Simplifying the universal health coverage narrative can help to achieve political action

The narrative on universal health coverage should be centred around four core elements: universality, equity, adequate financing, and preparedness in public health emergencies, write Katri Bertram and Justin Koonin

Universal health coverage means that “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.”1 All United Nations member states have committed to make progress towards universal health coverage. Despite two high level meetings on the topic, a persistent gap remains between ambitious commitment and concrete actions.23 One challenge limiting progress is the fragmented and convoluted way by which advocates make the case for it.3 Advocates can reduce such confusion and simplify political arguments by focusing on four core elements for what implementing universal health coverage needs to look like in practice.

The range of nuanced issues encompassed by universal health coverage can make its translation into digestible political action difficult.4 In a world of increasing demand, limited budgets, and short term political attention cycles, we need to attune the principles of universal health coverage to existing realities and translate it into actionable steps.

Firstly, we share this belief that universality is the central principle of universal health coverage and a foundation for the right to health.4 But to ensure that it does not remain an ambiguous political slogan ahead of elections, countries must commit to a clear, realistic roadmap to support implementation. This approach means developing action plans for how coverage can expand progressively to reach all communities. These plans must be driven by principles of human rights to prioritise people living in vulnerable situations.

Secondly, universal health coverage must be guided by equity. Technical approaches to strengthening and financing health systems are important, but equity must be a central feature. Universal health coverage cannot be implemented as health services only for people who can pay, or as poor quality services for those who cannot.5 The first step towards equity must be to provide access to a core package of health services that are affordable (ideally free of charge) to prevent financial hardship. Social protection interventions—including approaches and policies to eradicate poverty, social exclusion, and the root causes of inequality—are often ignored in debates that primarily focus on health services or financial protection. Social protection should be a core part of universal health coverage implementation as this approach recognises the wider social determinants of health.6 Countries must scale up their capacity to collect, analyse, and use disaggregated data to identify those individuals left without care and why, to help redesign equity focused policies. Again, such programmes need to be realistic, progressive, and acknowledge country capacity.

Thirdly, to ensure that universal health coverage is actionable, a clear and compelling ask to ensure adequate financing must be articulated for heads of state and finance ministers. This includes outlining the economic, societal, and political benefits of universal health coverage. It contributes to improved population health, educational outcomes, and higher labour-market outcomes.7 Achieving and sustaining universal health coverage is a cornerstone for human capital development and inclusive growth. Yet because universal health coverage is country driven and inherently political, specialists and policymakers have not been able to agree on explicit financing targets. But there is general agreement that domestic, pooled public financing is key to achieving and sustaining universal health coverage, supplemented by development aid and private financing. We recommend bodies such as the World Health Organization, international financial institutions, and the G20 Finance and Health Taskforce develop clearer guidance for countries that consider financing for national health systems and universal health coverage as an entry point for global health security.

Finally, our health systems are under increasing threat of major disease outbreaks and emergencies, stemming from the climate crisis, armed conflict, and other public health threats. These crises increase health system costs, straining overstretched public budgets and increasing out-of-pocket costs. Investment in universal health coverage helps make populations and societies—especially those in the most vulnerable situations—healthier before a crisis and more resilient to shocks during response and recovery. Universal health coverage is inextricably linked with efforts to strengthen health security. Investments that are made to support both can help harmonise financing and reduce fragmentation of health systems.8

We do not aim to provide a singular new narrative for universal health coverage, but to call on advocates to ensure that the narrative they use is action oriented and grounded in present realities. It should be centred around the four core elements we have outlined here: universality, equity, adequate financing, and supporting preparedness in public health emergencies. These four elements provide a focus so that political leaders receive a consistent message about what is most important for universal health coverage. In an area that requires many sectors and vast technical expertise, we can only be effective if we work and communicate more strongly together.