Gender and Development

The Universal Challenge Of Achieving Universal Health Coverage

Several years after the adoption of the United Nations Resolution on Global Health and Foreign Policy, Universal Health Coverage has achieved a priority status on the international agenda, despite its ambiguities. Ana Zhelyazkova explores the concept of Universal Health Coverage and makes the case for highlighting the quality of care as a second pillar of Universal Health Coverage along accessibility.


Notably after Universal Health Coverage (UHC) took center stage as the theme for the World Health Day in 2017, the term evolved into a trending topic among stakeholders. In the past few years, the rapidly increasing popularity of the concept helped place UHC on the international agenda and even bolstered its utilization as a tool for promoting multilateralism. Although the widespread dissemination of the term can generally be perceived as a positive development in global health, it simultaneously highlights the abstract nature of UHC as a concept and intensifies the challenge of assembling all stakeholders around one universal understanding and, thus, one common path towards achieving health care for all.

What is UHC?

As a concept intertwining universality and the fundamental human right to health, UHC represents the most comprehensive multilateral, interagency and impartial effort to ensure the actual implementation of a single article of Universal Declaration of Human Rights to date. Scalable outcomes require work by heterogeneous actors from civil society, private and public sector, government, and international organizations; a clear definition of UHC’s goal is a prerequisite for achieving success. In the case of UHC, the spectrum of interpretations triggers a dilemma: if coverage is the goal, to which extent is quality considered?

Beyond the occasional synonymous use of “care” and “coverage,” the dissonant nuancing of the abbreviation UHC has spurred some varying perceptions of the concept of quality as part of UHC: deriving from the UN Resolution on Global Health and Foreign Policy, the World Health Organization (WHO) states that “the quality of health services should be good enough,” the World Bank Group (WBG) explicitly incorporates the idea that all people should be able to “access quality essential health services” in its description of UHC while the European Commission highlights the “identification of quality.” The challenge of formulating a universal definition and, thus, approach to quality in UHC is recognized by the WHO and the WBG as the organizations state in their latest joint Global Monitoring Report that “Implicit in the definition of UHC is that the services are high quality, meaning that people are diagnosed correctly and receive the interventions currently agreed to be necessary.” Approximately a year later, the organizations (including Organization for Economic Co-operation and Development, OECD) issued a report calling for urgent action at the national level for developing and implementing measures to ensure and monitor quality standards. While addressing the issue of quality in UHC has long been due, this call for action at the national level shouldn’t be understood as a complementary measure to enabling access to care; rather it addresses the second pillar of UHC: ensuring quality care.

Beyond delivering access to care

The explicit introduction of quality as a fundament in achieving UHC can be viewed as an attempt by the international stakeholders to better the originally access-centered conception of UHC along the primum-non-nocere principle. Indeed, a recent systematic analysis calculated that, in low- and middle-income countries, improving the quality of already available care would amend more deaths than increasing the access to care. Emphasizing the validity of this estimation in a similar real-life scenario, the Implant Filesjust recently provided an example of how low quality of care in a high-coverage setting can cause harm. Beyond all reported patients’ stories, the Files and the greater number of European patients affected by low-quality medical implantable devices and products demonstrate the damage that universal accessibility of care can cause when the care is not sufficiently (or at all) regulated. Although the Implant Files might appear to be a revelation of continued and unexpected failure of national and international health authorities, the investigation emerged against the background of a health systems’ wreck: “Fewer than 30% of the world’s medicines regulatory authorities are considered to have the capacity to perform the functions required to ensure medicines, vaccines and other health products actually work and do not harm patients.”

Aside from the already evident need for stronger enforcement of quality standardization, potential developments in health coverage strengthen the argument for highlighting quality in UHC. With the increase of Chinese investments in African countries, the positive association between commercial-oriented financial flows from China to the African continent and the political and voting realignment of African countries toward China, promises to have a progressively larger effect on thelikelihood of African leaders adopting national and global health policies in accordance with the Chinese example. Thisunderlines the risk of prioritizing coverage and quantity while compromising quality, emphasizing the need to urgently focus on the quality of provided services under UHC. Concurrently and in addition to the presence of “traditional medicines” in the list of health measures included in the 2017 UN Resolution on UHC, the visibility of Chinese influence on global health has recently enhanced through the G20 Declaration of Buenos Aires and the explicit placement of “scientifically proven traditional and complementary medicine” among the evidence-based interventions towards achieving UHC.

As the visibility of substandard and not evidence-based care stealthily intensifies, the argument for highlighting quality along access as a fundament of UHC grows. It is imperative to acknowledge the steps that the international organizations and civil society are taking towards setting and improving the standards and regulations needed. With a large portion of the legislative and health systems’ infrastructure required to ensure high-quality care already available worldwide, the matter of actually implementing health care quality standards is one of political commitment and decisive enforcement.

Ana Zhelyazkova holds a Master’s Degree in Public Health and Bachelor’s Degree in Communication studies and Political Science. She currently works as a Research Associate at the Pettenkofer School of Public Health, LMU Munich, with focus on Health Communication and Policy. She also serves as Public Information Officer for the Association for UN Interns (AUNI), New York.

Please note that opinions expressed in this article are solely those of our contributors, not of Political Insights, which takes no institutional positions.

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