The Lancet series on universal health coverage

The issues surrounding universal health coverage – how an adequate standard of health care can be provided to all people – have never been more controversial or politically relevant than now. Globally, paying for medical expenses out of pocket is still the dominant method of meeting health care costs, and WHO estimates published in 2010 suggest that more than a billion people cannot use the health services they need, either because they are not available, or because they cannot afford to use them.

The Lancet today [Thursday, September 6, 2012] publishes a special collection of papers exploring the social, political, and economic issues around universal health coverage (UHC), addressing the evidence base for the effects of universal health coverage on population health, government involvement in universal healthcare, and how low-income and middle-income countries in Africa and Asia are making the transition to universal health coverage. Additionally, the Series features a Viewpoint by Jeffrey Sachs in which he asks how poor people in low-income countries can achieve an adequate standard of health care, plus Comment pieces by former Mexican health minister Julio Frenk and the World Health Organization's David Evans.

• Evidence suggests that progress towards universal health coverage results in substantial improvements to population health (Series 1)
• Universal health coverage has not be achieved in any system which relies on significant out-of-pocket payments (Series 2)
• Low-income and middle-income countries progressing towards universal health care do not conform to existing archetypes (Series 3)
• Professor Jeffrey Sachs: "Universal health coverage is in our reach – if we persevere" (Viewpoint)

Series 1 – Evidence suggests that progress towards universal health coverage results in substantial improvements to population health

It is often taken for granted that universal health coverage leads to improved health outcomes, but does the evidence support this assertion? In the first paper of The Lancet's Series on universal health coverage, Dr Rodrigo Moreno-Serra and Professor Peter Smith, of Imperial College London's Business School and Centre for Health Policy, provide a comprehensive assessment of the current evidence for the effects of universal coverage on people's health. They find that the evidence available suggests that broader health coverage leads to better access to necessary care and improved population health, particularly for the poorest people. However, the authors warn that progress towards universal health coverage may be at risk in the current financial climate, and if financial pressures result in universal health coverage being neglected in some countries, this is likely to have an adverse effect on people's health and their broader welfare.

Professor Peter Smith, Business School and Centre for Health Policy, Imperial College London, UK T) +44 (0)20 7594 1904 E) peter.smith@imperial.ac.uk

Series 2 – Universal health coverage has not been achieved in any system which relies predominantly on out-of-pocket payments

In the second Lancet Series paper, a group of experts led by Dr William Savedoff, who is a senior advisor at the Results for Development Institute in Washington D.C., examine the political and historical trends associated with progress towards universal health coverage. They note that no country has achieved universal health coverage so long as the health system relies predominantly on out-of-pocket payments for costly medical treatments or basic preventative care – countries generally make the transition to universal health coverage by increasing the proportion of publicly-managed or publicly-regulated financing mechanisms. The authors argue that government action is a necessary part of the transition to universal health coverage. As the authors state, "Universal health coverage costs money but it doesn't have to be expensive…Countries are likely to be more successful if they recognise that political action is needed to direct future growth in health spending through pooled financing mechanisms that enable the promotion of equitable and efficient health care."

Dr William Savedoff, Center for Global Development, Washington D.C., USA T) +1 207 443 2331 [initial contact by email preferred] E) wsavedoff@cgdev.org

Series 3 – Low-income and middle-income countries progressing towards universal health coverage do not conform to existing archetypes

Once a preserve of high-income nations, universal health coverage is now being implemented in many low-income and lower-middle-income countries. In the third Lancet Series paper, Gina Lagomarsino of the Results for Development Institute and colleagues analyse nine countries in Asia and Africa that are currently moving towards universal health coverage. The countries studied are India, Kenya, Mali and Nigeria – all of which are at an early stage of health care reform – and Ghana, Indonesia, the Phillippines, Rwanda, and Vietnam –which are at an intermediate stage of reform. Strikingly, the authors find that none of these countries have chosen a model of health care based on existing systems developed in higher-income countries, instead developing their own solutions to the challenges of establishing universal health coverage. However, there are some commonalities in the strategies these countries are employing as they proceed with reforms. The authors point to the critical importance of developing universal indicators of progress towards universal health coverage, which would allow policy makers and health workers to measure how well they are progressing and make improvements if necessary.

Gina Lagomarsino, Results for Development Institute, Washington D.C., USA T) +1 202 470 5720 [office] / +1 202-329-8104 [mobile] E) glagomarsino@resultsfordevelopment.org

Viewpoint – Professor Jeffrey Sachs: "Universal health coverage is within our reach – if we persevere"

In a Viewpoint published as part of The Lancet Series on universal health coverage, Professor Jeffrey Sachs, Director of Columbia University's Earth Institute, asks how poor people in low-income countries can achieve an adequate standard of health care. To close the financing gap for universal health coverage in the poorest countries, Professor Sachs identifies a need for global donor assistance of around $40 billion per year, corresponding to just 0•1% of high-income annual gross product – or roughly 10 cents per hundred dollars of donor national income. With current donor aid of around $27 billion per year, the shortfall is a very modest $13 billion per year. As Professor Sachs points out, "even in the midst of poverty, much of the excess disease burden can be controlled at fairly low cost, even before poverty itself is relieved." Professor Sachs also explores whether privately-provisioned healthcare deserves its widely-held status as the best model of healthcare provision. Controversially, Professor Sachs suggests that publicly-provisioned healthcare (such as the UK's National Health Service) shows some distinct advantages over private-sector provisioning.

For Professor Jeffrey Sachs, The Earth Institute, Columbia University, New York, USA, please contact Erin Trowbridge E) etrowbridge@ei.columbia.edu