Universal health coverage: the post-2015 development agenda.

The passage of a UN General Assembly resolution on universal health coverage (UHC) in December, 2012, underlines how UHC is becoming a key global health objective. Adopted by consensus, the resolution urged member states to develop health systems that avoid substantial direct payments at the point of delivery and to implement mechanisms for pooling risks to avoid catastrophic health-care spending and impoverishment. This resolution sets the stage for UHC to become a unifying central health goal in the post-2015 Millennium Development Goal framework. The Millennium Development Goals (MDGs) transformed global health: they galvanised politicians and citizens, stimulated civil society, encouraged robust monitoring and evaluation frameworks, motivated research communities, and created new institutions. By focusing global communities on a common agenda, the MDGs confi rmed that progress for poor and marginalised people is possible. Yet the MDGs also had major shortcomings. They ignored the central role of health systems, overlooked emerging health concerns such as non-communicable diseases, tended to exacerbate fragmented health systems by focusing on fi nal health outcomes related to vertical programmes rather than on building integrated health systems, and at times contributed to inequities in health. To redress these shortcomings and respond to new challenges, the global health community should consider using UHC to frame the health goal from a system perspective. UHC is defi ned by WHO as universal access to needed health services without fi nancial hardship in paying for them. UHC allows for a greater focus on the equitable distribution of access to health services and demands a universal focus within and across countries. Moreover, UHC is a goal relevant for all countries, rich and poor, as illustrated by the broad support for the UN resolution on UHC. Uniting the health sector around one health goal focused on UHC with multiple subgoals recognises that “one size” does not fi t all, but that there are a set of system-level constraints to scaling up access to health. Challenges such as absorptive capacity, human resources for health, and health fi nancing must be addressed. One global UHC goal would recognise these similarities in constraints, while giving each country the opportunity to customise their approach to achieving this system-level goal. To achieve sustainable UHC, health systems need to deliver and measure progress on two inter-related components: access to coverage for needed health services (prevention and treatment) and access to coverage with fi nancial risk protection. One possible indicator of the latter is out-of-pocket spending on health (the share of health spending paid for by the patient at the point of service). Worldwide, about 150 million people a year face catastrophic healthcare costs because of direct payments such as user fees, while 100 million are driven below the poverty line. To the extent that people are covered by a riskpooling mechanism, their out-of-pocket expenditure will not cause fi nancial hardship. Out-of-pocket expenditure for health also illuminates inequities in that richer countries—and richer populations within those countries—tend to have lower out-of-pocket expenditure. Additional indicators of access are needed for coverage, and experts at WHO are leading a working group on this challenging issue. The UN resolution on UHC illustrates the impressive momentum behind the need to accelerate action towards UHC as a strategy for improving health and ameliorating inequities in health. Using the postMDG process as a platform to build on the movement that sees health systems as the backbone of a healthy population, we hope to ensure that in another 15 years,