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Universal Health Coverage (UHC) is a health care system providing health care and financial protection to all its citizens. The World Health Organization (WHO) defines UHC as a health care system with a motive of equity in access through promotive, preventive, curative and rehabilitative health interventions.

With regards to the evolution of this concept, Germany, in the 19^th century had already come up with a health policy for all its citizens. The policy was very much in line with the current notion of equity in access to health services. In the modern context, New Zealand (1941), UK (1948), Sweden (1955), Iceland (1956) and Norway (1956) were the countries to have health care policies aligned with the equity in access model.

Under UHC policy, everyone is allowed treatment, but it does not mean everyone receives health care as some may choose not to receive treatment or may be ignorant about the availability of health care services. UHC is not a logical successor to the concept of Health for All. UHC is both a possible target and an input to the achievement of health outcomes. For the most part the MDGs defined the goals and targets but not the means necessary for their achievement. UHC could be the means for the achievement of goals and targets set out by Millennium Development Goals (MDGs).  UHC should be understood as a direction rather than a destination. No country - not even the richest one - is able to fully close the gap between the need for and use of services, but all countries want to reduce that gap, to improve quality and improve financial protection. Context-specific policy measures addressing the health and development priorities of a given country then become possible.

According to the World Bank, 22 countries namely Argentina, Brazil, Chile, China, Colombia, Costa Rica, Ethiopia, Georgia, Guatemala, India, Indonesia, Jamaica, Kenya, Kyrgyz Republic, Mexico, Nigeria, Peru, Philippines, Thailand, Tunisia, Turkey and Vietnam have expanded their access to health care in the last decade.  Drawing from the case studies of these countries, it has come up with some essential requirements to have an effective UHC Policy:

• Empowering users to demand the benefits promised to them;
• Strengthening the capacity of ministries of finance to ensure that promises of benefits are realistic;
• Strengthening the capacity of ministries of health to oversee the improvement of quality;
• Introducing systems that incentivize higher productivity and control costs;
• Ensuring that public subsidies prioritize the poor and vulnerable; and
• Requiring periodic reporting of the achievement of health coverage and health outcome milestones

With regards to availability of fund for operating health care policies, health care provisions of some Asian countries are presented below:

• Vietnam has Compulsory and Voluntary Health Insurance Schemes where the primary source of funding is the general government revenues. Revenues are collected from the formal sectors and monetary contributions are made in terms of paying the premiums. The entire cost of the scheme, which is 4.5% of minimum wage, is covered by the state budget.
• Indonesia has a scheme named Jamkesmas which collects fund through general government revenues. This scheme covers the entire population and contribution is made through co-payments of premiums. As funded by the central government, the beneficiaries are not responsible for premium payments nor are charged copayments at the time of visit.
• Kyrgyz Republic has devised a policy of Mandatory Health Insurance Fund collected through payroll tax and general government revenues, contributed by the formal and informal sectors as well as government employees through co-payments. Under this fund, employed population need to pay 2% of their income as roll tax, followed by farmers who pay 5% and payable for the employers.
• In Mali, there is a policy named Mutuelles which collects fund through general government revenues and member contributions. Informal sector is mainly responsible for collection of fund through premiums and co-payments.
• Taiwan's National Health Insurance policy has provision of contributions from members and employers as well as general government revenues. The formal and the informal sector along with the government employees contribute in the form of premiums and copayments.
• Thailand has a Universal Coverage Scheme which gathers fund from general government revenues. This scheme is financed through general tax revenues paid to local contracting units on the basis of population size.

These country-specific cases reiterate the fact that for a country to have a UHC policy, several arrangements need to be made in terms of recognizing the sources of fund to provide health services to all its citizens, the mechanisms and the institutions involved in collection of the fund and the methods of payment to be made by the contributors.

UHC as a health policy has received both accolades and lack of support owing to agreements and disagreements regarding its effectiveness. In order to advocate that UHC is a necessity, health policy makers have come up with the following advantages of the implementation of UHC policy:

• Due to increasing unaffordability of health care, free medical services would encourage the patients to practice preventive medicine and inquire about their problems early so that the treatment becomes much easier.
• Investments in businesses and productive sectors would be high owing to the assurance that their health insurance is covered.
• It extends care to anyone, regardless of social status or bank account.
• Overall costs of treatment would be reduced with reduction in tests, hospital stays and other procedures.
• The establishment of universal public systems early on will avoid stigma associated with public/private systems and facilitate more equitable provision.
• UHC ensures fairness, addressing the concept of imperfect competition, increase profitability among hospitals and lowers administrative costs.
• There is increased efficiency and decreased medical errors.

The Interim Constitution of Nepal, 2007 recognizes health as a fundamental right of the people. In terms of the development of health policies in Nepal, the 1975 health policy talked of providing minimum services to the maximum number of people followed by declaration of Health for All strategy in 1978. The 1991 National Health Policy focused on effective service delivery of primary health care in the rural areas of Nepal. Successive eighth (1992-1997), ninth (1997-2002) and tenth (2002-2007) five year plans followed by interim periodic plan (2007-2010) and second long term health plan (1997-2017) were formed as development to the National Health Policy of 1991.   

The UHC policy can only be implemented if there are supportive mechanisms. First and foremost, Nepal should have adequate physical and human resources to provide health care services to all the citizens. Secondly, there needs to be a proper system designed to recognize how the government fund is to be collected in terms of taxes to be borne by the citizens and revenues collected from various sources. To make UHC a meaningful and 'practical' concept, there should be a well-functioning health system with trained staff, equipment and drugs as well as preventive and rehabilitative services. There is a sizeable number of private health care institutions in the country. When the UHC policy is to be implemented, particularly in the context where there is more government presence in providing the health facilities, there is requirement of public-private partnership so as to keep private institutions within the framework of UHC policy. To ensure that there is maximum cooperation from the private sector, some incentives also need to be provided to the private sector.

From the 'public need' perspective, universal health coverage provides much public value as people are assured that health service is affordable and available to them when they are in need. This will reduce the morbidity, disability and mortality of the entire population ultimately resulting in healthy human resource. The 'humanitarian' model of global health ethics also extends this notion of moral obligation to assist less fortunate population in their desirability to reduce their disease and suffering.

The essence of UHC is to ensure that no citizen is deprived of health care. For a state, this concept moves beyond the understanding of right to health as a political right to being a social responsibility of ensuring that all citizens are provided with health care as means of social security. This gives an opportunity for better health outcomes as the success stories of several developing countries adopting UHC policy reveal that trend. Therefore, Nepal should seriously start considering adopting the UHC policy. 

References:

1.  The Political Economy of Universal Health Coverage, Stuckler et al 2010. Retrieved from: http://www.healthsystemsresearch.org/hsr2010/images/stories/8political_economy.pdf

2.  Universal Health Coverage, An Economist’s Perspective, Donald Hirasuna. Retrieved from: http://www.house.leg.state.mn.us/hrd/pubs/univhlth.pdf

3.  Health Policy Design and Implementation in Nepal: A Policy Discussion, Narendra Raj Paudel. Retrieved from: http://pactu.edu.np/contents/project/files/health_policy_design_and_impl...

4.  National Health Research Policy of Nepal, NHRC. Retrieved from http://nhrc.org.np/files/download/968163e34d708cf