The promise and peril of universal health care

Universal health care (UHC) is garnering growing support throughout the world, a reflection of social and economic progress and of the recognition that population health is both an indicator and an instrument of national development. Substantial human and financial resources will be required to achieve UHC in any of the various ways it has been conceived and defined. Progress toward achieving UHC will be aided by new technologies, a willingness to shift medical tasks from highly trained to appropriately well-trained personnel, a judicious balance between the quantity and quality of health care services, and resource allocation decisions that acknowledge the important role of public health interventions and nonmedical influences on population health. BACKGROUND: The September 1978 Alma- Ata Declaration is a landmark event in the history of global health. The declaration raised awareness of “health for all” as a universal human right,whose fulfillment reduces human misery and suffering, advances equality, and safeguards human dignity. It also recognized economic and social development and international security as not only causes, but also consequences, of better health. In addition, it highlighted the power of primary health care and international cooperation to advance the protection and promotion of health in resource-constrained settings. Building on the achievement of Alma-Ata and gaining further traction from the Millenium Development Goals and the Sustainable Development Goals set by the United Nations, universal health care (UHC) has emerged in recent years as a central imperative of the World Health Organization (WHO), the United Nations and most of its member states, and much of civil society. UHC characterizes national health systems in which all individuals can access quality health services without individual or familial financial hardship. More broadly, UHC covers social systems that provide medical and nonmedical services and infrastructure that are vital to promoting public health. ADVANCES: Although there are numerous articulations of the UHC agenda, the WHO and World Bank offer a relatively simple UHC service-coverage index that is useful for intercountry comparison. This index focuses on four categories of health indicators: reproductive, maternal, and child health; infectious disease control; noncommunicable diseases; and service capacity and access. Comparison of UHC index values for 129 countries reveals that country index scores are positively correlated with income per capita, though there is considerable variation in scores among countries with similar incomes. These variations presumably reflect differentials in income inequality, commitment to public health infrastructure, and the quality and reach of human resources for health. The WHO and World Bank also offer multiple measures of health spending–related financial hardship in assessing UHC, which do not increase monotonically with increasing income, health spending per capita, or coverage of health services. Rather, catastrophic health expenditures tend to be lower in countries that channel health spending through public social security or insurance programs, rather than private insurance schemes. OUTLOOK: The financial cost of massively expanding access to health care globally is a formidable barrier to achieving UHC. For example, the Disease Control Priorities Network estimates that low- and lower-middle-income countries would, on average, need to raise their respective annual per capita health expenditures by U.S.$53 and U.S.$61 per person to achieve coveragewith the essential UHC package of 218 core interventions, a sizable burden in relation to average expenditure increases in recent years. Wealthy industrial countries are much further along the path to achieving UHC, though they also face challenges involving rising costs of new health care technologies and the growing share of their populations at the older (and more health care–intensive) ages. Technically and economically efficient approaches to the achievement of UHC may include the use of electronic medical records, telemedicine systems, digital monitors for drug adherence, and clinical decision–support applications; expansion of the quantity and quality of human resources for health at the physician, nurse, and community health worker levels; improvements in inventory systems and supply chains for the delivery of vaccines, drugs, diagnostics, and medical devices; screening for risk factors and early signs of disease; and focusing on the often neglected domains of surgical care, reproductive health, and mental health. Also key will be efforts to ensure universal access to proven public health interventions that address social and environmental determinants of health, such as health education campaigns; access to safe water; regulation of excessive sugar and salt in the food supply; control of tobacco and the unsafe consumption of alcohol; road traffic safety; walkable city designs; expanding enrollment in high-quality primary and secondary schools; and more equitable distributions of income and wealth. Achieving UHC is an ambitious aspiration and a powerful indicator of human progress. Fortunately, it may be expected to deliver myriad health, economic, and social welfare benefits along the way, helping to mobilize the substantial political and financial resources needed for its continued future expansion.