Comment

plausible, suggestion that low grip strength represents

poor health. This explanation is not entirely consistent
with the ndings of other studies3 that show long-term
associations between grip strength in young people and
subsequent mortality.
An intriguing implication is that grip strength might act
as a biomarker of ageing across the life course.9 This is not
a new idea, but ndings from PURE add support. Loss of
grip strength is unlikely to lie on a single nal common
pathway for the adverse eects of ageing, but it might be
a particularly good marker of underlying ageing processes,
perhaps because of the rarity of muscle-specic diseases
contributing to change in muscle function. Interestingly,
similar age-related changes have been reported in other
species, such as Caenorhabditis elegans.10,11 Life-course
normative data12 have been described in a UK setting, and
birth and ageing cohort studies, particularly those with
long-term longitudinal data,13 provide ideal opportunities
to explore this hypothesis. Furthermore, linkage of
epidemiological ndings to new approaches in muscle
biology could yield informative insights into the nature of
human ageing.

We declare no competing interests.

1
2

4
5

7
8

9
10

11
12

13

*Avan Aihie Sayer, Thomas B L Kirkwood

MRC Lifecourse Epidemiology Unit, University of Southampton,
Southampton SO16 6YD, UK (AAS); and Newcastle University
Institute for Ageing, Newcastle University, Newcastle upon Tyne,
UK (AAS, TBLK)
aas@mrc.soton.ac.uk

Gale CR, Martyn CN, Cooper C, Sayer AA. Grip strength, body composition,
and mortality. Int J Epidemiol 2007; 36: 22835.
Rantanen T, Harris T, Leveille SG, et al. Muscle strength and body mass
index as long-term predictors of mortality in initially healthy men.
J Gerontol A Biol Sci Med Sci 2000; 55: M16873.
Ortega FB, Silventoinen K, Tynelius P, Rasmussen F. Muscular strength in
male adolescents and premature death: cohort study of one million
participants. BMJ 2012; 345: e7279.
Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging
adults. J Geriatr Phys Ther 2008; 31: 310.
Cooper R, Kuh D, Hardy R, on behalf of the FALCon and HALCyon study
teams. Objectively measured physical capability levels and mortality:
systematic review and meta-analysis. BMJ 2010; 341: c4467.
Leong DP, Teo KT, Rangarajan S, et al; on behalf of the Prospective Urban
Rural Epidemiology (PURE) Study investigators. Prognostic value of grip
strength: ndings from the Prospective Urban Rural Epidemiology (PURE)
study. Lancet 2015; published online May 14. http://dx.doi.org/10.1016/
S0140-6736(14)62000-6.
Yusuf S, Rangarajan S, Teo K, et al. Cardiovascular risk and events in 17 low-,
middle- and high-income countries. N Engl J Med 2014; 371: 81827.
Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM.
Handgrip strength and cause-specic and total mortality in older disabled
women: exploring the mechanism. J Am Geriatr Soc 2003; 51: 63641.
Syddall H, Cooper C, Martin F, Briggs R, Aihie Sayer A. Is grip strength a
useful single marker of frailty? Age Ageing 2003; 32: 65056.
Herndon LA, Schmeissner PJ, Dudaronek JM, et al. Stochastic and genetic
factors inuence tissue-specic decline in ageing C elegans. Nature 2002;
419: 80814.
Kirkwood TBL. Untangling functional declines in the locomotion of aging
worms. Cell Metabol 2013; 18: 30304.
Dodds RM, Syddall HE, Cooper R, et al. Grip strength across the life
course: normative data from twelve British studies. PLoS One 2014;
9: e113637.
Stenholm S, Tiainen K, Rantanen T, et al. Long-term determinants of muscle
strength decline: prospective evidence from the 22-year mini-Finland
follow up survey. J Am Geriatr Soc 2012; 60: 7785.

Universal health coverage: progressive taxes are key

On Dec 12, 2012, a UN General Assembly Resolution
was passed unanimously which called on all countries
to move their health systems towards universal health
coverage (UHC).1 Interestingly, this resolution was
cosponsored by the USAa country not known for
having achieved this goal.
With UHC now a common objective for all health
systems, the debate is shifting to how countries
should achieve it. Particularly since publication of the
2010 World Health Report,2 there has been growing
interest in how countries should nance their health
systems to reach the twin goals of universal coverage
of eective health services and nancial protection
from the costs of these services. Most recent research
evidence in this area is now showing that public
www.thelancet.com Vol 386 July 18, 2015

nancing is the key to achieving UHC.3 For example,

in the 2012 Lancet Series on UHC, Moreno-Serra and
Smith4 showed that pooled public nancing resulted
in improved health outcomes; private voluntary
insurance had no eect on indicators, and a greater
share of out-of-pocket expenditure was associated
with higher mortality rates.
In The Lancet, Aaron Reeves and colleagues5 reinforce
these ndings on the benets of public nancing, but
now provide new research evidence on which specic
public nancing mechanisms have the greatest eect
on UHC indicators. Using longitudinal data from
89 low-income and middle-income countries from
1995 to 2011, they show that increasing general
taxation nancing was associated with increased

Published Online
May 15, 2015
http://dx.doi.org/10.1016/
S0140-6736(15)60868-6
See Articles page 274

227

William Campbell/Corbis

Comment

health service coverage and improved nancial

protection. These associations were particularly
pronounced in countries with low tax revenues (less
than US$1000 per capita per year). Here an additional
$100 tax revenue per year substantially increased the
proportion of births with a skilled attendant present
by 674 percentage points (95 % CI 087126) and the
extent of nancial coverage by 114 percentage points
(551172).5
Furthermore, Reeves and colleagues ndings show
that how tax revenues are sourced also matters:
progressive tax revenues from prots, capital, and
income are much more eective in generating public
funds for health than are consumption taxes. Also,
whereas some indirect taxes (for example on luxury
goods) are not likely to aect poor people adversely,
and other indirect taxes might help improve health
outcomes (for example taxes on tobacco and alcohol),
other consumption taxes are highly regressive.
Health-care user fees and copayments, for example,
represent a consumption tax on the sick that take
countries away from UHC and adversely aect
health outcomes. Reeves and colleagues5 show that
infant mortality rates are strongly associated with
consumption taxes that include taxes on health services
(050%, 95% CI 018083).5
In presenting their evidence, the authors highlight
shortfalls in the quantity and quality of international
data for UHC and health nancing indicators. If UHC is
to be incorporated into the Sustainable Development
Goal for health, it will need to be addressed as a top
228

priority. The ongoing work by the World Bank and WHO

to develop an appropriate UHC monitoring framework6
and strengthen health information systems should
therefore be welcomed.
In using existing data sources, a limitation of Reeves
and colleagues study5 is that the authors seem to
downplay the potential role of compulsory social
health insurance (SHI) payments to public health
nancing. Since these contributions are also, in
eect, a progressive tax on incomes, this position is
unfortunate and might give the impression that SHI
nancing systems are inferior to those nanced by
general taxation. This impression would be misleading,
because health nancing debates are tending to move
beyond comparisons of the merits of pure Beveridge
(general taxation) and Bismarck (SHI) models.7 In fact,
many low-income and middle-income countries are
developing hybrid health nancing systems that mix
SHI contributions and general taxation revenues.8 In
recognising the superiority of progressive, compulsory
public nancing mechanisms over private voluntary
health nancing, it would be useful if future research in
this area could include SHI contributions too.
The ndings of Reeves and colleagues,5 similarly to
those of the 2012 report Transitions in Health Financing
and Policies for Universal Health Coverage,9 have profound
implications for health development policy. Both
of these papers highlight the importance of public
nancing reforms in delivering UHC, and recognise
that political processes are driving these transitions.
As Savedo and colleagues9 argue: The clearest
explanation for the long-term rise in the pooled share of
health spending is the persistence of political demands
for universalising health coverage.
With this being the case, and with aid nancing
potentially crowding out domestic tax nancing,10
this argument suggests that development agencies
should become much more engaged with the political
economy of health nancing reforms. As Reeves
and colleagues5 propose, this involvement could
include helping countries to expand their overall scal
capacity, but could also require encouraging countries
to allocate greater shares of their tax revenues to the
health sector.
The example given of India is an excellent one, where
the share of gross domestic product allocated to public
health nancing and health coverage indicators are
www.thelancet.com Vol 386 July 18, 2015

Comment

some of the lowest in the world.11 Furthermore, in view

of the size of Indias economy and the political context
of the country,12 external aid nancing is unlikely to have
much eect on closing coverage gaps in India. In view of
the experience of other large middle-income countries,13
only domestic health nancing reforms will deliver UHC
to the Indian population.
Such reforms will also have a benecial eect on global
health security, for which extending eective health
coverage might provide the best defence against the
threat from epidemics of infectious diseases and the
growing burden of non-communicable diseases.14 As the
current Ebola epidemic and growing rates of multidrug
resistant tuberculosis show, it is in everybodys interests
to reach universal coverage of some health services.
If UHC is to be realised globally, health development
agencies should therefore be paying a much keener
interest in helping countries make the transition to
nancing their health systems publicly.

4
5

10

11

Robert Yates
UHC Policy Forum, Chatham House, London SW1Y 4LE, UK
ryates@chathamhouse.org

12

I declare no competing interests.

13

Copyright Yates. Open Access article distributed under the terms of CC BY.
1

United Nations. United Nations General Assembly resolution on global

health and foreign policy A/67/L.3: resolution adopted by the General
Assembly on 12 December 2012. http://www.un.org/en/ga/search/view_
doc.asp?symbol=A/RES/67/81 (accessed April 24, 2015).

www.thelancet.com Vol 386 July 18, 2015

14

World Health Organization. World Health Report. Health systems

nancingthe path to universal coverage. Geneva: World Health
Organization, 2010.
Rottingen JA, Ottersen T, Ablo A, et al. Shared responsibilities for healtha
coherent global framework for health nancing. Final report of the Centre
on Global Health Security Working Group on Health Financing. London:
Chatham House, 2014.
Moreno-Serra R, Smith PC. Does progress towards universal health
coverage improve population health? Lancet 2012; 380: 91723.
Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D.
Financing universal health coverageeects of alternative tax structures
on public health systems: cross-national modelling in 89 low-income and
middle-income countries. Lancet 2015; published online May 15.
http://dx.doi.org/10.1016/S0140-6736(15)60574-8.
World Bank, World Health Organization. Monitoring progress towards
universal health coverage at country and global levels: framework,
measures and targets, May 2014. Geneva: World Health Organization, 2014.
Kutzin J, Ibraimova A, Jakab M, ODougherty S. Bismarck meets Beveridge
on the Silk Road: coordinating funding sources to create a universal health
nancing system in Kyrgyzstan. Bull World Health Organ 2009; 87: 54954.
Maeda A, Cashin C, Harris J, Ikegami N, Reich M. Universal health coverage
for inclusive and sustainable development: a synthesis of 11 country case
studies. Washington DC: The World Bank, 2014.
Savedo WD, Bitrn R, De Ferranti D, et al. Transitions in health nancing
and policies for universal health coverage: nal report of the transitions in
health nancing project. Washington DC: Results for Development
Institute, 2012.
Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ.
Public nancing of health in developing countries: a cross-national
systematic analysis. Lancet 2010; 375: 137587.
Reddy KS, Patel V, Jha P, Paul VK, Kumar AKS, Dandona L. Towards
achievement of universal health care in India by 2020: a call to action.
Lancet 2011; 377: 76068.
Gilligan A. India tells Britain: we dont want your aid. The Telegraph Feb 4,
2012. http://www.telegraph.co.uk/news/worldnews/asia/india/9061844/
India-tells-Britain-We-dont-want-your-aid.html (accessed May 6, 2015).
Evans TG, Chowdhury AMR, Evans DG, et al. Thailands universal coverage
scheme successes and challengesan independent assessment of the rst
10 years (20012011). Nonthaburi, Thailand: Health Insurance System
Research Oce, 2012.
Heymann DL, Chen LC, Takemi K, et al. Global health security: the wider
lessons from the Ebola outbreak. Lancet 2015; 385: 1884901.

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