimates can provide a more comprehensive equity assessment, and align with the equity-oriented monitoring aims of universal health coverage and the sustainable development goals.