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Analysis Universal Health Coverage

Rethinking assumptions about delivery of healthcare: implications for universal health coverage

BMJ 2018; 361 doi: (Published 21 May 2018) Cite this as: BMJ 2018;361:k1716

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  1. Jishnu Das, lead economist1,
  2. Liana Woskie, assistant director2,
  3. Ruma Rajbhandari, instructor3,
  4. Kamran Abbasi, executive editor4,
  5. Ashish Jha, K T Ki professor of international health5
  1. 1World Bank, Washington, DC, USA
  2. 2Harvard Initiative on Global Health Quality, Cambridge, MA 02138, USA
  3. 3Harvard Medical School, Boston, MA, USA
  4. 4The BMJ, London, UK
  5. 5Department of Health Policy and Management, Harvard T H Chan School of Public Health, Harvard Global Health Institute, Boston
  1. Correspondence to: A K Jha ajha{at}

Simply providing more resources for universal coverage is not enough to improve health, argue Jishnu Das and colleagues. We also need to ensure good quality of care

We are at an inflection point in global health. People are living longer, healthier lives than ever before, and we are rightly celebrating disease focused programmes that have greatly reduced or eradicated diseases such as smallpox and river blindness. Better diagnosis and treatment of HIV/AIDS, malaria, and other diseases have saved countless lives.12 Yet, as populations age and the burden of morbidity grows more complex, the limitations of programmes focused on single diseases have become increasingly evident.

Policy makers have shifted towards a broader “systems” view of universal health coverage (UHC)—one that seeks to provide all people with access to essential health services without financial hardship—as the defining approach to improve the health of the world’s poorest people. As one of the key focuses of the sustainable development goals, UHC has become a rallying principle for all countries. Indeed, the new director general of the World Health Organization has made UHC his top priority for the agency.

UHC can achieve its primary objective of creating better health, but to do so, patients must have access to services that are high quality. This idea of “effective UHC” is not new. It has long been recognised that translating healthcare into health outcomes requires that services meet some basic standard of quality.3 However, without systematic data on quality, the working assumption has been that adequately trained doctors and nurses with access to infrastructure (such as well equipped facilities and medicines) will be sufficient to guarantee adequate quality. Emerging data suggest that this understanding may be incorrect. For example, even when resources are in place in countries as far afield as Bangladesh and …

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