According to the World Health Organization (WHO), universal health coverage (UHC) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’.1 Sustainable Development Goal (SDG) target 3.8 calls on states to ‘achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’.2 Although a growing number of studies link UHC with a range of health, economic and social outcomes, recent estimates indicate that about 930 million people in the world spend more than 10 per cent of their household income on health care and therefore lack full financial protection for essential health services; the problem is not confined to low-income countries.3 The WHO’s well-established universal coverage ‘cube’ identifies three dimensions of coverage: the population covered (who is covered), the services covered (which services are offered and received) and the proportion of costs covered (how much users must pay directly), together with the question of how the health system is administered.4 A high-quality health system has been defined as one that optimises health care in a particular setting by consistently delivering care that improves or maintains health, by being valued and trusted by the community it serves, and by responding to the changing needs of the population.5 The quality of care currently provided appears insufficient, especially in low- and middle-income countries (LMICs). Although the era of the Millennium Development Goals (MDGs) expanded access to essential health services, the quality of that care remains a problem in LMICs, which continue to record consistently high rates of infant, child and maternal death.6 The objective of this paper is to make a comparative study of the private and public healthcare systems under the UHC framework in India.
UHC entails recognising and respecting an extensive set of human rights: the rights to life, health, personal security and bodily integrity; to equality and non-discrimination; to an adequate standard of living, including access to water, food, housing and education; to freedom of movement, association, assembly, information, thought and expression; to social security, privacy and participation; and to certain minimum conditions of livelihood, such as water, food and a roof over one’s head. All of these rights are protected in international and regional treaties and in national constitutions and, taken together, many of them are recognised as customary international law. Above all, they can be traced back to the Universal Declaration of Human Rights.7 The Universal Declaration was adopted in the aftermath of the discrimination and polarisation of the Second World War, not long after the founding of the United Nations, for which the promotion of human rights was one of the core purposes.8 The aspiration to realise the highest attainable standard of health as a human right is found in the preamble to the Constitution of the World Health Organization (1946).9 In addition, particular laws and a growing body of case law show how human rights standards and principles can be used to shape national health systems and to set bounds for what governments, as stewards of their health systems, ought and ought not to do.10
The resolutions adopted by the World Health Assembly over the years in support of UHC have championed the notion that human rights, and especially the right to health, offer ‘the broad parameters of UHC’.11 Similarly, the UN Special Rapporteur on the right to health has argued that UHC should be understood through the lens of the right to health.12 The overarching goal of UHC is to ‘ensure that all people have access to the health services they need without suffering financial hardship when paying for them’.13 An examination of the elements of the right-to-health framework and of UHC reveals links between them. Although the right to health is part of the rights-based framework, the constitutions of many countries do not contain these elements. After analysing the constitutions of 191 countries, Kinney and Clark (2004) found that 67.5 per cent contained provisions on health or health care.14 Backman and others (2008), in a critical review of the health systems of 194 countries against right-to-health indicators, reported that 121 countries had no constitutional provision on the right to health and that many had no comprehensive plan to regulate the private health sector.15 The legal obligations flowing from the right to health apply not only to the public but also to the private health sector. Human rights treaties impose three types of obligation on governments: to respect, to protect and to fulfil. The obligation to respect requires governments to refrain from interfering, directly or indirectly, with the enjoyment of the right to health; the obligation to protect requires them to take measures to prevent interference with the right to health by third parties; and the obligation to fulfil requires them to take positive measures, including the adoption of suitable policies, towards the full realisation of the right to health.16
Universal health coverage rests on three terms, each with its own definition. ‘Universal’ means ‘covering all ... without limit or exception’;17 ‘health’ is defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’;18 and ‘coverage’ denotes ‘something that covers’, here both health services and financial protection.19 Taken together, the three terms point back to the declaration of ‘health for all’ and the 1978 commitment to primary health care (PHC); their shared aspiration is a healthier world.20 Following the Millennium Development Goals, the UHC agenda seeks to improve access to quality health services while safeguarding households and individuals from the economic costs of seeking care.21 Globally, advances have been made towards UHC, but half the world’s population still lacks access to essential health services.22 It is further estimated that about 2 billion people worldwide face financial hardship because of health spending, of whom about 1 billion experience catastrophic out-of-pocket expenditure and 344 million are pushed deeper into extreme poverty.23 Fewer than a third of countries (42 of 138) managed both to expand service coverage and to reduce catastrophic out-of-pocket health expenditure after 2015, which suggests that, at the current pace, global progress towards the 2030 target is behind schedule.24 The reasons include a lack of political will, discordance between private and public welfare, insufficient health policies and weak health systems in middle- and low-income countries.25 It is not, however, entirely clear what UHC means: there is no shared understanding of its definition and breadth, and it has been poorly interpreted in some countries.26 In Kenya, for instance, stakeholders disagreed widely on how the concept of UHC should be defined.27 Such misunderstanding of what constitutes UHC can create confusion in service delivery, in monitoring progress, in celebrating success and in sustaining momentum towards UHC.28 Horton and Das contend that ‘the great gap that now exists for countries trying to deliver UHC is access to a library of knowledge to assist their decision-making’.29 To address this gap, a growing body of research has appeared, evaluating and mapping the literature on UHC,30 identifying best practices for realising UHC31 and measuring the attainment of UHC for older people.32
In some contexts (for example, the Asia-Pacific region), UHC is defined as a process of providing quality, equitable and comprehensive care and services, including promotive, preventive, curative, rehabilitative and palliative care, at a cost that people can afford or free of charge.33 The meaning of ‘affordability’ of care differs across settings: it may mean free care through the avoidance of direct payments; prepaid services through a government-funded health scheme; larger risk pools that enable robust cross-subsidy between the healthy and the sick and between the rich and the poor; or financial coverage of the informal sector and of households living on or below the poverty line.34 UHC has been conceived in several ways: as a legal and humanitarian concept; as a social concept (entitlement and enrolment comparable to the social security system); as a health-economic concept (financial protection); and as a public-health concept (comprehensive versus essential services).35 The monitoring indicator for the service dimension is known as effective coverage: ‘effective coverage is one measure that combines intervention need, utilization, and quality’.36 Nevertheless, UHC goes beyond the effective service coverage index. It offers ‘a comprehensive set of services with a high level of coverage with a view to improving equity of access’.37 Effective service coverage under UHC refers to the core package of services, or health benefits package (HBP), which is given higher priority for assessment and subsequently included in the scheme.38
Globally, the UHC effective service coverage index is calculated with tracer indicators across four categories: reproductive, maternal, newborn and child health; infectious diseases; non-communicable diseases (NCDs); and service capacity and access.39 Because countries differ, country-specific indicators for tracking UHC have also been formulated. In India, for instance, the tracer indicators have been expanded to include indicators for governance, stewardship and financing, and for palliative care.40 Likewise, the health workforce, the status of the health information system, mental health and injuries, health financing, efficiency and the utilisation of health services are used as UHC monitoring indicators on the supply side.41
The surest way to attain the SDGs would be to provide everyone with access to at least a minimum level of good health services.42 Both the public and the private sector are growing in the healthcare market. The demands on each sector depend largely on the efficient use of resources, on the unpredictability of how the healthcare market will respond to these institutions, and on new management concepts.43 Hollingsworth carried out a meta-analysis of 317 published articles on efficiency measurement44 and observed that ‘public provision could potentially be more efficient than private’.45 According to Lee and others, non-profit hospitals in the United States are more efficient than for-profit hospitals.46 It is generally accepted that the boards of for-profit hospitals have a business-oriented culture; they must, because they answer to investors, and an emphasis on quality of care over profit is not always evident.47 Private health insurance markets are also developing as a means of managing healthcare systems, using their capacity and serving as an alternative source of funding. This is not a simple matter, since private insurance involves a more complex financing mechanism which affects, and interacts with, public systems.48 Non-profit healthcare organisations, on the other hand, are generally more service-oriented and negotiate more aggressively with cost drivers such as managed-care contracts.49
The Indian system is fraught with varying degrees of inefficiency. The country has poorly trained human resources, especially in rural and inaccessible areas. The Indian state is paying the penalty for decisions taken in the early 1990s to cut public support to medical colleges heavily and to open up medical and nursing education to the private sector.50 Fewer doctors wish to work in the public sector even after private training, and even students from the top medical colleges tend to move into the highly rewarding private sector because of the better facilities and pay on offer.51 The considerable political will shown in placing more than 700,000 Accredited Social Health Activists (ASHAs), introduced in 2005, in rural areas has, at least to some extent, made its mark. Yet the programme is underfunded, and these health workers receive very poor compensation for a demanding and back-breaking workload.52
In addition, the proposal to create an ‘enlarged’ basic training (a three-year course for health staff) in order to recruit personnel for high-priority health problems has the ambition of combining wide adoption of primary-level care for common primary problems with an appropriate skill mix. This has not materialised, except to a very limited extent in a couple of states, owing to opposition from the medical fraternity.53 Education and training must be wide-ranging for primary-care general practitioners, nurses and paramedics, and must be matched to the needs of the setting rather than to the specialist skills needed in secondary care, which have little direct relevance outside tertiary hospitals. The curriculum must be designed to match these needs, and this may include bridging courses, special packages or the registration of new categories of health worker.54
Secondly, there is overuse of some services and underuse of others; some facilities are crowded and others under-utilised. Facilities, equipment and funds are mismatched to demand and are not used efficiently: high-traffic facilities exhaust their money in a matter of weeks, whereas low-traffic facilities cannot spend the money allocated to them. As a result, large sums lie idle while standards of quality at high-volume sites are very poor.55 It is estimated that about 40 per cent of Indians are still served by the government sector for in-patient care, while many communities have no facilities, or have facilities that are overcrowded for want of doctors and other health workers, and stocks of medicines and other consumables are inadequate.56
Because of shortages of health workers in rural communities, the cost of transporting patients to the nearest health facility can be enormous for some, and assured patient-transport schemes have reduced this only to some extent. The National Rural Health Mission (NRHM), launched in 2005, is an initiative to improve the quality of health delivery in the remoter areas where it is most needed. Quality has begun to improve, but in some cases progress has been inconsistent.57
The share of total health expenditure (THE) accounted for by out-of-pocket expenditure (OOPE) in India remained significant in 2019-20, at 47.1 per cent; this is the expenditure incurred by patients through direct payments for health care.58 Although about 72 per cent of the population lives in rural areas, roughly three-quarters of the country’s health infrastructure, medical manpower and other health resources are concentrated in urban centres.59 OOPE is especially significant in healthcare financing in developing and middle-income countries, where on average it represents no less than two-thirds of total health expenditure.60 In order to assess OOPE properly, it has to be distinguished from third-party payments, that is, payments by government-funded health programmes or by public or private insurers.61 OOPE becomes catastrophic when it exceeds 10 per cent of household consumption expenditure.62
About 3 per cent of the Indian population (around 38 million people) is estimated to be pushed into poverty every year by out-of-pocket spending on medicines alone.63 A large share of Indian households continues to incur OOPE despite social security schemes such as the Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), which seeks to ensure the availability of affordable, quality medicines, and health insurance schemes such as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the Central Government Health Scheme (CGHS), the Employees’ State Insurance Scheme (ESIS), the Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) and the Vajpayee Arogyashree Scheme (VAS).64 A weak public health system with a high burden of medical expenditure and low insurance penetration, combined with a perception that the private sector offers better quality, drives spending towards the costlier private sector and magnifies the OOPE burden.65 The impact of OOPE is most visible in countries with poor public systems and heavy dependence on private providers. In these conditions, household payments are compounded by two factors: the direct costs of sickness and the income forgone through absence from work.66
Social health insurance and tax-based funding not only reduce OOPE considerably in high-income economies but also ensure access to care for those without means.67 Out-of-pocket expenditure on health has been extensively researched in India and other South Asian countries. In most cases, this has been done quantitatively, using household survey data and econometric tools to estimate the financial burden on individuals or households.68 OOPE is the main contributor to impoverishment and catastrophic health expenditure in the region.69 Research from sub-Saharan Africa shows that the burden of OOPE often increases where public health facilities are unavailable or of poor quality, because patients then opt for the more expensive private sector.70
Although demand for private hospitals has been rising for the reasons above, it is likely to have been driven above all by the demand for faster, more responsive service and higher-quality care, since private hospitals generally have better facilities and faster service, but charge more.71 Cost is a significant determinant of healthcare choices, leading most people, especially those in lower income groups, towards public facilities because of their affordability and the free treatment provided there. This is consistent with the observation that the cost of care prompts people to use government hospitals despite concerns about quality.72 Others are more willing to pay extra out of their own pockets for private hospitals than to incur the indirect costs of public hospitals, on the basis of perceived better quality of care and shorter waiting times. This tension between credibility and cost mirrors the wider trend in public versus private care and underlines the need for government intervention to improve both the cost and the quality of public health care.73
Quality of care is not measured in a standardised, replicable and comparable manner in low- and middle-income countries.74 Poor quality is often attributed to a lack of resources.75 Substantial variation in processes of care has, however, been reported both between and within countries.76 The data that are available relate mainly to elements of the health system such as infrastructure, the availability of human resources, supplies and equipment, services and coverage, and outcomes.77 The views of users and patients are now also increasingly accessible.78 Among Donabedian’s three categories (structure, process and outcome),79 however, a gap remains in measuring the performance of processes of care. Process is as much a part of good health care as the end result.80 In most situations the link between processes and outcomes is not well defined,81 and outcome information is of little help in identifying which processes should be improved.
In high-income countries, quality measures are both common and useful.82 The data are used for monitoring healthcare quality, assessing quality improvement initiatives, implementing pay-for-performance and public reporting.83 Unfortunately, these measures often depend on complex health information systems and electronic health records (EHRs), which remain a far cry from reality in many low- and middle-income countries.84 Medical records have historically been used for quality audits and improvement projects.85 Audits of medical records, routinely performed in conjunction with feedback to providers, can enhance adherence to clinical guidelines.86
The application of explicit techniques leads to the development of ‘quality indicators’ with performance standards for assessing clinical practice.87 Such indicators are chosen, following the development of clinical guidelines and the deliberations of expert panels, to capture the most clinically relevant measures.88 Patients are aggregated into diagnosis groups and assessed to determine whether complications, comorbidities or other patient characteristics predict the utilisation of hospital resources.89 While the use of algorithms and conditional logic complicates data collection, computer-assisted data-abstraction software makes it possible to implement skip patterns, conduct data-quality checks and perform calculations during the abstraction process.90
Additional documentation would, moreover, improve the precision of the data abstracted. Where patient outcomes are recorded in the notes, such an effort has a direct effect on quality; it may also encourage practitioners to adhere to clinical protocols, which has been shown to produce better results.91 As countries move closer to universal health coverage, the global health agenda should focus on improving the quality of care. Measuring quality indicators in national health surveys, along the lines of the Multiple Indicator Cluster Surveys (MICS),92 could be an initial step.
A primary goal of health systems is to reduce the financial hardship associated with the use of health services. In recognition of the close links between health and social circumstances, this function of financial protection (FP) seeks to sustain living standards in the face of illness.93 Both the WHO’s social determinants of health framework and the UHC framework identify FP as one of the tools that can improve health equity, by ensuring access to health services according to need rather than ability to pay.94 Consequently, as a key indicator of health system performance, FP has interrelated health, economic and ethical implications that must be explored.95
There are many forms of financial protection for health, such as benefits and transfers designed to reduce or remove patients’ out-of-pocket (OOP) spending on health, and the prepayment and pooling of health-related financial risk.96 In the context of UHC, the principal concern is out-of-pocket health expense in the form of payments for services or materials, insurance premiums, cost-sharing for items or services (for example, co-payments, co-insurance and user fees) and indirect costs (for example, transport) incurred in order to use health care.97 The majority of efforts on UHC policy have been directed at improving the benefits package in low- and middle-income countries.98
In the light of growing concern over health inequities and the equitable distribution of health care, growing pressure on health-system resources and declining returns to certain kinds of marginal health expenditure, FP is an ever more pertinent issue for these countries too.99 Statistical measures of FP fall under three broad headings: ‘threshold indicators’ of FP, based on OOP spending measured against specified financial thresholds; the value of the FP provided to recipients of health care; and the impact of financial barriers on access to health care.100 These measures cannot, however, identify inequalities in health in terms of cost, or whether people are forgoing health care that they need because of a failure of FP.101 It can be argued that measuring the effect of financial barriers under UHC goes beyond FP as a health coverage instrument, since it is designed to measure phenomena related to intervening strategies.102 Yet this view might shed further light on many common phenomena that cannot be explained simply by separating the health and financial implications of coverage: for instance, the joint distribution of health and financial consequences, the process by which trade-offs between them evolve over time, and the way in which unmet FP produces costly health consequences. Synthesising health and financial considerations remains a challenge.103
The OECD defines it thus: ‘Household out-of-pocket expenditure on health comprises cost-sharing, self-medication and other expenditure paid directly by private households, whether or not the contact with the health care system was made through referral or on the patient’s own initiative’.104 A certain level of OOP payment is regarded as desirable, being a sustainable and efficient means of resource collection so long as it remains below a certain threshold. When OOP payments exceed that threshold (the WHO currently sets it at 10 per cent or more of the resources available to a household, although a threshold of 40 per cent or more of the household’s capacity to pay is also used), they are labelled catastrophic.105
SDG indicator 3.8.2 measures the proportion of the population with large household expenditure on health as a share of total household expenditure or income; catastrophic expenditure is assessed at two thresholds, namely more than 10 per cent and more than 25 per cent of total household expenditure or income.106 On the World Bank’s indicator of out-of-pocket expenditure as a share of current health expenditure, India’s share is among the highest in the world.107 India is also among the countries that spend little on health. Under the National Health Policy 2017, the Government of India intends to raise public health expenditure to 2.5 per cent of gross domestic product (GDP) by 2025,108 from the level of 1.15 per cent recorded when the policy was framed.109
India devotes only around 3 to 3.5 per cent of GDP to current health expenditure, well below the world average of roughly 10 per cent.110 Despite being among the largest funded programmes, the National Health Mission (NHM) also saw its allocation fall: its allocation for 2018-19, roughly 55 per cent of the total budget of the Ministry of Health and Family Welfare (MoHFW), was a 2 per cent decrease on the revised estimates for 2017-18.111 The Government of India, in its Economic Survey 2020-21, nevertheless advocated the development of the general healthcare system rather than spending on specific areas.112
There are serious problems in primary care provision because of inadequate resources and personnel, the absence of integrated funding and financial arrangements, and a lack of good performance governance.113 The Indian healthcare system is thus peculiar in that nearly 70 to 80 per cent of people have to pay for health care themselves.114 Only a minority, around 20 per cent of the population, is covered by central and state government health insurance schemes, around 10 per cent is covered by private insurance, and the rest must foot the bill themselves.115 These considerations point to the deprived state of consumers of health care in India and to the need for an early basic universal healthcare delivery system.116 Given this undercutting of the accountability of healthcare providers to the population, patient choice is a way of empowering patients and also of increasing the accountability of government to the patients it represents.117
Yet it can also be said that, through appropriate cooperation and communication with the patient, the physician can balance the patient’s choice architecture with expert advice so as to facilitate the patient’s decision-making among the available options for his or her benefit.118 The patient-empowerment paradigm is relevant not only in health care but also in any health-marketing intervention that seeks to influence health behaviour and quality of life. An empowered consumer is one who can convert the options available into action and make more informed decisions.119 Developed countries, and the United Kingdom in particular, have begun to put the concept of choice into practice by helping patients on waiting lists to choose their hospital for elective surgery and for the management of chronic illness.120
Out-patient services constitute the most important component of the ‘product’ when hospitals market health services.121 The patient experience is considered fundamental to the co-production of value in health care.122 Findings also repeatedly point to a positive and linear relationship between patient experience and overall patient satisfaction with both the service provider and the health system.123
The Constitution of India places public health and sanitation, and hospitals and dispensaries, within the legislative competence of the states. Providing health care to the people is therefore primarily the responsibility of the states, which are charged with raising the standard of health of their populations.124
Private hospitals tend to have more flexible, multi-layered management structures. Institutional decisions are made relatively rapidly, since their administration is largely autonomous and can adapt to, or dispense with, partial criteria of need; private clinics may be run by trustees or corporate structures for efficiency and profitability. Government hospitals, by contrast, are administrative organisations within a hierarchy of state or national health policy; management is often bureaucratic, with decisions flowing from the top down, and these hospitals usually give primacy to public health over financial return, so that medical services are available to everyone.125
Private hospitals have the advantage of massive capital investment, which has produced state-of-the-art infrastructure and the latest medical technology. Government hospitals are generally constrained by limited budgets and administrative setbacks, and their infrastructure is often outdated, which affects service delivery.126
Private hospitals generally offer better pay and working conditions and are more competitive, which reduces staff attrition. Government hospitals, on the other hand, may suffer from flawed sources of motivation for those who work in them; they may face workforce shortages, lower motivation and lower-quality training.127
Research has found that private hospitals are often better at achieving patient satisfaction, owing to their more tailored approach to the individual patient, their efficiency, shorter waiting times and better facilities. Government hospitals cater for a larger section of society, including those without sufficient funds, and thus balance the services available.128
Private hospitals are patient-centred; they provide good customer service, use performance-based management and promote continuous quality improvement, in addition to being more cost-effective. Government hospitals, although a necessary instrument of public health, can suffer inefficiencies arising from bureaucratic inertia and lack of resources.
According to the health equity framework of the Agency for Healthcare Research and Quality (AHRQ) in the United States, one of the five ‘pillars’ of health equity is access to health care.129 Access is the ability to obtain health care when it is needed, so that healthcare needs are met.130 These problems increase in magnitude when an individual’s or a population’s intersectionality is taken into account. Intersectionality denotes the intermingled experiences of oppression and discrimination of people who belong to more than one social category, such as race or ethnicity, sex, disability, and sexual and gender minorities (for example, lesbian, gay, bisexual, transgender and non-binary or gender-non-conforming people).131
This points to the need to investigate the underlying reasons for disparities, which partly involve marginalisation, structural oppression and racism, and calls for access to health care to be evaluated from the perspective of health equity.132 Health equity is ‘the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically’.133 Structural barriers to health equity include limited access to health services because of the uneven distribution of health professionals,134 and gaps in insurance coverage, which exacerbate inequitable access to care.135
Specific evidence of the disparities caused by these barriers can be seen across the access spectrum. In the United States, people in racially and ethnically marginalised groups are more likely to be uninsured: 14 per cent of Black, 25 per cent of Hispanic and 24 per cent of American Indian and Alaska Native (AI/AN) adults are uninsured, compared with only 8 per cent of White adults.136 White adults with mental illness were more likely to receive mental health treatment in 2021, with 52 per cent receiving such care, than their Black (39 per cent), Hispanic (36 per cent) and Asian (25 per cent) counterparts. Minoritised groups are also more likely than Whites to report not seeking care because of cost (18 per cent of Hispanic, 15 per cent of AI/AN and 14 per cent of Black adults, compared with 9 per cent of Whites).137 This, along with other access inequities, has led to the accumulation of health inequities.138
It is equally true that responsive systems must take into account the health literacy, knowledge and beliefs of the populations they aim to serve. While health literacy is trending positively at the population level, disparities remain for certain subpopulations, such as minoritised populations and those living in rural areas.139 Most current research on health literacy examines samples that already have contact with the health system; this pre-existing relationship prevents such studies from showing how low health literacy affects a person’s ability to make contact with the system when he or she has limited or no contact with it. Patients with low health literacy are more likely to delay care and to have trouble contacting providers than patients with adequate health literacy.140
It is vital to reach proactively those groups that are difficult to access before they need to reach out to the health system.141 In order to promote health equity and reduce disparities, social efforts to improve health literacy must be connected to the underlying, multifaceted predictors of a person’s capacity to recognise the need for care before seeking it, and then to identify, comprehend and apply health information.142 Trust in health care has declined over the past fifty years and is even lower in many racial minority communities, principally Black communities in the United States, which have faced long-standing obstacles to accessing health care, disparate outcomes and overt racism in the delivery of care.143
Across the world, an increasing number of nations are willing to adopt universal health coverage. UHC is one of the principles of the global health agenda; it seeks to ensure health care on the basis of equality of access regardless of a person’s income from work, and the idea has been incorporated into the otherwise comprehensive and unifying global development plan.144 Through the 2030 Agenda (United Nations, 2015), countries have in effect already committed themselves to UHC, and they reaffirmed that commitment at the high-level meetings on UHC in 2019 and 2023.145 Each country’s journey to UHC will vary in shape and form and will be influenced by such factors as health-system structure, resource availability, political systems and governance.146
Analytical frameworks for UHC have been designed to be useful in evaluating health policies in countries where UHC cannot be taken for granted because of political, economic and structural constraints. In developing such frameworks, researchers have been guided by existing definitions of UHC and by relevant reports such as the World Bank’s ‘Universal Health Coverage in Africa: A Framework for Action’ and the 2030 Agenda for Sustainable Development.147 Population coverage under UHC refers to the population covered for a defined set of health services.148
Adequate and sustainable financing is one of the ‘building blocks’ of UHC. The economies of many countries, particularly low- and middle-income countries, are so strained, however, that raising finance for health systems is relatively hard for governments.149 Considerable leadership and strategic governance are needed for progress towards UHC, which requires political will and the implementation of health-system reforms. A useful framework therefore considers to what extent UHC policies articulate goals and objectives and whether they specify indicators to monitor progress over time. Progress towards UHC is a process that requires political commitment, the mobilisation of key players, and the development of steering groups and systems for the transparent monitoring of progress.150
Health promotion should be carried out through effective community involvement in identifying needs and in planning, agreeing and implementing actions and strategies to meet those needs so as to achieve better health. Effective provision of health services can only be guaranteed if such participation is guaranteed by states.151 Participation in health is generally placed among the fundamental rights of the people and is the mainstay of successful development activity; it treats people as partners rather than as recipients of developmental benefits, thus establishing an egalitarian process.152 A survey of health systems worldwide found that participation has positive effects on health outcomes, lessens information asymmetries, strengthens social capital and enhances the democratic process.153
According to the WHO, the regulation of health services is now part of everyday health care, ensuring standards, safety and access in the provision of care.154 Health-services regulation comprises a broad system of laws, policies, standards and oversight mechanisms created by governmental and non-governmental organisations at multiple levels. One objective of regulation is to promote patient safety through the development and enforcement of clinical standards.155 Through licensing, certification and accreditation, regulatory agencies ensure that healthcare providers and facilities comply with established standards of competence, responsibility and quality.156 Administering health-services regulation is a key means of enhancing the quality of health services.157 The rules on professional conduct, conflicts of interest, informed consent and patient confidentiality all help to sustain medical ethics and public confidence in the health service.158
It is also important that the regulation of health services enables the system to respond to emerging challenges and opportunities in healthcare delivery.159 The creation of, and adherence to, quality standards and regulatory frameworks are vital to the pursuit of excellence in health care.160 Accreditation is a process by which a profession establishes standards against which its members can be evaluated as having achieved defined levels of professionalism, competence and knowledge in the field, and thereby makes a public declaration of their capability. It is an evaluation process which indicates, for example, that an organisation is up to date, meets and complies with recognised standards, and offers positive quality assurance.161
Alongside the push towards universal health coverage in every country, private healthcare services are becoming more widespread. The ethical questions raised by private healthcare systems are numerous: equity of access, competition with not-for-profit providers, the commercialisation of medicine, increased problems of doctor-patient communication, reduced quality of care, the devaluation of physician education, and the manipulation of health-related public policy. Private health care poses further challenges, including potentially serious equity issues and increased costs of care.
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1. World Health Organization, Regional Office for the Eastern Mediterranean, Universal Health Coverage (2023).
2. United Nations Statistics Division, SDG Indicators: Metadata Repository, Goal 3, Target 3.8 (2023), https://unstats.un.org/sdgs/metadata/?Text=&Goal=3&Target=3.8.
3. World Health Organization, Primary Health Care on the Road to Universal Health Coverage: 2019 Monitoring Report, Executive Summary (2019), https://www.who.int/docs/default-source/documents/2019-uhc-report-executive-summary.
4. World Health Organization, The World Health Report 2010: Health Systems Financing, the Path to Universal Coverage (2010), https://apps.who.int/iris/handle/10665/44371.
5. Margaret E. Kruk et al., High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution, 6 Lancet Glob. Health e1196 (2018), https://doi.org/10.1016/S2214-109X(18)30386-3.
6. World Health Organization, Organisation for Economic Co-operation and Development & World Bank, Delivering Quality Health Services: A Global Imperative for Universal Health Coverage (2018), https://doi.org/10.1787/9789264300309-en, also available at https://www.worldbank.org/en/topic/universalhealthcoverage/publication/delivering-quality-health-services-a-global-imperative-for-universal-health-coverage.
7. G.A. Res. 217 (III) A, Universal Declaration of Human Rights (Dec. 10, 1948).
8. U.N. Charter pmbl., art. 1, ¶ 3.
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