The Quest for Universal Health Coverage

By Richard Skolnik, MPA
Author of Global Health 101

The quest for Universal Health Coverage (UHC) is central to all efforts in global health. Indeed, all high-income countries, except the United States, have had a system of universal health coverage for some time and all low-and middle-income countries have at least a commitment in principle to achieving UHC as soon as possible.

In this context, it is important for those of us who teach global health to understand the concept of UHC, some of the key reference materials that deal with UHC, and some of the countries that we want our students to study to best understand the “quest for universal health coverage.”

The World Health Organization (WHO) defines Universal Health Coverage as:

“ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.”

In 2010, WHO issued a report called Health systems financing – the path to universal coverage http://www.who.int/whr/2010/en/ ) that laid out a basic framework for considering universal coverage and how to pay for it. The report also included a well-known graphic – the “universal health coverage box” that highlights the key questions that countries must address as they move toward universal health coverage: who should be covered, for what services, and for what services will the health system pay?

Dimensions of Universal Coverage

Figure 1: Dimensions of Universal Health Coverage. Source: http://www.who.int/health_financing/strategy/dimensions/en/

As we work with students to deal with these questions, what are some of the other key materials that we can use?

Undergraduate students generally have little familiarity with the goals of health systems and how different countries organize, manage, and finance them. Thus, it is valuable for us to expose students to an overview of health systems and the concept of UHC, before we address UHC in greater depth. For this, I hope faculty and students will find helpful the health systems chapter of my Global Health 101, third edition, textbook.

Some faculty may wish to complement this reading by asking students to review the video sessions that relate to health systems and UHC of my massive open online course (MOOC) Essentials of Global Health https://www.coursera.org/learn/essentials-global-health ). This would include Session 9 on “The Organization and Management of Health Systems” and Session 10 on “Health Expenditures, the Quest for UHC and Pharmaceuticals”.

For those who wish to pursue UHC in greater depth, some valuable starting points would be:

  • The Lancet 2012 series on Universal Health Coverage (http://www.thelancet.com/journals/lancet/issue/vol380no9845/PIIS0140-6736(12)X6037-9).
  • The Lancet has also produced other series on UHC, including one, for example, on Latin America – “Universal Health Coverage in Latin America” (http://www.thelancet.com/series/latin-america-UHC) and another on the role of the private sector in achieving UHC – “ Universal Health Coverage: markets, profit, and the public good” (http://www.thelancet.com/series/private-sector-health)
  • The Lancet Commission on Investing in Health also produced a report with many valuable insights about efforts by low- and middle-income countries to achieve universal health coverage: Global health 2035, a world converging within a generation ( http://www.thelancet.com/commissions/global-health-2035).
  • The third edition of Disease Control Prioritieshttp://dcp-3.org/) will shortly issue an important volume that focuses on universal health coverage. This will include an analysis of what a model “universal health coverage package” might include in low-, lower-middle, and upper middle-income countries. This information should add substantial value to the discussions of universal health coverage. The summary of these findings will also be published in The Lancet in late 2017.

Of course, even if students get a good grasp of the concepts in the above materials, they are still likely to be interested in examples of how different countries have sought to achieve UHC.

A good point of departure for this information will be the Commonwealth Fund annual report on health systems in the high-income countries, such as International Profiles of Health Care Systems (http://www.commonwealthfund.org/publications/fund-reports/2017/may/international-profiles). The Commonwealth Fund also publishes a range of related materials that compare and contrast the health systems of high-income countries. Such materials will be of special importance for American students, given the current debate about what the US healthcare system should look like.

There is also an increasing range of studies about efforts to achieve UHC in low- and middle-income countries. The World Bank produced one important compilation of such studies:

Universal Health Coverage Study Series (UNICO) ( http://www.worldbank.org/en/topic/health/publication/universal-health-coverage-study-series ).

As we all know, however, there is never enough time to cover all the materials that we want to cover or believe we must cover. I would probably expose my students to case studies of some of the following countries if I wanted them to see a range of efforts to achieve UHC:

  • High-income countries –The National Health System (NHS) of the United Kingdom and the social insurance systems of the Netherlands, Germany, and Taiwan.
  • Cuba – The last “completely government owned and operated system”
  • Africa – Ghana and its NHS style approach and Rwanda’s community-based insurance schemes
  • Latin America – Costa Rica’s national health system; Chile and its insurance program; Argentina and its Plan Nacer; Mexico and its efforts to achieve UHC through Seguro Popular; and Brazil and its efforts to create a more unified health system through the Sistema Unico do Saude
  • Southeast Asia – Thailand has been a “model” in many ways of a middle-income country that sought to achieve UHC in fair ways. Learning about the development of the Thai health system is important for any student of global health. It will also be interesting to follow the progress toward UHC in Indonesia and Vietnam, which appear to be learning much from the Thai experience.
  • Turkey – This country has made impressive gains in addressing UHC and in improving health outcomes related to UHC
  • China and India – Both China and India are of immense importance and following their efforts to develop UHC will also be very important, including learning from the important gaps they still face in meeting this goal.

Richard Skolnik, MPA -- Author of Global Health 101

Richard Skolnik, MPA, Author of Global Health 101

Richard Skolnik is the author or Global Health 101, Third Edition. He has spent over 40 years working in international development and health. He also taught global health to undergrads, and grad students in public health and business for 15 years at the George Washington University and Yale.

Brie Adderly, Robert Hecht, Greg Martin, and Rachel Strodel kindly offered comments in the draft of this blog.

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