The New Era of Health Goals: Universal Health Coverage as a Pathway to the Sustainable Development Goals

Abstract

Abstract—The inclusion of universal health coverage (UHC) as a target in the health Sustainable Development Goals speaks to its importance as both a foundational and an end goal for global health. Across the globe, countries are in varying stages of progress toward UHC. To help countries where there is a wide gap between the reality of limited access and the aspirations of universality, we must prioritize investments to progressively realize UHC. For these countries, we must focus on the poor at the outset. For countries in the midst of economic transition with greater capacity and resources, we must focus on mobilizing domestic resources to ensure sustainable financing for UHC. As members of the global health community, we must continue to invest in global public goods to properly support monitoring and measurement to track progress on UHC.

Keywords:

• development assistance for health
• domestic resource mobilization
• economic transition
• grand convergence
• measurement
• Sustainable Development Goals
• sustainable health financing
• universal health coverage

In September 2015, the United Nations General Assembly ushered us into a new era with the ambitious Sustainable Development Goals (SDGs). Access for all to appropriate medical and public health services without incurring financial hardship has been a key driver of global health. The inclusion of universal health coverage (UHC) as a target in the health SDGs speaks to its importance as both a foundational and an end goal for global health. The progressive realization of UHC will be a key component to reaching the topline SDGs to “ensure healthy lives and promote well-being for all, at all ages” and “end poverty in all its forms everywhere.”¹ In itself, achieving UHC, “including financial risk protection, access to quality essential health-care services and access to safe effective quality and affordable essential medicines and vaccines for all”¹ embodies the fundamental right of equitable access to countries' health systems and the universality pursued by the SDGs.

UHC enables countries to seize the historic opportunity to achieve a grand convergence in global health. The Lancet Commission on Investing in Health showed that the world can achieve a grand convergence in key health indicators between rich countries and the rest of the world, ending centuries of gross geographic inequalities.² UHC will help address health equity within countries. The resultant health improvements would yield contributions to economic growth; access to quality services for all also means access for the poorest; and financial protection means that seeking health care would no longer mean impoverishment and poverty traps. All of these contribute to ending preventable child and maternal deaths and removing catastrophic health expenditure as a top cause of extreme poverty.

UHC is not a pipedream for developing countries. Countries like Thailand, Rwanda, and Mexico show that the ambition of UHC is not just for high-income countries. Their leaders harness national political processes to fundamentally change the social contract in health. The political will to prioritize and implement UHC has yielded major gains in health and financial protection for their citizens. In doing so, these countries have seen a concurrent improvement in health outcomes and access for their poorest populations. In Thailand, for example, the introduction of its UHC reform in 2001 led to a reduction in infant mortality among the poor, with a potential overall 13% to 30% reduction between 2000 and 2002.³

We must support the progressive realization of UHC. The global population gap in coverage is enormous, although China's recent expansion of health coverage means that over half of the world now enjoys it. Many low- and middle-income countries fail to provide access to essential health services. At least 400 million people lack access to one of seven essential services for the Millennium Development Goals.⁴ To close this gap, we must focus at the outset on providing cost-effective public health and clinical interventions that tackle the greatest health threats to the poorest and most vulnerable populations. Tertiary care should become available as a country's economy, demand, and capacity grow but not at the expense of essential health services for all.

As countries' economies transition, the role of development assistance for health (DAH) will also evolve. DAH must be used to catalyze domestic financing and to help ministries of health organize the quality provision of public and private health services with equitable and sustainable financing for UHC. The demand for health care increases with economic growth. As DAH is diluted by domestic growth, governments typically lag in meeting the demand for health services (and insist on their public provision). This leads to a predictable explosion of unregulated private providers paid out of pocket—an inefficient and regressive form of financing, biased to urban medical care. Out-of-pocket spending reaches close to 35% and 60% of the total health expenditure in Africa and South Asia (the equivalent figure in advanced economies is under 15%), respectively.⁵ Paradoxically, reforming the health system and agreeing on a long-term blueprint for health financing is easier earlier in the economic transition, when vested interests and fiscal considerations are less challenging.

There is no standard prescription for achieving UHC. UHC depends on high-level political commitment, a high societal value placed on health, and effective evidence-based processes for policy development and implementation. Every country's history, culture, and political and fiscal situations combine to chart a unique path. Despite such heterogeneity, lessons are emerging on how to organize governance and financing arrangements to help countries at different stages of their UHC journey. Domestic resource mobilization (DRM) for health aims to accelerate organized contributions from the public and private sectors (excluding out-of-pocket spending), to increase pooled financing arrangements, and to improve spending efficiencies that are pro-poor and emphasize quality public health. The conversation around DRM is not just about raising resources. It is intrinsically linked to how those resources are used. DRM reorients the donor dialogue around how to organize financing for high-impact interventions and alters the suite of interventions that donors use to engage with government.

To manage mixed public–private financing and service delivery, arrangements will require greater stewardship capacity and new institutions in most developing countries. Not driven by any single disease program, UHC builds and is based on integrated platforms for primary health care and appropriate referral networks, careful planning of the health workforce skills mix, stronger information and performance systems, and new or merged risk financing pools.

Donors are not expected to pay for health insurance premiums but to support countries in their transition to a better and sustainable health system. We have both relied on and contributed to countries charting their health reforms and system investments on their way to UHC, with much progress in Latin America and Central and Eastern Asia. The United States Agency for International Development's own goals for international development, ending extreme poverty, and more specifically in global health to end preventable child and maternal deaths, achieve an AIDS-free generation, and protect communities from infectious diseases rely on the progressive realization of UHC. We are now intensifying our support for health finance and governance in Africa and South Asia, from community-based health insurance to national financing strategies commensurate with their economic transition. We see great experiments in India, successful models in Thailand, and inspiring schemes from Ghana to Ethiopia.

Health financing will progressively rely on domestic financing except in a small number of fragile states. One fundamental need for donors to continue to invest in is global public goods. This includes investments in tools to monitor progress and standardize measurement on UHC, including subnational and public–private health accounts. Normative guidance on the stewardship of mixed health systems is paramount, as well as better performance in supply chain and service delivery. Our investments in national health accounts have helped lay the foundation for identifying progress to date in identifying the financing challenges to achieving UHC. But more resources are needed to continue investing in measurement and analytic capacity to track progress and assure universalism. This includes moving beyond numbers and identifying the actors, decision points, and policy measures that are part and parcel of achieving UHC. More work is needed to be able to develop ways of evaluating the process of change in a systematic manner that provides lessons across countries.

Under the umbrella of the health Millennium Development Goals, we have had remarkable success with disease-specific, maternal health, and child survival goals and interventions. We need now to ensure greater attention to health systems strengthening to sustain progress and achieve the next era of health goals. This is critical for both countries on their way to UHC and countries with established UHC. Both will continue to expend considerable effort to adapt their systems to effectively respond to new challenges and ensure optimal health outcomes. Building a strong foundation helps developing countries prepare for emerging challenges such as noncommunicable diseases, the costs of integrating new health technologies, and the double-edged sword of the economic transition of health underway in many countries. As a rallying point for the global health community, including governments and civil society, UHC focuses our attention on prioritizing investments in health systems to prepare for new health challenges and also achieve national health goals and the SDGs.

DISCLAIMER

The views and opinions expressed in this article are those of the authors and not necessarily the views and opinions of the United States Agency for International Development.

DISCLOSURE Of POTENTIAL CONFLICTS Of INTEREST

There are no conflicts of interest.

Acknowledgments

The authors are grateful for comments from Randy Kolstad, Aye Aye Thwin, Scott Stewart, Kamiar Khajavi, and A. K. Nandakumar.