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When Implementing Universal Health Coverage, Context Matters

As the WHO’s Millennium Development Goals reach their final phase, Sara Gorman reflects on what we have learned about how political, cultural and financial contexts impact the success of universal health coverage systems. 

Image Credit: Edith Soto, Flickr
Image Credit: Edith Soto, Flickr

In May of 2013, Margaret Chan affirmed the WHO’s commitment to achieving universal health coverage worldwide, proclaiming “universal health coverage is the single most powerful concept that public health has to offer”. For Chan, public health measures such as universal health coverage represent a key component of development work in the 21st century. As the Millennium Development Goals (MDGs) begin to wind down with their 2015 expiration date looming, the WHO has turned its attention toward the next set of goals for world health. With statistics revealing that more than 100 million are pushed into poverty each year due to excessive health care costs, it seems ever more urgent to advocate for universal health coverage, spreading the costs across entire populations.

Yet even as it is essential to embrace a global move toward universal health coverage, it is equally vital to continue asking whether there is enough evidence to show that universal health coverage really improves population health. If not, it will become important to search for ways to make universal health coverage more effective at achieving its underlying goal: improving health. Thus, questions must be asked not only about whether countries are implementing universal health coverage but also about whether this implementation seems to be working. What are the constraints to achieving better population health as a result of universal health coverage?

What is the evidence that universal health coverage improves population health? As Moreno-Serra and Smith have observed, much of the research on the relationship between healthcare financing and health outcomes has failed to take causality into account. A series of studies have demonstrated a correlation between greater pooling of health funds and increased life expectancy. Yet these correlations are not enough to suggest that this change in the structure of healthcare financing is causing an increase in life expectancy, especially in low- and middle-income countries facing a demographic transition.

More recent longitudinal studies have managed to show a causal relationship between universal health coverage and better health. Recent research in PLOS Medicine has noted the success of universal health coverage on women’s health in low- and middle-income countries, including Afghanistan, Mexico, Rwanda, and Thailand. However, the effects of universal health coverage can vary depending on the robustness of a given country’s governance. Countries with strong governance tend to benefit the most from increased health coverage, while countries with weak governance benefit much less. It therefore seems essential that health coverage expansion in countries with poor governance infrastructure be accompanied by improvements in public administration. Because the effects of universal health coverage seem prone to the influences of context, there is a need for more studies of ways in which particular small changes in local institutions and government and financial structures can affect the relationship between universal health coverage and improved population health.

Some low- and middle-income countries have faced serious setbacks in implementing universal health coverage. In Nigeria, for example, universal health coverage has largely faltered due to poor infrastructure and low-quality health services. Problems with implementing universal health coverage in Mexico are another example of poor infrastructure and efficiency before the implementation of the new plan carrying over into the new plan and reducing its potential effects on population health. A lack of health facilities in rural areas remains a major barrier for poor people who are now covered but have nowhere to go for healthcare. In addition, since the system is financed through central government allocations to states, the country has faced problems with lack of accountability and transparency regarding use of these state funds.

In theory, universal health coverage is among the most powerful tools public health has to improve population health. Yet in reality, implementing universal health coverage has to be accompanied by a wide range of other health systems strengthening approaches within a broader development framework. Attention to context is key. The structure of universal health coverage plans must be sensitive to the particulars of the government infrastructure and financial structures in place in the country in question. In addition, attending to issues of supply and quality is essential. Implementing a universal health coverage plan without insuring that there are enough quality doctors and hospitals means spending a lot of money with little chance of better health results, especially for the most disenfranchised portions of the population. Universal health coverage is no magic bullet, but it is a vital tool in improving population health in the post-MDG era.


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