EXECUTIVE BOARD 132nd session Provisional agenda item 10.3
EB132/22 18 January 2013
Universal health coverage Report by the Secretariat 1. Universal health coverage is increasingly seen as being critical to delivering better health and as a unifying goal for health system development. In 2012 alone, four key high-level international events focused on the importance of working towards universal health coverage, resulting in the Bangkok Statement; the Kigali Ministerial Statement; the Mexico City Political Declaration; and the Tunis Declaration. 2. These declarations and statements build on The world health report 2008 in which universal coverage was seen as one of the four guiding principles of primary health care; The world health report 2010, which showed how countries could modify their health financing systems in the search for universal health coverage; and the Berlin Ministerial Level Meeting on financing for universal health coverage, which launched the 2010 Report. 3. Universal health coverage contributes to, benefits from, and provides a way of measuring progress on sustainable development. Its role in this regard was noted at the United Nations Conference on Sustainable Development (Rio+20)1 and in a new United Nations General Assembly resolution on Global Health and Foreign Policy.2 4. Other international processes reinforce the link between coverage with essential health services and financial risk protection, including: the United Nations Every Woman Every Child initiative (September 2010) and the United Nations High-level Meeting on Prevention and Control of Non-communicable Diseases (September 2011). 5. Recent decisions in international forums on universal health coverage as an objective of health and development policy reflect what is happening at country level. Low- and middle-income countries as diverse as Brazil, China, Ghana, Indonesia, Rwanda, Sierra Leone and Thailand are among those that have taken steps to modify their health systems in order to move closer to universal coverage, and several high-income countries facing the effects of the continuing financial and economic crisis are trying to find ways to maintain their past achievements. 6. In implementing these strategies, countries see universal health coverage as comprising two interrelated components: coverage with needed health services (prevention, promotion, treatment, rehabilitation and palliative care) and coverage with financial risk protection, for everyone.3 Universal 1 2 3
See resolution 66/288, The future we want. See document A/67/L.36.
Health systems financing: the path to universal coverage. The world health report 2010. World Health Organization, Geneva, 2010.
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health coverage aims to ensure that all people obtain the health services they need without the risk of financial ruin. Universal coverage with needed health services in turn incorporates many different components, including universal access to essential medicines and health products, sufficient, motivated health workers of the right mix located close to people, and information systems that provide timely information for decision-making, for example. 7. To illustrate, a recent review of the Thai Universal Coverage Scheme showed that health insurance (paid entirely from general government revenues) for the poor and the informal sector increased their access to the services they needed and improved financial risk protection. To enable this to work, however, a variety of other actions were taken across all parts of the health system, including ensuring that essential medicines were available, health workers could be retained in rural areas, priority health programmes were addressed at the appropriate level of the health system, and health promotion and prevention were adequately funded. 8. Moving towards universal health coverage is a process that needs progress on several fronts: the range of services that are available to people (consisting of the medicines, medical products, health workers, infrastructure and information required to ensure good quality); the proportion of the costs of those services that are covered; and the proportion of the population that is covered. These gains need to be protected during financial or economic downturns. Universal health coverage is not about achieving a fixed minimum package. 9. Coverage with needed services improves or maintains health, allowing people to earn incomes, and children to learn, thereby providing them with a means through which to escape from poverty. At the same time, financial risk protection prevents people from being pushed into poverty as a result of having made out-of-pocket payments for health. It therefore contributes to poverty reduction and is, by definition, a practical expression of the concern for health equity and the right to health. 10. The two components of universal health coverage are valued for their own sake. People have greater peace of mind when they know that the health services they might need to use are available, of good quality and affordable. However, actually being able to use the health services they need also contributes to reductions in mortality, morbidity and disability in all populations. Of note is the fact that the health sector is only one contributor to such reductions. A wide variety of other factors are involved, including broader development policies and social, economic and environmental determinants of health.1 11. Recognizing this, in resolution WHA64.9 of 2011 the Health Assembly requested the Director-General, inter alia, to prepare a plan of action for the Secretariat to support Member States in realizing universal coverage. Resolution WHA64.9 built on resolution WHA58.33 of 2005,2 and also requested a report of progress towards universal health coverage, particularly in regard to equitable and sustainable health financing and social protection of health in Member States. Since 2005, more than 80 resolutions relating to health financing or health system development have been adopted by the World Health Assembly or regional committees. This illustrates the collective commitment to health system strengthening and the principles of universal health coverage.
See also documents EB132/11 and EB132/12, which relate to universal health coverage, reporting respectively on the achievement of the health-related Millennium Development Goals and health in the post-2015 development agenda, including the application of the Rio+20 outcome document: health and sustainable development objectives. 2
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See also document A65/26, Progress report A, on health system strengthening.
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PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE 12. Steady progress has been made towards universal health coverage globally, in terms of increasing coverage with health services related to the Millennium Development Goals, in levels of financial risk protection, and in health system strengthening more broadly. 13. This is one of the reasons for the substantial decreases in rates of child and maternal mortality ratios in most parts of the world since 2000. 14. An improvement in overall social and economic conditions also helped. The Human Development Index captures three important components namely, health, education and income. From 2005 to 2011, the index reveals improvements in all parts of the world, with those improvements happening most rapidly in the least-developed countries. The proportion of the world’s population living in poverty also declined, although there were indications that, paradoxically, income inequalities had increased during the same period within many countries. Improvements in these areas, as well as in other social determinants, make it easier to raise funds for health, increase the range, quality and coverage of needed health services, and translate into improved health. 15. Despite this, much remains to be done. An estimated 1000 million of the world’s poor still do not receive the health services they need. Deliveries attended by skilled health workers increased from 44% to only 45% between 2000 and 2010 in sub-Saharan Africa, for example, while coverage with many of the health services needed to prevent or treat noncommunicable diseases is believed to be low in many parts of the world. Inequalities remain considerable in health service coverage and in levels of financial risk protection within countries. 16. Many countries still have critical shortages of health workers and find it hard to retain them in underserved areas. Access to affordable essential medicines was higher in the period 2007–2011 than in the previous five years, but the availability of essential (generic) medicines in a sample of low-income and lower-to-middle-income countries was only 50.1% in public health facilities and 67% in private facilities. More than 1000 million people did not have access to essential medicines. Information systems remain unable to provide data on coverage for most interventions for the prevention and treatment of noncommunicable diseases in most settings. 17. Despite increased health spending, funds are still insufficient to ensure universal coverage with even a minimum set of health services (that is, to support prevention, promotion, treatment, rehabilitation and palliative care) in many countries. The high-level Taskforce on Innovative International Financing for Health Systems estimated that countries required an average of US$ 44 per capita in 2009 rising to US$ 60 in 2015 in order to ensure coverage with even a minimum set of services.1 In 2010, the average health expenditure per capita in low-income countries was US$ 32 per capita; 26 Member States still spent less than US$ 44 per capita on health from all sources including donor support. 18. Levels of out-of-pocket payments remain high in many parts of the world. An estimated 150 million people suffer financial catastrophe because they are not sufficiently covered by a form of financial risk protection, and 100 million are pushed under the poverty line for the same reason.
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All averages are unweighted unless otherwise indicated.
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19. In 2013, formal discussions begin in the United Nations to reflect on progress towards the current set of Millennium Development Goals and to decide on new goals in the period after 2015. It is critical to accelerate work on the current health-related Millennium Development Goals, as well as to take action to address the mounting burden of diseases that are not included in the Millennium Declaration, including noncommunicable diseases. Moving towards universal coverage requires that work on each of the priority health problems is brought together by strengthening health systems. 20. The goal of universal health coverage provides a framework for the consolidation of streams of work described above, and a clear direction for work on national health policies and strategies.
SECRETARIAT RESPONSE 21. The plan of action to support Member States in moving closer to universal health coverage has been finalized. 1 The plan, requested by the Health Assembly in resolution WHA64.9, focuses on technical and policy support to countries, and collating, analysing and disseminating the evidence that countries need. It also promotes and fosters the sharing of experiences among countries recognizing that countries will need to tailor solutions to their own needs. 22. One aspect of technical support in the plan provides information on how countries can assess their status in terms of universal health coverage and the functioning of their health systems. This evidence feeds into the policy dialogues that are developing and implementing plans for moving forward. 23. The goal of the plan of action is to ensure that all countries receive timely technical support when they request it. Already more than 70 countries have sought some form of WHO support in the area of health financing since publication of The world health report 2010. To meet the increasing demand, the Secretariat collaborates with partners in the Providing for Health Network and Harmonization for Health in Africa initiative. 24. Although the plan of action focuses primarily on health financing, the focus of resolutions WHA58.33 and WHA64.9 on technical and policy support in the area of health financing is part of the broader work with Member States on policy dialogue around overall national health policies, strategies and plans. The analysis feeding into the policy dialogues identifies obstacles to moving forward regardless of where they are found in the health system, leading to the development and implementation of subsequent plans to remove impediments. 25. For example, awareness of the burden of noncommunicable diseases has increased the attention given to the role of primary care services in delivering long term and chronic care, the place of prevention and promotion, and the appropriate role of hospitals. Continued efforts are being made to support Member States in their provision of increased affordable access to essential medicines and technologies; their development and retention of a strong, motivated health workforce; and the improvement of health governance. Capacity-building activities are also being undertaken; one example is the European Region’s training programme for health financing policy-makers that started in 2011, which focuses on universal health coverage.
Health systems financing: the path to universal health coverage, plan of action is available at: http://www.who.int/health_financing/en/index.html.
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26. The approach described above to policy dialogue for the health system as a whole has led to more systematic efforts in bringing coherence to fragmented systems. It has also supported the incorporation of disease control programmes in overall health system strengthening efforts, in concert with the International Health Partnership’s efforts to increase harmonization and alignment in aid. The goal is to develop a clear focus on outcomes. 27. Recognizing that countries will choose to track their own progress towards universal health coverage in different ways depending on their own health problems and capacities to monitor and evaluate, the Secretariat is working with partners to develop and suggest a set of indicators that could be used for this purpose. 28. Some of the new indicators will also be relevant for the discussion of whether and how universal health coverage should be included as a goal with targets and indicators in the post-2015 Millennium Development Goals framework. A ministerial-level meeting on progress towards universal health coverage is planned for February 2013, organized jointly with the World Bank.
ACTION BY THE EXECUTIVE BOARD 29. The Executive Board is invited to note this report.
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