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Rethinking the concept of Universal Health Coverage

Dr. Niraj Shrestha and Dr. Krishna Paudel 

Nepal’s health sector has got some ambitious targets to meet by 2030. However, the buzzword is the “Universal health coverage” or “UHC”, which is technically target 3.7 under the Sustainable Development Goals (SDGs). The textbook definition of UHC as the World health organization (WHO) puts it is that it is the use of equitable and quality health services including promotive, preventive, curative, rehabilitative and palliative services, by every individual without getting exposed to the financial hardships. 
 
The concept of UHC is indeed more than just a definition, it is an idea or simply a way of life for the progressive health systems. Unfortunately, we are all guilty of constricting the idea into logframes where people are merely numbers and those unable to access health care gaps in services. The target of UHC in the SDG logframe represents the faces of people whose lives will take a beautiful turn because of the accessibility to equitable, affordable, and quality health care. We have approximately a decade’s time to pursue this outreach and it is high time that we started reflecting on some of its fundamental aspects. 
 
Coverage vs Care
First, the word “coverage” in the term Universal Health Coverage sounds very convincing for the health policymakers, program planners, public health professionals, and students. Coverage is a programmatic term born out of the progress indicators and realistically people would be least worried about coverage. For policymakers, it is worth reflecting on the self-limits imposed by the term coverage in the context of the universality of health care. Coverage often makes us think about who gets covered? What does it cover? How much does it cover? Then comes the obvious question who or what gets left out? In fact, no one should have to be left out of the fundamental right to health care enshrined in the World Health Organization’s constitution of 1948 which is also the basis of UHC. Therefore, one major shift that health policymakers will have to take is as fundamental as accepting UHC as Universal Health Care rather than Universal Health Coverage. 
 
Curative vs preventive and promotive care
Second, UHC is not just one-way traffic. Understandably, the government is responsible for the health of the people because of our health gains or incurs losses as a result of the policy decisions. Nevertheless, it is “we the people” who are the biggest suppliers of one’s own health. Often health in practical terms comes down to doctors, hospitals, laboratories, nurses, ambulance services, distance to the health facility and payment to health care institutions. But health starts a lot before we start making an appointment with the doctor in times of ill-health. It starts with a simple intent that we must remain healthy. In order to keep oneself healthy, measures must be taken at an individual level to opt for a healthy lifestyle which is as basic as regular exercise, maintaining a healthy sleep/wake cycle, a healthy diet, and preventive health check-ups. 
  
It can be argued that the market forces deter the path to good health because they flood the market with highly processed food rich in saturated fats, sugar, and salt. Nevertheless, it is the consumer who decides and consumer’s subscription to such processed food violates the concept of UHC which includes people’s need for preventive and promotive health services. Therefore, people must start thinking about health fundamentally as an art and skill of living a life free from disease or ailments through the application of a healthy lifestyle in all spheres of life.  Considering the universality of UHC, individuals also must fulfill their share of the responsibility for health promotion.
 
Affordability of the UHC
Third, UHC creates hype around its scope and reporting its limitations will prevent a fallout. UHC requires funds to ensure that individuals do not run out of theirs while trying to get back to good health or maintain one. This is particularly important in the so-called low-income where individuals pay for their health care mostly out of their own pockets.  The cost considerations of UHC means that some things are affordable, and others are not. Therefore, it is about time to clarify the limitation of UHC to the general public i.e. not all health services people need can be covered under the UHC.
 
The technology requirement of the UHC
Fourth, the introduction of technology to improve health service is sometimes projected as a panacea for the problems. Technology can certainly improve efficiency and ultimately the quality of services, but it can compromise it at the same time. It is observed that health workers must adapt to the technology rather than the technology confirming to the needs of the health professionals. Therefore, if we do not begin to frame the technological needs considering the priorities of the health system, we will end up doing more harm than good. 
 
The human aspect of UHC
Fifth, the human aspect of UHC is a delicate thread linking the amount of work that goes into improving the coverage and getting people to believe that health services have improved. UHC primarily looks at cost, service and population coverage with equity, quality, and financial risk protection as cross-cutting issues. We can improve the cost allocation and coverage of health services across the population but if the person delivering care at the point of service is unable to present it with an acceptable standard all that work goes into vain. Primarily, the path to UHC is not built with logistics or progress indicators but by and with the motivation of the health workers who make the best use of available resources.  
 
Global priorities vs country priorities
Fourth, countries around the world are more interdependent than any other time in the history of mankind. Cross-border trade, the opening of multiple channels of communication and travel among and between countries has meant that goods grown in one country are turned into finished products in the second and sold in the third. The geo-political and economic dependence on one another has resulted in interdependence in the health sector. The global health targets are a by-product of such interdependence. The idea that humanity faces similar health threats and therefore needs to address as one is a uniting force. Nevertheless, the multilateralism of global targets such as UHC can play a role in undermining national health priorities. The priorities of a nation’s health system can be a lot different from global health priorities. Further, the availability of funds to address the issues is relatively more abundant when issues separating the national and global priorities get blurred. The performance of national health systems should not be assessed by global health indicators but by in-country context. Also, it is important that country-specific concerns and priorities are given due importance in global platforms and initiatives. Therefore, it is time to rethink our approach to global targets and start assessing if country-level priorities coincide or clash with global health initiatives. 
 
Nepal and the UHC
According to the latest estimates released by the WHO South-East Asia region, the UHC service coverage index will get as far as 73% by 2030.  Meanwhile, Thailand’s figure is projected to reach 94% during the same time period. It is important how we absorb such estimates. UHC is not the sprint to 100% coverage and if we fall into the number games, we go back to Millennium development goals (MDGs) era where the focus was on improving coverage at the expense of quality or equity. UHC is like a marathon where an athlete maintains a healthy pace, saves energy and builds a foundation for the last mile. 
 
Comparisons are important to inspire us to do better than what we think we can, nevertheless, falling behind in comparison should not undermine the hard work that Nepal’s health system has put in to get so far. Although we are part of a global commitment to UHC, our challenges and limitations are country-specific. The local context is beyond the scope of a global target to fathom or set a level playing field. Hence, our competition should be with our last best performance.In 2017, If there was a child born into your household or in the neighborhood you have more than one reason to celebrate.  National estimates suggest that babies born in 2017 will live 12.6 years longer babies born in 1990. Such a leap in life expectancy figures has been made possible by thousands of dedicated health workers across the country. Further, if people have doubts on the ability of health system to mobilize the community to tackle a public health issue, they should be reminded that Nepal declared itself polio-free in May 2014, a feat which that would have been impossible to achieve without a health system that is willing to take up challenges. 
 
We all agree that the performance of the health system needs to improve. However, we should avoid the blame game. It is time to re-focus, re-organize and re-strategize our efforts for a healthy and prosperous Nepal.  

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