Universal health coverage and universal access.

Editorials 546 Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda. 1 Whether it is a means to an end or an end in itself and whether it is measure-able are subjects of heated debate. 2 In this issue of the Bulletin, Kutzin argues that universal health coverage not only leads to better health and to financial protection for households, but that it is valuable for its own sake. 3 More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access. This editorial focuses on this question. Universal health coverage is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments. 4 It involves coverage with good health services – from health promotion to prevention, treatment, rehabilitation and palliation – as well as coverage with a form of financial risk protection. A third feature is universal-ity – coverage should be for everyone. Although many countries are far from attaining universal health coverage, all countries can take steps in this direction. 3,4 Improving access is one such step. Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things. Hence, universal health coverage is not possible without universal access, but the two are not the same. Access has three dimensions: 5-8 • Physical accessibility. This is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them. • Financial affordability. This is a measure of people's ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation to and from facilities and of taking time away from work). Affordability is influenced by the wider health financing system and by household income. • Acceptability. This captures people's willingness to seek services. Acceptability is low when patients perceive services to be ineffective or when social and cultural factors such as language or the age, sex, ethnicity or religion of the health provider discourage …