Intended for healthcare professionals


Universal health coverage: a policy whose time has come

BMJ 2013; 347 doi: (Published 23 October 2013) Cite this as: BMJ 2013;347:f6360
  1. Margaret E Kruk, assistant professor of health policy and management
  1. 1Columbia University Mailman School of Public Health, New York, NY 10025, USA
  1. mkruk{at}

It is both the right and the smart thing to do

Despite competition from a panoply of other health challenges, universal health coverage has been increasingly in the spotlight. Universal health coverage is defined as the ability of all people to obtain good quality health services when they need them, without experiencing financial hardship.1 The topic of two recent reports by the World Health Organization, it has been proposed for inclusion in the new global development agenda that will replace the millennium development goals after 2015.

Adding to the push for universal health coverage is a new report jointly published by Save the Children, Rockefeller Foundation, Unicef, and WHO, which was launched at the 68th United Nations general assembly in New York this September.2 The report makes a compelling case for why universal health coverage is needed for rich and poor countries alike.

Unlike previous global health policy initiatives, the policy aims to expand access to healthcare and to protect people from financial hardship as a result of receiving care. Around 150 million people annually spend more than 40% of their non-food budget on healthcare—so called catastrophic health spending.3 These figures underestimate the problem because they exclude travel costs and lost wages. One in four low and middle income households resort to borrowing or selling household assets to pay for treatment, forcing some to forgo schooling for their children or to incur ruinous debt.4

What would the world with universal health coverage look like? Probably much like the United Kingdom, Canada, France, and other countries that pool tax revenues to pay for a broad array of services for all—in effect, transferring money from rich to poor and sharing risk between those who are healthy and sick. When such a system is well funded and managed, people can obtain healthcare on the basis of need rather than ability to pay. Although specifics of financing and healthcare delivery vary widely, universal coverage is the norm among wealthy countries. Even the United States, long the holdout on national insurance, is now moving toward universality with the Patient Protection and Affordable Care Act. This law mandates insurance coverage through a combination of employer based, public, and individual private insurance, with subsidies for poor people.

The situation is very different in low and middle income countries. Access to many basic health services is inadequate. In rich countries, most women deliver their babies with the help of a doctor or midwife, but in Africa only one in two women do.5 And less than half of children in low and middle income countries with symptoms of pneumonia seek help from a health professional.6 To compound the problem, people who do obtain care have little or no health insurance to defray costs: 70% of all health spending in low income countries is out of pocket. By contrast, in rich countries only 15% of all spending comes directly from patients, with public insurance picking up the rest.7 Low coverage and lack of insurance result from low government health budgets and poorly functioning health systems, marked by weak financing capacity.

But people in middle and low income countries increasingly demand better health services—the top global priority of African and Asian respondents to a recent UN survey.8 This rising interest comes as economies in low income countries grow and citizens ask more of their governments, including a stronger social safety net. And governments seem to be listening. After WHO published its report on financing for universal health coverage, more than 70 countries asked for technical help in designing systems to promote such coverage.2

Paradoxically, the gap between rich and poor can be widened by expanding health insurance and services—for example, the introduction of private insurance that only rich people can afford or that covers health services mainly available in cities. To counter this, the report recommends financing public insurance through progressive taxation and eliminating charges at the point of care, which disproportionately hurt the poor. This has increased access and reduced medical impoverishment in wealthy countries and in emerging economies, such as Thailand and Mexico.9 10

To ensure that poor people are not left behind on the road to universal health coverage, insurance must also prioritize coverage for diseases that are common in these populations, such as infectious and maternal and child health conditions, injuries, and, increasingly, chronic diseases. In many countries, expansion of the insurance package will require governments to spend much more on healthcare, and in the poorest countries, help may be needed from international donors.

Yet the move toward universal health coverage is likely to be well worth the effort. Analysis commissioned for the report found that countries with a greater reliance on insurance tended to have lower child mortality. The authors estimate that increasing the share of prepaid funds in health spending by 10 percentage points would result in 15 fewer deaths in children under 5 per 1000—equivalent to 500 000 children’s lives saved each year in India and Nigeria alone—and this without increasing total spending.2

The report pays insufficient attention to quality of care, which is weak in many low income countries.11 Poor quality of care—absent or unmotivated providers, poor clinical and interpersonal skills, lack of drugs and equipment—will discourage people from using newly insured services or motivate them to seek private or specialized care, undoing the benefits of financial protection. Improvements in quality must go hand in hand with the expansion of access and financial protection.

Universal health coverage is the right and the smart thing to do. It puts countries on the path to realizing people’s right to health—a global commitment made, but as yet unfulfilled, in many countries. And it is an efficient way to finance healthcare—getting more health from healthcare investments while minimizing patients’ financial burden.


Cite this as: BMJ 2013;347:f6360


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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