What does universal health coverage mean?

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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. Fulfilment of this potential, however, requires a clear definition of the term UHC otherwise it could suffer the same fate of the refrain of Health for All, which received high-level political support but failed to produce sufficiently widespread policy and budgeting changes to realise its aims.

An empirically grounded framework to guide definition 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. In the context of UHC, the term universal has been defined 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.

Health is another contested term. The UN General Assembly resolution implies a much broader definition of health than provision of basic or essential health services could achieve. Discussions of the term coverage typically note that access to essential services cannot be removed from barriers such as the financial hardships associated with payment. However, definitions of coverage must go past mere accessibility of services to incorporate an assessment of effective utilisation.

Imprecision of these three terms hinders discussions around key policy questions for UHC, such as who to include, for which services, with what level of quality, and to what extent it can increase equity. Moving forward a genuinely broad-based consensus on a precise operational framework would make UHC achievement a more inclusive and country-led process, rather than simply one swayed by global pundits. Development of such a framework would demystify UHC and encourage sensible measures for tracking and global comparisons, build on lessons learnt during the pursuit of the MDGs, and contribute meaningfully to the post-2015 agenda.

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