Health systems

Questions and Answers on Universal Health Coverage

Q&A on UHC

Q: What does universal health coverage mean?

Universal health coverage means that all people have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) without the risk of financial hardship when paying for them.

This requires an efficient health system that provides the entire population with access to good quality services, health workers, medicines and technologies. It also requires a financing system to protect people from financial hardship and impoverishment from health care costs.
Access to health services ensures healthier people; while financial risk protection prevents people from being pushed into poverty. Therefore, universal health coverage is a critical component of sustainable development and poverty reduction, and a key element to reducing social inequities.
Universal health coverage is not something that can be achieved overnight, but all countries can take action to move more rapidly towards it, or to maintain the gains they have already made.

Q: What is needed to achieve it?

For a community or country to achieve universal health coverage, several factors must be in place including:

  • A strong, efficient, well-run health system that meets priority health needs through people-centred integrated care 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
    • ensuring sensitive palliative care where needed.
  • Affordability – a system for financing health services so people do not suffer financial hardship when using them.
  • Availability of essential medicines and technologies to diagnose and treat medical problems.
  • A sufficient capacity of well-trained, motivated health workers to provide the services to meet patients’ needs based on the best available evidence.
  • Actions to address social determinants of health such as education, living conditions and household income which affect people’s health and their access to services.

Q: What services should be included in universal health coverage?

Essential health services (including for HIV, tuberculosis, malaria, non-communicable diseases and mental health, sexual and reproductive health and child health) should be available to all who need them.

The dilemma for most countries, in particular low-income countries, is that they are not able to provide everyone with all the health services they need at an affordable price, even with the large increases in external donor assistance for health since 2000.

The goal should be to provide an increasing number of health services over time while at the same time reducing out-of-pocket costs to patients. Decisions about the services that can be guaranteed to the population initially, and which ones should be added over time, are based on peoples’ needs, public opinion and costs.

The priority should be to ensure access to the key interventions targeting the health Millennium Development Goals – births attended by a trained health worker, family planning, vaccinations, and prevention and treatment of diseases such as HIV, malaria and tuberculosis – while considering how to address the growing problem of noncommunicable diseases.

Q: How this can be financed?

Universal health coverage is fundamental to ensuring social protection for health. The poorest populations often face the highest health risks and need more health services.

A key element of financing for universal health coverage is sharing resources to spread the financial risks of ill-health across the population.

The system should collect large pools of prepaid funds that can be used to cover the health care costs of those in need, regardless of their ability to pay.

The countries that have made the most progress on providing universal health coverage have implemented mandatory contributions for people who can afford to pay through taxation, and/or compulsory earmarked contributions for health insurance.

Reducing the reliance on direct, out-of-pocket payments lowers the financial barriers to access and reduces the impoverishing impact of health payments.

Q: Are the most vulnerable people covered?

In terms of financial protection, the most vulnerable people should have access to the health services they need without restrictions. In all countries, it has been found that governments have to use general budget revenues to meet the health costs (and/or insurance premiums) of poor and vulnerable people.

Ensuring access to health facilities, workers and medicines in remote, rural areas is also important, as is providing special interventions for stigmatized populations.

Universal coverage is firmly based on the WHO Constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma-Ata declaration in 1978. Equity is paramount. This means that countries need to track progress in providing access not just across the national population but within different groups (e.g. by income level, sex, age, place of residence, migrant status and ethnic origin).

Q: Isn't it too ambitious? Are countries succeeding in implementing?

Countries at all income levels can take steps to move closer to universal health coverage.

  • Nepal, where free universal health care was introduced in 2008, is now on track to achieve its health-related MDGs.
  • In 2008, the Afghan Government, using considerable donor funding, removed user fees in public health facilities and healthcare utilization more than doubled.
  • Thailand has just celebrated ten years of its universal coverage scheme which has dramatically reduced impoverishment caused by out-of-pocket payments.
  • More recently, El Salvador has launched an ambitious plan to expand health coverage including abolishing user fees and strengthening primary health care in remote and poor rural areas.
  • Other countries moving forward in Africa include Liberia, Gabon, Ghana, Sierra Leone and Rwanda.

Q: How can we measure universal health coverage?

As universal health coverage is a combination of whether people obtain the health services they need and financial risk protection, measurement needs to include both components. Coverage of health services can be measured by the percentage of people receiving the services they need: for example women in fertile age groups accessing modern methods of family planning or children immunized. On the other hand, financial risk protection can be evaluated by a reduction in the number of families pushed into poverty or placed under severe economic strain due to health costs. The impact of these steps on population health and household financial wellbeing can also be measured, as can many of the factors that make it easier to increase coverage. These include the availability of essential medicines, for example.

The main challenge is that many countries do not have the capacity to measure coverage of all of the many health interventions that their populations needs. So they will need to choose a set of key indicators to track performance in service coverage. A sub-set of these could be used to compare performance between countries.

Q: What is the impact of universal health coverage on the population?

Universal health coverage has a direct impact on a population’s health and welfare. Access and use of health services enables people to be more productive and active contributors to their families and communities. It also ensures that children can go to school and learn. At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets.

Universal health coverage is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities. Universal coverage is the hallmark of a government’s commitment to improve the wellbeing of all its citizens.

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