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Marie-Paule Kieny ¹ and David B. Evans ²

Universal health coverage (UHC), sometimes called universal coverage, is the aspiration that all people obtain the health services they need without suffering financial hardship paying for them. This requires coverage with a range of promotive, preventive, curative, rehabilitative and palliative services, and in particular coverage with services linked to the current health-related Millennium Development Goals (MDGs) and to noncommunicable diseases and injuries.

UHC is increasingly seen by countries at all income levels as an important goal for their health system development, as reflected in resolutions of governing bodies of the World Health Organization (WHO) (e.g. WHA 58.33 of 2005 and 64.9 of 2011; EM/RC59/R.3 of 2012) and in five recent global ministerial-level meetings, including a joint WHO/World Bank meeting between ministries of health and finance in Geneva in February 2013.

But UHC is also broader than health. By improving people’s health, it enables adults to work and earn an income and children obtain an education – allowing many to escape from poverty. By protecting people from financial hardship as a result of paying for health services, it prevents others from being pushed into poverty [1]. Recognizing this, the Member States of the United Nations adopted a resolution in December 2012 (A/67/L.3) emphasizing that UHC was important to overall human development and suggesting that it should be included in the post-2015 development agenda.

Moving closer to UHC contributes to “the enjoyment of the highest attainable standard of health” which, as stated in the WHO constitution, is “one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” [2]. It is consistent with the concept of “health for all” and the Alma Ata Declaration of 1978 [3].

In addition, within the concept of UHC it is recognized that achievement of the highest attainable level of health is not possible without health financing systems that guarantee financial risk protection and health systems that function appropriately. Only then can people access the health services they need secure in the knowledge that they will not suffer financial hardship as a result of paying for them.

Many factors help countries move closer to UHC and help protect the gains they have already made in coverage with needed services and financial risk protection. Social determinants – the conditions under which people are born, grow up, live, work and age (e.g. levels and inequalities in income, wealth, education and power structures in society) – are important [4]. For example, education helps people not only protect their own health, but to access health services when they need them. Within health systems, the World Health Report of 2010 (Health systems financing: the path to universal coverage) focused largely on health financing and more than 80 countries have since requested WHO for technical support to help modify their health financing systems to: raise sufficient funds for health; reduce financial barriers and spread risks across the population through prepayment and pooling; and use the available funds efficiently and equitably [5].

Other parts of the health system are also critical. Service delivery at the primary care level is crucial, ensuring access to integrated health services across all priority health problems. This requires motivated and responsive health workers located close to the population they service [6,7] and adequate supplies of good quality essential medicines and technologies for diagnosis and treatment [8]. A well-functioning referral system allowing integrated management and care supports this, as does sufficient funding for prevention and health promotion services. Systems for generating evidence through research and for collating and analysing the data necessary for informed decision-making and for governing all parts of the health system complete the picture.

It can be technically and politically difficult to adapt all the various components of the health system at the same time while also engaging in intersectoral actions targeting the social determinants of health. Countries must themselves lead in this process, but some will also require support from the global community.

The steps that countries can take, with support from WHO where desired, are:

• Undertake a situation analysis of UHC and identify the main obstacles and opportunities within the health system for moving closer to UHC;
• Engage in inclusive policy dialogue with all stakeholders to assess policy options for moving closer to UHC or maintaining existing gains;
• Develop and implement holistic strategies and plans for health systems strengthening to move closer to UHC;
• Engage in intersectoral action designed to encourage health-in-all policies for UHC, focusing on the areas that are likely to have the biggest impact first;
• Monitor, evaluate and adapt plans and strategies as necessary.

People cannot enjoy the greatest attainable level of health, or live long, dignified, healthy, and productive lives without being able to use the health services they need. They cannot use these services if financial barriers threaten them with financial ruin each time they seek care. People want the assurance that good quality health services are available and affordable, the aspiration of UHC.

Moving closer to UHC is not a dream. Momentum is building and increasingly countries at all income levels are developing strategies and policies to move forward and make progress towards UHC.

References

1. Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet, 2012, 380(9845):864–865.
2. Constitution of the World Health Organization. Geneva, World Health Organization, 1948.
3. World Health Organization and United Nations Children’s Fund. Declaration of Alma Ata. In: Primary health care. Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva, World Health Organization, 1978.
4. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008.
5. The world health report 2010. Health systems financing: the path to universal coverage. Geneva, World Health Organization, 2010.
6. Kuehn BM. Global shortage of health workers, brain drain stress developing countries. Journal of the American Medical Association, 2007, 298(16):1853–1855.
7. Henderson LN, Tulloch J. Incentives for retaining and motivating health workers in Pacific and Asian countries. Human Resources for Health, 2008, 15:6.
8. Millenium Development Goal 8. Delivering on the global partnership for achieving the Millenium Development Goals. MDG Gap Task Force Report 2008. New York, United Nations, 2008:35–43.