Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

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Abstract

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with “health for all (HFA)”, prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

Keywords: universal health coverage (UHC), health financing, conceptual analysis, social health protection, health service access, population and financial coverage, historical and policy review

Background

Universal health coverage (UHC) means that the whole universe's population has access to all types of healthcare. It refers to a government system or program that guarantees that all people under that government have access to available health services. The system will provide such services when and as required without causing financial challenges for the individual receiving such services. UHC programs by design offer all essential and quality health services, namely, health promotion, preventive health, medical treatment, rehabilitation, palliative care, and hospice care (1).

Despite the core definition, UHC is fundamentally a human right and political scheme. The human rights-based approach (HRBA) has established its legacy in inclusive development that follows the United Nations Development Program (UNDP)'s human development approach and integrates standards and principles of human rights, such as participation, non-discrimination, and accountability (2). It provides a procedural way for implementing UHC at the national level and concludes by highlighting critical areas in which consistent, authoritative, and practical guidance is urgently needed to support countries in getting onto the right road to UHC (3, 4). In the same line, addressing UHC requires changing a wide spectrum of laws, policies, and practices that reflect the willingness and capacity of governments to deliver on their commitments and meet their human rights obligations. UHC has been established in a wider, longer, and deeper journey toward the realization of human rights using various legal, historical, institutional, and social arguments.

Globally, there is no consistency in providing healthcare in terms of access, equity, and quality. The UHC concept was developed during the millennium development goal (MDG), 2000–2015. There was a challenge in developing the healthcare package to achieve UHC in Malawi (5). There is some confusion when setting the priority and designing the policy in Uganda (6) due to the conceptual unclarity of UHC. Previous assessments have mainly focused on the provision of essential services, the availability of healthcare resources, and health service utilization rates in high-income countries rather than in low-income and middle-income countries (7). A study in China has revealed that there is some unclarity about the resource pooling in healthcare for ongoing health insurance programs (8). There is a power imbalance in the global governance sectors, health disparities, few choices in health service access, and institutional barriers according to The Lancet-University of Oslo Commission Report (9). Due to the different dimensions of the power structure, there has been a shift in obligation from public provision of health services to an individualized responsibility for health outcomes where health is increasingly commodified and citizens are recast as consumers (10). In low- and middle-income countries, political destination, governance, and resource allocation are lacking to achieve UHC (11). On the other hand, proper health financing modality is a pathway to achieving UHC. Inappropriate health financing models and disproportional resource allocation are bottlenecks that can hinder achieving UHC (11). Since UHC is a multisectoral and multidimensional issue with an ambitious health goal, careful and smart resource distribution in healthcare is needed. There is also a need for conceptual and contextual clarity in UHC. There is no uniformity in the conceptual definition or scope of UHC, including whether UHC is achievable, how to move forward, common indicators for measuring its progress, regular monitoring of those indicators, and clear interpretations of those indicators (12). Therefore, conceptual clarity, proper measurement, and the formation of community-based essential healthcare package are needed (13). An American education publication company has suggested that a link of historical development of healthcare with UHC should be mandatory to track those indicators (14). The aim of this study was to describe theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC. A review of past efforts, analysis of current trends, and clear future directions are necessary to achieve UHC.

Methodology

We used a general review approach to dissect UHC from multiple perspectives. To be more focused, conceptual and historical developments toward UHC have been presented from the available literature. We fixed the article's content in light of policy and program confusions in various countries (15), the multiple foundations of UHC (16), gaps in healthcare equity and excess during historical paradigm shifts (17), and the current and future challenges on the path of UHC (18). The future challenges for UHC presented in this article were articulated on the basis of epidemiological, demographic, existing policy discrepancies, and lifestyle factors associated with healthcare (11, 19). We selected the literature in 4 steps as follows: (1) search the literature by keywords through Google, (2) sort the title by those that best match in first 5 webpages, (3) go for full access to the literature from the titles, and (4) pick up it, if the paper is useful or discard it. Major keywords searched for studies were universal health coverage, health disparity, healthcare access, equity, philosophy, historical development, conceptual analysis, social health protection, public health emergency, and so on. The nature of our study does not demand hard inclusion and exclusion criteria. Regarding the quality of literature, almost all were taken from peer-reviewed journals, books, and reports, and all references are available online. A concept analysis is a process to guide the explanation of a concept that might be vague, ambiguous, confusing, or incomplete (20). It is a well-established methodology in public health practice that is used to examine many contents, which are key for preventive health and health promotion including cultural aspect (21), empowerment (22), participation (23), equity (24), and health literacy (25). This study adopted an evolutionary concept analysis process developed by Rodgers (26) to incorporate ideas by Risjord (26, 27). This concept analysis needs to explore contextuality in terms of time, place, and discipline. In contrast, a “theoretical concept analysis” aims to represent the concept as it appears in a particular body of scientific and theoretical literature. A concept analysis is often used to explore new and underdeveloped concepts and theories. Additionally, it can also be used to clarify and define concepts that are open to individual interpretation, multiple truths, and subjectivity (28).

Historical analysis was performed for health service equity, access, and quality in different stages as a method where the gradual development of UHC was ovulated. We presented healthcare philosophy, theories, and policy practices in three historical periods, namely, health for all (1978–2000), millennium development goal (2000–2015), and ongoing sustainable development goal (SDG, 2015–2030), which includes WHO's 13th General Program of Work (WHO GPW13) period, 2018–2025 (with extension agreed by its member states). We presented health service coverage, financial service coverage, and population coverage using historical trend analysis of modern healthcare. Furthermore, issues of healthcare equity and access have been linked to politics, health financing, human right, and each individual responsibility ( Table 1 ).

Table 1

Review approach, conceptual, and historical analysis summary.