The Three Pillars
Progress towards UHC requires government action in three main areas:
Countries that have been successful in introducing national health systems have done so by pooling funds so that the cost of healthcare is shared more equally across society. This can be done by using income tax, or by asking every citizen to pay into a national insurance scheme according to how much they earn. Many countries provide free health care to those who are not earning, including children and young people, the elderly and those on low incomes. For example, Mexico has been able to move towards UHC by increasing government – or public – spending on health by an average of 5% annually from 2000 to 2006.
Domestic Health Financing Mechanisms
How do countries pay for healthcare? In countries with national health systems, this is done through taxation (for example, in Brazil, Thailand and the UK) or other government income (for example, in Bahrain, Kuwait and the UAE). However, many countries also have national health insurance schemes, whereby citizens pay an annual membership fee (for example, in Belgium and Ghana). Some countries, including Kenya and Tanzania, are considering innovative financing mechanisms. Botswana for example has used a tax on alcohol since 2008 to fund the Ministry of Health and other initiatives.
To achieve UHC, governments also need to promote different sectors to work together to address the non-medical causes of ill-health and disease, such as low education, conflict, discrimination and poverty. Research has shown that these social causes (known as social determinants of health ) can be more important than health care or lifestyle choices in influencing health.
While health financing and service delivery are essential, health system governance is critical for success. Without good governance, UHC implementation can become narrowly defined, inequitable and ineffective. According to WHO, effective health governance requires the full engagement of three key stakeholders:
- The State (government organizations and agencies at central and district level)
- Health service providers (public and private, for and not for profit, clinical, para-medical and non-clinical health services providers; unions and other professional associations; networks of care or of services)
- The citizen (population representatives, patients’ associations, CSOs, NGOs, citizens associations protecting the poor, grassroots advocates, etc.)
Good governance involves dialogue between the government and its people, not only to build trust and enable effective implementation, but also to ensure that reforms are co-owned by populations, communities and civil society.
To achieve equitable policies for health, citizen’s voices must be strengthened and fostered with meaningful roles in decision-making. There must be policy and legal frameworks that protect against discriminated health service delivery, regulate the sector appropriately, and allow transparent governance. Lastly, it is important to build coalition-building and opportunities for collective action and partnership.
The importance of civil society participation in UHC planning, implementation and monitoring is explored in more depth in Part Two: Why civil society should engage in UHC.
National health policies, strategies and plans (NHPSPs)
This is a generic term for the range of national government health policies, strategies and health plans that set out policy on health reform and UHC. NHPSPs ensure that countries allocate domestic resources efficiently and fairly, and that domestic budgeting for health is consistent and predictable.
“Planning is often made into something complicated, a mystery wrapped in jargon, process and politics. Planning is sometimes left to the professional planners or the managers to control and do. That is a mistake. The best operational plans, and certainly the ones most likely to be implemented, are those that are developed with the people who will carry them out.”
– Strategizing National Health in the 21st Century: A Handbook | A UHC Partnership Resource, UHC Partnership
All CSOs, NGOs and CBOs responsible for health service provision or programmes should be involved in operational planning, either directly or through having their interests represented by someone involved in the formal planning process. Patients or the end users of a health system are also key stakeholders and should therefore also be engaged in the development of operational plans.
How UHC Works: Three Dimensions
WHO encourages countries to see their health reforms as an ongoing journey in which they aim to make continuous progress towards UHC. One of the most helpful ways to think about the strategic choices facing governments as they undertake this journey is the cube used by WHO in the World Health Report of 2010.
This diagram proposes that governments plan their UHC strategies taking into account three key policy questions, making up the three dimensions of the cube:
- Who in the population is covered?
- What services are they covered by – and at what level of quality?
- What level of financial protection do citizens have when accessing services?
Health Benefit Package
The services that are to be covered by the government as part of the UHC are described as the ‘Health Benefit Package’. Also referred to as the essential health services package (EHSP) or minimum health benefit package, this is the core set of services that a government considers essential to meet the health needs of the population and for which they are willing to pay.
The content of the health benefit package should be informed by three considerations:
- Equity – ensuring equal and fair access to services
- Disease burden profile – the main health needs of the population
- Cost-effectiveness analysis – aiming to achieve the greatest impact given the available resources
Global Political Commitment
In 2015, all countries in the world committed to achieve UHC by 2030 as part of the Sustainable Development Goals (SDGs). It is a truly global goal in that there is scope for improvement in all countries, even where there is national health insurance or where health services are already provided free of cost to all citizens.
Progress on this goal is measured by the population covered by essential health services and the number of people who experience financial hardship from health costs.
SDG 3: Good Health and Wellbeing: Ensure healthy lives and promote well-being for all at all ages
Target 3.8: Achieve universal health coverage, 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.
- Indicator 1: Coverage of essential health services
- Indicator 2: Proportion of population with large household expenditures on health as a share of total household expenditure or income
This global commitment was confirmed again in 2019 at the UN High Level Meeting (HLM) on UHC, with the resulting Political Declaration (link) setting out the “most comprehensive set of health commitments ever adopted.”
Brazil provides free, universal access to medical care to anyone legally living in the country. Known as SUS (Sistema Único de Saúde), the Unified Health System was created in 1989 and is the largest non-discriminatory government-run public health care system in the world.
The SUS is a decentralized system managed by Brazilian states and municipalities. To access healthcare, a National Health Identification card is required so that medical records can be coordinated between public and private services. More than 80% of the Brazilian population depend on SUS to receive medical treatment.
Health is a right of all and an obligation of the State, guaranteed by socio-economic policies which seek to the reduction of the risk of disease and of other grievances and to the universal and equal access to the actions and services in its promotion, protection and recuperation.
– Constitution of Brazil, 1988
In 2004, Ghana introduced the first National Health Insurance Scheme (NHIS), a system funded by government tax income and individual memberships. The scheme covers 95% of diseases, including treatment for malaria, respiratory diseases, diabetes and hypertension. Children and the elderly are exempt from paying the annual fee, which for adults ranges between 7.2 Ghanaian Cedis (GH¢) and 48 GH¢ ($2.0–$10 USD), based on income and ability to pay. In 2017, the scheme was covering 47% of the population.
In December 2020, Ghana finalized a UHC Roadmap committing the country to attaining at least 80% coverage of citizens to essential health services by 2030.
The involvement of communities in the design, planning and development of health interventions facilitates the achievement of high levels of commitment, ownership and empowerment of communities to champion interventions to improve their own health.
– National Health Policy 2020-2030, Ghana
Japan celebrated its 50th anniversary of achieving UHC in 2011. All residents are required by the law to have health insurance coverage, either through their employer or via the government Citizens Health Insurance scheme.
The health insurance system is funded through taxation and individual contributions. Under the government system, the patient must pay 30% of the costs, unless you are on a low income, or have a chronic condition or disability. This can be covered by private health insurance. Medical fees are strictly regulated by the government to keep them affordable.
Lessons from COVID-19
The COVID-19 pandemic has clearly shown the linkages between health systems, emergency preparedness, and economic development, exposing major weaknesses in and lack of investment in many of the world’s health systems.
To protect both the health of their citizens and health systems from becoming overwhelmed, governments have had to implement drastic strategies, such as lockdowns and curfews. The pandemic and these response strategies have negatively affected the livelihood and well-being of all people, especially marginalized and vulnerable population groups, making existing gaps in access to health wider.
Global health security is threatened by a lack of political will and investment in UHC. With deep economic recessions in lower income countries due to COVID-19, health budgets are likely to be hit more than during the 2008 economic crisis. According to the recent GHE report, countries with health systems that depend on out-of-pocket payments are likely to be among those worst hit by the macro-economic impacts of the pandemic – lowering their public spending even further.
In addition, the consequences of COVID-19 on affected individuals, including the long-term physical impacts and financial burdens, and the consequences of disruptions to other health services are still not fully understood. While the focus in most countries is currently still on immediate emergency response, it would be an error to consider moving back to business as usual and miss the opportunity to analyse the political and policy failures that contributed to the severe impact of the COVID-19 pandemic.
Key resource: For more information on the links between COVID-19 and UHC, see the recent CSEM paper on Health and economic impacts of COVID-19 containment strategies.