Elsevier

The Lancet

Volume 380, Issue 9845, 8–14 September 2012, Pages 924-932
The Lancet

Series
Political and economic aspects of the transition to universal health coverage

https://doi.org/10.1016/S0140-6736(12)61083-6Get rights and content

Summary

Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care—in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. This paper describes common patterns in countries that have successfully provided universal access to health care and considers how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.

Introduction

Countries have reached universal health coverage by different paths and with highly diverse health systems. Nonetheless, the trajectory towards universal health coverage almost always has three common features. The first is a political process driven by a range of social forces to generalise access to health care. Countries have responded to these social forces by creating public programmes or regulations that expand access to care, improve equity, and pool the financial risks of care across populations. The second feature is a growth in incomes and a concomitant rise in health spending. This increased spending enables the buying of more health services for more people and contributes to improved health. The third feature is an increase in the share of health spending that is pooled rather than paid out-of-pocket by individuals and families. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care, in other cases it is mobilised in the form of contributions to public insurance or mandatory private insurance. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage.

In this paper, we describe the historical, political, and economic trends associated with progress toward universal health coverage. We begin by reviewing different ideas of universal health coverage. We then relate lessons from historical research with regards to the political pressures for universal health coverage, the centrality of the public sector, and the contingent paths of reform. We then discuss the economic factors that lend support to expanded coverage, finance access to a growing range of medical services, and restructure health financing through pooling mechanisms. In this way, we consider how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health. Countries seeking to reach universal health coverage can learn from these trends by identifying the political sources of support for expanding coverage, designing policies to manage expected increases in spending, and facilitating the shift away from out-of-pocket spending.

Key messages

  • Universal health coverage has been defined in terms of rights to health care, financial protection, and utilisation of health-care services

  • Universal health coverage can be achieved through many different health financing systems, although the pooled share of health expenditures predominates in all successful cases

  • The political processes leading towards universal health coverage differ between countries, but they are all ubiquitous, persistent, and contingent

  • Political action to universalise health coverage is the major force behind the rising share of pooled financing of health expenditures

  • Growth in health spending is driven primarily by rising national income and the expanding range of medical interventions, with population ageing playing a small part

  • Countries that want to achieve universal health coverage need to adopt public policies that reduce reliance on out-of-pocket spending and improve the institutions that manage pooled funding to address the equity, efficiency, and sustainability of health expenditures

Section snippets

What is universal health coverage?

In its simplest form, universal health coverage is a system in which everyone in a society can get the health-care services they need without incurring financial hardship.1 Whether or not a country has achieved universal health coverage therefore depends on three related factors: who is covered, for which services are they covered, and with what level of financial contribution? Every society seeking to improve access to health care has debated who should be eligible and on what basis—whether

How have countries achieved universal health coverage?

When examined in a historical context, almost every country shows a consistent drive towards the provision of universal health coverage. The trajectory is not smooth or free of conflict, but the general pattern of political action to mobilise funds, mandate participation in health financing schemes, and expand access to care is widespread. Countries have financed this expansion of care by increasing the share of national income devoted to health and have increased the equity of access by

Health spending and universal health coverage

Although political trends drive the key reforms necessary to achieve universal health coverage, economic trends also play a substantial part. In particular, economic growth generates both resources and demand for expanded health-care provision. As a result, countries dedicate increasing shares of national income to health-care services, more services are provided, and this contributes to better health. The way countries reform their systems also affects the composition of this growing health

Implications for reaching universal health coverage

Countries of all income levels are pursuing the goals of universal health coverage. Middle-income and high-income countries that have achieved universal health coverage are still reforming their systems to address remaining inequities, improve efficiency, and contain costs. Low-income and middle-income countries that have yet to attain universal health coverage are at various stages of policy reform and resource mobilisation.

Low-income and middle-income countries face a series of challenges

Conclusions

Universal health coverage costs money but it doesn't have to be expensive. Good health can be achieved at low cost whenever countries allocate resources towards more cost-effective care as shown in several low-income countries and regions.11, 60 Countries are likely to be more successful if they recognise that political action is needed to direct future growth in health spending through pooled financing mechanisms that enable the promotion of equitable and efficient health care. Countries are

Search strategy and selection criteria

We used quantitative and qualitative data from academic studies and grey literature to review definitions and identify trends in achieving universal health coverage. We searched PubMed, JSTOR, and Google Scholar for relevant books and articles using the terms “universal health coverage”, “universal coverage”, “health reform”, and “social welfare reform”, combining each of these terms with the word “history”. We assessed and analysed material through a mix of historical, economic, and political

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