Countries are seeking to diversify sources of revenue for Universal Health Coverage (UHC), and strategies vary among countries at different stages on the road to UHC. The study tends to document these trade-offs by factoring successful economies across the globe. A review of peer-reviewed literature retrieved country-wise on the basis of successful UHC economies to establish the major factor associated with development of UHC. Political will has been recognized as one of the critical factors. Overcoming barriers associated with development of an adequate and sustainable financing mechanism and selecting the right package of services are other essential determinants. Reaching vulnerable groups and efficient use of resources were other factors that contributed to UHC development in Mexico and south-east Asian countries. UHC development is at threshold where nations should learn from one another, especially from those systems which appear to be doing better, and are more prepared to innovate, test and evaluate new approaches.
WHO’s constitution of 1948 declared “health a fundamental human right” and the Alma-Ata declaration in 1978 reinstated “Health for All” agenda. With equity constitutionalised as the most important feature of health systems, universality has become the next core principle of an Integrated Health System. This means that countries need to track progress of national population and provide health benefits to all groups irrespective of sex, age, place of residence, migrant status and ethnic origin [
Universal health coverage has a direct impact on a population’s health. It ensures access to health services and enables people to be more productive and active contributors to their families and communities. It provides financial risk protection by preventing out of pocket health expenditures. Universal health coverage thus, is a critical component of sustainable development and a key element of any effort to reduce social inequities [
The ideological foundation of UHC consists of three interrelated components: 1) the full spectrum of health services according to need; 2) financial protection from direct payment for health services when consumed; and 3) coverage for the entire population as shown in
The WHO states (verbatim): “For a community or country to achieve universal health coverage, several factors must be in place, including: 1) A strong, efficient, well-run health system that meets priority health needs through people-centred integrated care (including services for HIV, tuberculosis, malaria, non-communicable diseases, maternal and child health) by: ・ informing and encouraging people to stay healthy and prevent illness; ・ detecting health conditions early; ・ having the capacity to treat disease; and ・ helping patients with rehabilitation 2) Affordability: a system for financing health services so people do not suffer financial hardship when using them. This can be achieved in a variety of ways. 3) Access to essential medicines and technologies to diagnose and treat medical problems. 4) A sufficient capacity of well-trained, motivated health workers to provide the services to meet patients” needs based on the best available evidence. |
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and management should be separated from provisioning [
Analysis of UHC has been conducted by many disciplines using a variety of methods, ranging from economics, sociology, political sciences, to public health. Of these traditions, we attempted to factor successful UHC economies and what made their healthcare system fruitful irrespective of main theoretical positions that have been previously identified to explain the expansion of health coverage. This article tends to describe main themes and determinants in the literature on UHC’s successful implementation, drawing on illustrative examples of the leading paradigms of thought from various countries.
How Were These Studies Chosen?This paper draws on the expertise of the health systems for countries where apparent progress has been made to provide universal health coverage. This is a rapid review of the health literature (grey and peer-reviewed articles). For published articles, both empirical and review, searches were conducted on PubMED and Google Scholar as well as specific journals focusing on positive impact of universal health coverage in various countries across the globe. The following key words were used for searches: “universal health coverage”, “universal coverage”, “health care financing”, “health financing reforms”, “insurance”, “impact”, “demand-side financing”, “health”, “access”, “equity”, “equality” and “efficiency”. The search limits included all articles published since 2000 in English. The research strategy was borrowed from another work on UHC [
a) What Does It Take to Develop a UHC System?
Each country unravels its own unique path towards UHC, driven by its own history, politics, and existing health and financing structures. Therefore, though strategies that countries adopt to achieve UHC vary yet in planning their programs, countries typically weigh three dimensions of coverage expansion: who (breadth of cube―extent of the population covered), which services (depth of cube―proportion of services covered), and what proportion of costs will be covered (height of cube―extent of financial protection) of health coverage [
a1) Political Will and Economy
As political scenario of a state is responsible for enabling or constraining social and economic reforms, political will has been recognized as one of the critical factors for UHC development. As UHC reforms intentionally redistribute resources in the health sector and across households, these policies inevitably involve political trade-offs and negotiations [
a2) Where It Worked
Bangladesh and Ethiopia have emerged as clear examples of how social and political support can overcome macroeconomic constraints to realize their policy goal of adopting UHC. This has been recognised as an expression of national aspirations and as a means to mobilize efforts towards health reforms [
1) Lack of political will and understanding of social determinants that undermine access for vulnerable and marginalized groups 2) Insufficient attention has been paid to the interaction of social determinants of health and health financing 3) There is an emphasis on equity, McKee and colleagues were of the opinion that some groups have higher health needs and lower financing capabilities than others; this implies the need for picking the right package for fitting the need of the population and increasing uptake with coverage. 4) The idea is find money, to understand how to mobilize the revenues to provide and sustain coverage; establishment of effective pooling and redistributive mechanisms to ensure equity and financial protection; and building of capacities to manage future expenditures as presented by Reich and co-workers. |
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Ghana has established a national health insurance program as a platform for creating a unified risk pool through National Health Insurance Scheme, which integrated multiple community based plans under a single national program [
b1) Securing Sustainable Financing
Health care is costly. Out-of-pocket payments and financial catastrophe or impoverishment are major financial barriers that prevent people from seeking and receiving needed health services. When states adopted the resolution of providing universal coverage, their first huddle was to develop an adequate and sustainable financing mechanism for health services [
b2) Where It Worked
France and Japan have reduced overreliance on payroll taxes and have included other forms of tax revenues to sustain UHC [
Countries are seeking to diversify sources of revenue for UHC, and strategies vary among countries at different stages on the road to UHC. It is the combination of specific rules in revenue collection, pooling and purchasing as well as the effectiveness of organizations in implementation determines the efficiency of a health financing system [
c1) Selecting the Right Package of Services
WHO recommends that benefits included in UHC schemes of countries should be comprehensive, prioritize prevention and primary care, and address the diseases most prevalent in the area being considered [
c2) Where It Worked
Countries should strive to ease into increased services coverage. In Thailand and Turkey, for example, effective policies included a balanced approach to prioritizing services and medicines for benefits package expansion, strong negotiation with pharmaceutical companies, and the leveraging of provider payment systems so as to bring more benefits to more people [
d1) Reaching Vulnerable Populations
Identifying and reaching disadvantaged populations and estimating unmet need is another crucial component for UHC systems [
d2) Where It Worked
Japan and some other European countries started their coverage expansions with formal sector workers for ease of taxation and identification [
e1) Efficient Use of Resources
Cost, safety, and availability of resources are key components of sustainable universal health coverage systems for it is a challenge to efficiently using these scarce health resources [
e2) Where It Worked
In Europe, national decision makers have had to develop strategies to deal with resource scarcity and infrastructure insufficiency along with the controlling the cost of the human resources (e.g. salaries) to ensure universal access to health care and equitable geographical distribution of resources [
f1) Integrating and Strengthening Health Systems
Universal health coverage has the potential to provide additional resources for strengthening health systems by establishing integrated and comprehensive healthcare systems. UHC also needs a component of preventive care to deal with communicable diseases and set standards for care which need to be enforced. This is in response to the presence of broken health systems in countries like India with huge gaps in supply and infrastructure, and human resources [
f2) Where It Worked
Integration of health system is a challenge for most countries firstly due to medical pluralism especially in LMIC’s and also to various political and cultural values of a country, which drive the choices undertaken in UHC. For example core features of Canadian health care are enshrined federally, in the Canada Health Act which unified public administration, comprehensiveness, universality, portability, and accessibility. From the patient’s standpoint, with exceptions, such as home care, long-term care, dental care, physiotherapy and pharmaceuticals, the system is free of charges for hospital and medical care, thereby approaching the aim of “reasonable access to health services without financial or other barriers”. Yet, WHO’s landmark study from 2000 of health systems performance in almost 200 countries, ranked the UK in 18th place, Canada in 31st place, and the US (the most expensive health care in the world) in 37th place. Most European countries performed better than Canada [
Making quality, affordable health services available to an entire population is a
difficult undertaking―one that entails a variety of resource and implementation challenges and requires sustained political will [
UHC is being called the third global health transition; it has emerged as the single most powerful concept that public health has to offer. It is inclusive and sole tool to establish continuum of care by linking strategies to equities. It has the potential to unify services and delivers them in a comprehensive way as seen in France which combines private and public sectors to provide UHC as has received prime rank in doing so or Japan that ranks 10 and runs an employer-based system or through the national health care program. Lessons can also be learnt from UK’s NHS for it has been lauded its quality of care, efficiency and low cost at the point of service. These economies have proved that universal coverage is the hallmark of a government’s commitment to improve the wellbeing of all its citizens. The whole ideas is to learn lessons from countries with successful health systems and best practices to shape one’s own journeys to UHC, making adjustments and adaptations as they build experience. We suggest that the focus should be on the groundwork, which needs to be carefully laid, so the services and facilitates provided under UHC are able to meet the health needs of all being covered by it regardless of how it is being funded, when and who paid for it. The concern is that in order for it to be a successful UHC, it should be that these services are accessed by all people when needed. For an effective UHC strategy:
1) Focus on vulnerable groups must be assured.
2) UHC must not be a choice but prioritised involving political forces, bureaucracy and stakeholders alike.
3) Emphasis should be laid on strengthening, the three pillars of UHC systems making it accessible, affordable and a quality product.
4) Eliminate barriers to access and lay its foundations on equity
5) Countries spending less than 3% of GDP in public expenditure should commit to increase funding by 0.3% especially for low and middle income countries [
6) Foundations for paying for UHC may rise from national funds, but strategies must be designed to include private sector through regulations and partnerships.
7) Establish strict accountabilities and a lucid priority-setting technique to define what will be included in the UHC service package for every country which should be fluid and adaptable [
The most important point is whether fundamental equity or should equality be the bedrock of health in country―that everyone should have basic health insurance coverage or a certain vulnerable group should be pushed up the ladder. For decades after countries made a commitment to health, it is a good time to include the rest of the people who remain left out.
The authors declare that they have no competing interests.
Bhasin, P. and Bhardwaj, R. (2018) Universal Health Coverage: Factoring Successful Economies. Health, 10, 1018-1030. https://doi.org/10.4236/health.2018.107076