Universal Health Coverage and Essential Packages of Care

Health systems have several key objectives; the most fundamental is to improve the health of the population. In addition, they are concerned with the distribution of health in the population—for example, with health equity—and they strive to be responsive to the needs of the population and to deliver services efficiently (WHO 2007). Notably, they also seek to provide protection against the financial risks that individuals face when accessing health services. Ideally, this financial risk protection (FRP) is accomplished through mechanisms such as risk pooling and group payment that ensure prepayment of most, if not all, health care costs (Jamison and others 2013).

An effective health system is one that meets these objectives by providing equitable access to affordable, high-quality health care—including treatment and curative services as well as health promotion, prevention, and rehabilitation services—to the entire population. Unfortunately, most countries lack health systems that meet this standard. Shortfalls in access, quality, efficiency, and equity have been documented extensively, both in low- and middle-income countries (LMICs) and in some high-income countries (HICs) (WHO 2010). In addition, in many countries, households routinely face catastrophic or impoverishing health expenditure when seeking acute or chronic disease care (Xu and others 2007). These financial risks can result in further health loss and reduced economic prosperity for households and populations (Kruk and others 2009; McIntyre and others 2006).

The current universal health coverage (UHC) movement emerged in response to a growing awareness of the worldwide problems of low access to health services, low quality of care, and high levels of financial risk (Ji and Chen 2016). UHC is now a core tenet of United Nations (UN) Sustainable Development Goal (SDG) 3. UHC was preceded by the aspirational notion of a minimum standard of health for all, enshrined in the Universal Declaration of Human Rights (adopted by the UN General Assembly in 1948) and the declaration of Alma-Ata in 1978, and many HICs have provided universal coverage for decades. The World Health Assembly endorsed the modern concept of UHC as an aspiration for all countries in 2005. Subsequent World Health Reports by the World Health Organization (WHO) expanded on various technical aspects of UHC, and in 2015, UHC was adopted as a subgoal (target 3.8) of SDG 3 (UN 2016; WHO 2013b).

Mechanisms and approaches, summarized elsewhere (WHO 2010; WHO 2013b), have been proposed or attempted as specific means of achieving UHC, but the objectives of UHC are the same in all settings, regardless of approach: improving access to health services (particularly for disadvantaged populations), improving the health of individuals covered, and providing FRP (Giedion, Alfonso, and Díaz 2013). There are three fundamental dimensions to UHC—proportion of population covered, proportion of expenditures prepaid, and proportion of health services included in UHC—that any given health care reform strategy seeks to achieve in some prioritized order (Busse, Schreyögg, and Gericke 2007). Recent reports, including the Lancet Commission on Investing in Health and the WHO Making Fair Choices consultation, have endorsed a “progressive universalist” approach to public finance of UHC (Jamison and others 2013; WHO 2014). Progressive universalism makes the case, on the basis of efficiency and equity, for an expansion pathway through the three UHC dimensions that prioritizes full population coverage and prepayment, albeit for a narrower scope of services than could be achieved at lower coverage levels or through cost-sharing arrangements. (It has been argued that full population coverage and full prepayment are necessary conditions to ensure that UHC leaves no one behind [WHO 2014].)

If progressive universalism is the preferred approach to UHC, then a critical question for health planners is which health interventions should be included. HICs are able to provide a wide array of health services, but LMICs have the resources to deliver a smaller set of services, necessitating a more explicit and systematic approach to priority setting (Glassman and others 2016). In this spirit, the Making Fair Choices report recommended that UHC focus on interventions that are the most cost-effective, improve the health of the worst off, and provide FRP (WHO 2014). The extended cost-effectiveness analysis (ECEA) approach developed for this third edition of Disease Control Priorities (DCP3) assesses policies in these dimensions and can help identify efficient, fair pathways to UHC. Chapter 8 of this volume provides an overview of ECEA methods and results of ECEAs undertaken in conjunction with DCP3 (Verguet and Jamison 2018).

The set of prioritized health services publicly financed through a UHC scheme has been termed a health benefits package (Glassman and others 2016). The limited experience of LMICs with benefits packages suggests that such packages can be part of a coherent and efficient approach to health system strengthening, but many countries lack the technical capacity to review a broad range of candidate interventions and summarize the evidence for their effectiveness or cost-effectiveness. In this regard, DCP3 provides guidance on priority health interventions for UHC in LMICs in the form of a model health benefits package that is based on DCP3’s 21 essential packages (see chapter 1 of this volume, Jamison and others 2018).

This chapter proposes a concrete set of priorities for UHC that is grounded in economic reality and is intended to be appropriate to the health needs and constraints of LMICs, particularly low-income countries and lower-middle-income countries. It develops a model benefits package referred to as essential UHC (EUHC) and identifies a subset of interventions termed the highest-priority package (HPP). The chapter presents a case that all countries, including low-income countries, could strive to fully implement the HPP interventions by the end of the SDG period (2030), and many middle-income countries could strive to achieve full implementation of EUHC. The chapter also presents estimates of the EUHC and HPP costs and mortality consequences. It concludes with a discussion of measures that improve the uptake and quality of health services and with some remarks on the implications of EUHC and the HPP for health systems.

The chapter does not, however, prescribe one correct approach to UHC, nor does it attempt to review the wide array of delivery mechanisms, policy instruments, and financial arrangements that support the transition to UHC; these have been covered in detail elsewhere (WHO 2010; World Bank 2016). Rather, this chapter stresses that the UHC priority-setting process is contextual, depending on political economy as well as local costs, budgets, and demographic and epidemiological factors—all of which influence the value for money of specific interventions.

Because the development and refinement of a benefits package is an incremental and iterative process, many ministries of health probably will not use DCP3’s recommendations as a template for their packages but rather as an aid in reviewing existing services, identifying outliers, and considering services that are not currently provided. The DCP3 model benefits package can thus serve as a starting point for deliberation on a new health benefits package or refinement of an existing package. However, as construed here, it would not be a perfect package for a particular country. To translate the DCP3 findings into an actionable UHC agenda at the national or subnational level will require context-specific technical analyses and public consultation, ideally as part of a clearly articulated political agenda and an institutionalized priority-setting process that can govern public and donor resource allocation in the health sector.