Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates

BMC International Health and Human Rights

Manuela De Allegri²  Gilbert Abotisem Abiiro¹ 

[1] Department of Planning and Management, Faculty of Planning and Land Management, University for Development Studies, University Post Box 3, Wa, Upper West Region, Ghana;Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany

关键词: Global debates;    Conceptual literature;    Health system;    Access to health services;    Financial protection;    Population coverage;    Rights-based;    Multi-dimensional concept;    Universal health coverage;   

Others  :  1218617
DOI  :  10.1186/s12914-015-0056-9

 received in 2015-01-15, accepted in 2015-06-29,  发布年份 2015

【 摘 要 】

Background

There is an emerging global consensus on the importance of universal health coverage (UHC), but no unanimity on the conceptual definition and scope of UHC, whether UHC is achievable or not, how to move towards it, common indicators for measuring its progress, and its long-term sustainability. This has resulted in various interpretations of the concept, emanating from different disciplinary perspectives. This paper discusses the various dimensions of UHC emerging from these interpretations and argues for the need to pay attention to the complex interactions across the various components of a health system in the pursuit of UHC as a legal human rights issue.

Discussion

The literature presents UHC as a multi-dimensional concept, operationalized in terms of universal population coverage, universal financial protection, and universal access to quality health care, anchored on the basis of health care as an international legal obligation grounded in international human rights laws. As a legal concept, UHC implies the existence of a legal framework that mandates national governments to provide health care to all residents while compelling the international community to support poor nations in implementing this right. As a humanitarian social concept, UHC aims at achieving universal population coverage by enrolling all residents into health-related social security systems and securing equitable entitlements to the benefits from the health system for all. As a health economics concept, UHC guarantees financial protection by providing a shield against the catastrophic and impoverishing consequences of out-of-pocket expenditure, through the implementation of pooled prepaid financing systems. As a public health concept, UHC has attracted several controversies regarding which services should be covered: comprehensive services vs. minimum basic package, and priority disease-specific interventions vs. primary health care.

Summary

As a multi-dimensional concept, grounded in international human rights laws, the move towards UHC in LMICs requires all states to effectively recognize the right to health in their national constitutions. It also requires a human rights-focused integrated approach to health service delivery that recognizes the health system as a complex phenomenon with interlinked functional units whose effective interaction are essential to reach the equilibrium called UHC.

【 授权许可】

   
2015 Abiiro and De Allegri.

【 参考文献 】

• [1]Garrett L, Chowdhury AMR, Pablos-Méndez A. All for universal health coverage. Lancet. 2009; 374:1294-9.
• [2]The World Health Report 2010 - Health Systems Financing: the path to universal coverage. World Health Organization, Geneva; 2010.
• [3]Mills A, Ally M, Goudge J, Gyapong J, Mtei G. Progress towards universal coverage: the health systems of Ghana, South Africa and Tanzania. Health Policy Plan. 2012; 27(suppl 1):i4-12.
• [4]Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013; 91:602-11.
• [5]Global Health and Foreign policy. Agenda item 123. The Sixty-seventh session (A/67/L.36). United Nations, New York; 2012.
• [6]Sustainable health financing, universal coverage and social health insurance. World Health Organization, Geneva; 2005.
• [7]WHO. World Health Report 2008 - primary health care - now more than ever. Geneva: World Health Organization; 2008.
• [8]WHO World Health Report 2013: research for universal health coverage. World Health Organization, Genena; 2013.
• [9]Reddy KS, Patel V, Jha P, Paul VK, Kumar AKS, Dandona L. Towards achievement of universal health care in India by 2020. A call to action. Lancet. 2011; 377:760-8.
• [10]Gorin S. Universal health care coverage in the United States: Barriers, prospects, and implications. Health Soc Work. 1997; 22:223-30.
• [11]Collet T-H, Salamin S, Zimmerli L, Kerr EA, Clair C, Picard-Kossovsky M et al.. The quality of primary care in a country with universal health care coverage. J Gen Intern Med. 2011; 26:724-30.
• [12]O’Connell T, Rasanathan K, Chopra M. What does universal health coverage mean? Lancet. 2013; 6736:13-5.
• [13]de Noronha JC. Universal health coverage: how to mix concepts, confuse objectives, and abandon principles. Cad Saúde Pública. 2013; 29:847-9.
• [14]Kieny M-P, Evans DB. Universal health coverage. East Mediterr Health J. 2013;19:305-6.
• [15]Stuckler D, Feigl AB, Basu S, McKee M. The political economy of universal health coverage. Background paper for the global symposium on health systems research. World Health Organization, Geneva; 2010.
• [16]Bärnighausen T, Sauerborn R. One hundred and eighteen years of the German health insurance system. Are there any lessons for middle-and low-income countries. Soc Sci Med. 2002; 54:1559-87.
• [17]Savedoff W, de Ferranti D, Smith A, Fan V. Political and economic aspects of the transition to universal health coverage. Lancet. 2012; 380:924-32.
• [18]McKee M, Balabanova D, Basu S, Ricciardi W, Stuckler D. Universal health coverage: a quest for all countries but under threat in some. Value Health. 2013; 16(1, Supplement):S39-45.
• [19]Constitution of the World Health Organization. World Health Organisation, Geneva; 1948.
• [20]Declaration of Alma-Ata. International Conference on Primary Health Care, Al ma-Ata, USSR, 6–12 September 1978.http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf. Accessed 4 May, 2015.
• [21]Bristol N. Global action towards Universal health coverage: a report for the CSIS Global Health Policy Center. Centre for strategic and International Studies, Washington DC; 2014.
• [22]Oxfam. Universal Health Coverage : Why health insurance schemes are leaving the poor behind. Oxford: Oxfam International; 2013.
• [23]World Bank WHO. WHO/World Bank Ministerial-level Meeting on Universal Health Coverage 18–19 February 2013. World Health Organization’s headquarters, Geneva; 2013.
• [24]Monitoring Progress towards Universal Health Coverage at Country and Global Levels: A Framework. Joint WHO/World Bank Group Discussion Paper. World Health Organization, Geneva; 2013.
• [25]Towards Universal Health Coverage by 2030. World Bank Group, Washington DC; 2014.
• [26]Latko B, Temporão JG, Frenk J, Evans TG, Chen LC, Pablos-Mendez A et al.. The growing movement for universal health coverage. Lancet. 2011; 377:2161-3.
• [27]Borgonovi E, Compagni A. Sustaining universal health coverage: the interaction of social, political, and economic sustainability. Value Health. 2013; 16(1, Supplement):S34-8.
• [28]Kutzin J. Anything goes on the path to universal health coverage? No. Bull World Health Organ. 2012; 90:867-8.
• [29]Rodin J, de Ferranti D. Universal health coverage. The third global health transition? Lancet. 2012; 380:861-2.
• [30]Chan M. Best days for public health are ahead of us, says WHO Director-General. Address to the 65th World Health Assembly, Geneva, Switzerland; 2012.
• [31]Lee Y-C, Huang Y-T, Tsai Y-W, Huang S-M, Kuo KN, McKee M et al.. The impact of universal National Health Insurance on population health: the experience of Taiwan. BMC Health Serv Res. 2010; 10:225. BioMed Central Full Text
• [32]Moreno-Serra R, Smith PC. Does progress towards universal health coverage improve population health? Lancet. 2012; 380:917-23.
• [33]World Development Report 1993. Investing in Health. Oxford University Press, New York; 1993.
• [34]Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A et al.. Global health 2035: a world converging within a generation. Lancet. 2013; 382:1898-955.
• [35]Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet. 2012; 380:864-5.
• [36]D’Ambruoso L. Global health post-2015: the case for universal health equity. Global Health Action. 2013;6:19661.
• [37]Sheikh M, Cometto G, Duvivier R. Universal health coverage and the post 2015 agenda. Lancet. 2013; 381:725-6.
• [38]Adopting consensus text, General Assembly encourages member states to plan, pursue transition of National Health Care Systems towards Universal Coverage. Sixty-seventh General Assembly Plenary 53rd Meeting (AM). Department of Public Information • News and Media Division, New York; 2012.
• [39]Vega J. Universal health coverage. The post-2015 development agenda. Lancet. 2013; 381:179-80.
• [40]Victora C, Saracci R, Olsen J. Universal health coverage and the post-2015 agenda. Lancet. 2013; 381:726.
• [41]Sengupta M. Universal Health Coverage: Beyond rhetoric. In: McDonald DA, Ruiters G, editors. Municipal Services Project, Occasional Paper No 20 - November 2013. http://www.alames.org/documentos/uhcamit.pdf. Accessed 14 May, 2015.
• [42]Holmes D. Margaret Chan: committed to universal health coverage. Lancet. 2012; 380:879.
• [43]Horton R, Das P. Universal health coverage: not why, what, or when—but how? Lancet. 2014; 384:2101.
• [44]Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 2012; 380:933-43.
• [45]The Right to Health: Joint Fact Sheet WHO/OHCHR/323. World Health Organization, Geneva; 2007.
• [46]International Covenant on Economic, Social and Cultural Rights: Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 entry into force 3 January 1976, in accordance with article 27. United Nations, New York; 1966.
• [47]Young S. The United Nations Convention on the Rights of the Child: An Introduction -A Middle School Unit (Grades 6–8). Fund for UNICEF/Mia Brandt, U.S. Malawi; 2006.
• [48]Convention on the Rights of Persons with Disabilities. United Nations, New York; 2006.
• [49]Convention on the Elimination of All Forms of Discrimination against Women. United Nations, New York; 1979.
• [50]Bárcena A. Health protection as a citizen’s right. Lancet. 2014; 6736:61771-2.
• [51]Scheil-Adlung X, Bonnet F. Beyond legal coverage: assessing the performance of social health protection. Int Soc Secur Rev. 2011; 64:21-38.
• [52]Forman L, Ooms G, Chapman A, Friedman E, Waris A, Lamprea E et al.. What could a strengthened right to health bring to the post-2015 health development agenda?: interrogating the role of the minimum core concept in advancing essential global health needs. BMC Int Health Hum Rights. 2013; 13:48. BioMed Central Full Text
• [53]Fried ST, Khurshid A, Tarlton D, Webb D, Gloss S, Paz C et al.. Universal health coverage: necessary but not sufficient. Reprod Health Matters. 2013; 21:50-60.
• [54]Hammonds R, Ooms G. The emergence of a global right to health norm - the unresolved case of universal access to quality emergency obstetric care. BMC Int Health Hum Rights. 2014; 14:4. BioMed Central Full Text
• [55]Kingston LN, Cohen EF, Morley CP. Debate: limitations on universality: the “right to health” and the necessity of legal nationality. BMC Int Health Hum Rights. 2010; 10:11. BioMed Central Full Text
• [56]Yamin AE, Frisancho A. Human-rights-based approaches to health in Latin America. Lancet. 2014; 6736(14):61280.
• [57]Rosen G. A History of Public Health. John Hopkins University Press, Maryland; 1993.
• [58]Wilkinson R, Marmot M. Social determinants of health. The solid facts. World Health Organization, Copenhagen; 1998.
• [59]Marmot M, Wilkinson R. Social determinants of health. Oxford University Press, New York; 2005.
• [60]Social determinants of health: report by the Secretariat EB132/14. World Health Organization, Geneva; 2012.
• [61]McIntyre D. Health service financing for universal coverage in east and southern Africa, EQUINET Discussion Paper 95. Regional Network for Equity in Health in East and Southern Africa (EQUINET), Harare; 2012.
• [62]Ooms G. From international health to global health: how to foster a better dialogue between empirical and normative disciplines. BMC Int Health Hum Rights. 2014; 14:36.
• [63]Backman G, Hunt P, Khosla R, Jaramillo-Strouss C, Fikre BM, Rumble C et al.. Health systems and the right to health: an assessment of 194 countries. Lancet. 2008; 372:2047-85.
• [64]Ooms G, Latif LA, Waris A, Brolan CE, Hammonds R, Friedman EA, et al. Is universal health coverage the practical expression of the right to health care? BMC Int Health Hum Rights. 2014; 14:3.
• [65]Ooms G, Hammonds R. Financing Global Health Through a Global Fund for Health? Working Group on Financing PAPER 4. CHATHAM HOUSE (The Royal Institute of International Affairs), London; 2014.
• [66]Chen LC, Evans T, Cash R. Health as a global public good. In: Global public goods: international cooperation in the 21st century. Kaul I, Stern M, Grunberg I, editors. Oxford University Press, New York; 1999: p.284-304.
• [67]Frenk J, Gómez-Dantés O, Moon S. From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence. Lancet. 2014; 383:94-7.
• [68]Stuckler D, McKee M. Five metaphors about global-health policy. Lancet. 2008; 372:95-7.
• [69]Lencucha R. Cosmopolitanism and foreign policy for health: ethics for and beyond the state. BMC Int Health Hum Rights. 2013; 13:29. BioMed Central Full Text
• [70]Knaul FM, González-Pier E, Gómez-Dantés O, García-Junco D, Arreola-Ornelas H, Barraza-Lloréns M et al.. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet. 2012; 380:1259-79.
• [71]Universal health coverage post-2015: putting people first. Lancet. 2014; 384:2083.
• [72]Allotey P, Verghis S, Alvarez-Castillo F, Reidpath DD. Vulnerability, equity and universal coverage – a concept note. BMC Public Health. 2012; 12 Suppl 1:S2. BioMed Central Full Text
• [73]Ravindran TS. Universal access: making health systems work for women. BMC Public Health. 2012; 12 Suppl 1:S4. BioMed Central Full Text
• [74]Yates R. Universal health care and the removal of user fees. Lancet. 2009; 373:2078-81.
• [75]McIntyre D. What healthcare financing changes are needed to reach universal coverage in South Africa? SAMJ: S Afr Med J. 2012; 102:489-90.
• [76]Mills A, Ataguba JE, Akazili J, Borghi J, Garshong B, Makawia S et al.. Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage. Lancet. 2012; 380:126-33.
• [77]Rodney AM, Hill PS. Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success. Int J Equity Health. 2014; 13:1-72. BioMed Central Full Text
• [78]Goudge J, Akazili J, Ataguba J, Kuwawenaruwa A, Borghi J, Harris B et al.. Social solidarity and willingness to tolerate risk- and income-related cross-subsidies within health insurance: experiences from Ghana, Tanzania and South Africa. Health Policy Plan. 2012; 27(suppl 1):i55-63.
• [79]Hickey S, Du Toit A. Adverse incorporation, social exclusion and chronic poverty, CPRC Working Paper 81. Manchester, UK, Chronic Poverty Research Centre; 2007.
• [80]Abiiro GA, Mbera GB, De Allegri M. Gaps in universal health coverage in Malawi: a qualitative study in rural communities. BMC Health Serv Res. 2014;14:234.
• [81]Palmer N, Mueller DH, Gilson L, Mills A, Haines A. Health financing to promote access in low income settings—how much do we know? Lancet. 2004; 364:1365-70.
• [82]Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure. A multicountry analysis. Lancet. 2003; 362:111-7.
• [83]McIntyre D, Ranson MK, Aulakh BK, Honda A. Promoting universal financial protection: evidence from seven low-and middle-income countries on factors facilitating or hindering progress. Health Res Policy Syst. 2013; 11:36. BioMed Central Full Text
• [84]Kutzin J, Ibraimova A, Jakab M, O’Dougherty S. Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan. Bull World Health Organ. 2009; 87:549-54.
• [85]Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Affair. 2007; 26:972-83.
• [86]Cleary S, Birch S, Chimbindi N, Silal S, McIntyre D. Investigating the affordability of key health services in South Africa. Soc Sci Med. 2013; 80:37-46.
• [87]Moreno-Serra R, Millett C, Smith PC. Towards improved measurement of financial protection in health. PLoS Med. 2011; 8: Article ID e1001087
• [88]Dekker M, Wilms A. Health insurance and other risk-coping strategies in Uganda. The case of Microcare Insurance Ltd. World Dev. 2009; 38:369-78.
• [89]Kruk ME, Goldmann E, Galea S. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff. 2009; 28:1056-66.
• [90]Leive A, Xu K. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bull World Health Organ. 2008; 86:849-56.
• [91]Sachs JD. Achieving universal health coverage in low-income settings. Lancet. 2012; 380:944-7.
• [92]Adam T, Hsu J, de Savigny D, Lavis JN, Røttingen J-A, Bennett S. Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan. 2012; 27(suppl 4):iv9-19.
• [93]Rao KD, Ramani S, Hazarika I, George S. When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India. Health Policy Plan. 2014; 29:495-505.
• [94]Health in the framework of development: Technical Report for the Post-2015 Development Agenda. Sustainable Development Solutions Network: Global Inititative for the United Nation, New York; 2014.
• [95]Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974; 9:208-20.
• [96]Arnold C, Theede J, Gagnon A. A qualitative exploration of access to urban migrant healthcare in Nairobi, Kenya. Soc Sci Med. 2014; 110:1-9.
• [97]Dillip A, Alba S, Mshana C, Hetzel MW, Lengeler C, Mayumana I et al.. Acceptability – a neglected dimension of access to health care: findings from a study on childhood convulsions in rural Tanzania. BMC Health Serv Res. 2012; 12:113. BioMed Central Full Text
• [98]Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004; 19:69-79.
• [99]Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bull World Health Organ. 2013; 91:546-546A.
• [100]Goudge J, Gilson L, Russell S, Gumede T, Mills A. Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa. BMC Health Serv Res. 2009; 9:75. BioMed Central Full Text
• [101]Jacobs B, Ir P, Bigdeli M, Annear PL, Damme WV. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012; 27:288-300.
• [102]Macha J, Harris B, Garshong B, Ataguba JE, Akazili J, Kuwawenaruwa A et al.. Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy Plan. 2012; 27(suppl 1):i46-54.
• [103]McIntyre D, Thiede M, Birch S. Access as a policy-relevant concept in low- and middle-income countries. Health Econ Policy Law. 2009; 4(Pt 2):179-93.
• [104]O’Donnell O. Access to health care in developing countries: breaking down demand side barriers. Cad Saúde Pública. 2007; 23:2820-34.
• [105]Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981; 19:127-40.
• [106]Silal SP, Penn-Kekana L, Harris B, Birch S, McIntyre D. Exploring inequalities in access to and use of maternal health services in South Africa. BMC Health Serv Res. 2012; 12:120. BioMed Central Full Text
• [107]Meessen B, Malanda B. No universal health coverage without strong local health systems. Bull World Health Organ. 2014; 92:78-78A.