What does universal health coverage mean?

The recent UN General Assembly resolution calling for universal health coverage (UHC) was testimony to the continuing high-level political commitment to achievement of global health goals—an achievement that has the potential to transform health systems, especially for the poorest people. Fulfi lment of this potential, however, requires a clear defi nition of the term UHC otherwise it could suff er the same fate of the refrain of Health for All, which received high-level political support but failed to produce suffi ciently widespread policy and budgeting changes to realise its aims. Ambiguously, UHC has been labelled universal health coverage (the term used in this Viewpoint), universal health care, universal health-care coverage, or universal coverage. Descriptions of what UHC entails are equally diverse, with no consistent framework to guide policy makers seeking improved equity of access and use of services to achieve more equitable health outcomes. Such imprecision can lead to unintended policy consequences. For example, UHC is often used to mean an expansion of service provision or health fi nancing to remove access barriers. This notion is exemplifi ed in the UN General Assembly resolution that adopted the language of a 2005 World Health Assembly resolution background paper describing UHC as “access to key promotive, preventive, curative and rehabilitative health interventions for all at an aff ordable cost, thereby achieving equity in access”. This description seems to imply that equity is a natural consequence of implementation of UHC policies. However, examples from country implementation show that the extent to which equity is improved through UHC policies is conditional on how UHC terms and policies are defi ned, designed, implemented, and sequenced. An empirically grounded framework to guide defi nition of each word in UHC is needed upfront to establish practical boundaries on what policies can achieve, creating a normative and operational means by which to gauge national strategies and progress. Otherwise, important considerations that should aff ect policy outcomes could remain unaddressed. We suggest that the starting point of such a framework is to defi ne each term—universal, health, and coverage—that provokes discrepancies in interpretation. These areas of uncertainty hinder the ability to develop a consensus about what UHC means, and make it diffi cult to create an objective set of UHC metrics, which is needed well before analysis and eff ective resolution of the barriers to UHC can occur. In the context of UHC, the term universal has been defi ned as a legal obligation of the state to provide health care to all its citizens, with particular attention to ensure inclusion of all disadvantaged and excluded groups. Yet, noble as a commitment to universality sounds, it might do little to change policies under which many governments either deliberately or passively refuse to grant access to health services to some people living within their national borders. So-called stateless people, such as refugees, undocumented migrants, nomadic people, or those denied birth registration, are often seen by authorities as without legal entitlement to any rights to health care. Other people are excluded because of systematic discrimination based on disability, sex, sexual orientation, religion, ethnic origin, or political affi liation. Being female, or a member of a religious or ethnic minority, can be the basis for denial of access to health and other social services even for legal citizens. If UHC is to be a credible development benchmark, there must be clarity about how global aspirations of health for all are balanced against how a state defi nes citizenship and sets limits to its obligations under UHC. Health is another contested term. The UN General Assembly resolution implies a much broader defi nition of health than provision of basic or essential health services could achieve. It calls for UHC and social health insurance to deliver equitable opportunities for the “highest attainable standard of physical and mental health” including “work on determinants of health”. This perspective is strongly supported by civil society groups desiring global UHC targets that would oblige and support national action on social determinants to reduce inequities, and mandate actions beyond the health sector. However, in most countries the move towards UHC gradually expands access starting from a narrow set of essential health services that are accessible to public and private sector wage earners. But this approach has often increased health inequities since these groups are more likely to access these services than are poor people or those working in informal sectors. To address inequities, experiences from countries that have adopted a broader defi nition of health indicate that UHC policies might require, at a minimum, establishment of a comprehensive social health platform that provides a continuum of care across an individual’s lifespan for communicable and non-communicable diseases. This platform would encompass other essential policies, such as those for childhood nutrition and education, occupational health, retirement health insurance, and, in some countries, traditional health systems. This approach, however, would require buy-in from a range of sectors and ministries who might have diffi culty regarding health as their primary concern. Clarity is needed about how much of health UHC policies address, whether or not they include other sectors, and, correspondingly, what degree of health inequities UHC can plausibly act upon. Lancet 2014; 383: 277–79