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Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Bill & Melinda Gates Foundation.

Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003–13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003, to 10·2 million in 2011. Health service access increased across the country—in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost-sharing) and the supply side (expansion of infrastructure, health human resources, and health services).

Background Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC. Methods This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis. Results Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable. Conclusion To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access.

Background Health system governance plays a crucial role in the performance of health reforms. In Nigeria, recent reforms like the decentralization of social health insurance to sub-national levels, aimed at improving access to services and financial risk protection, established Anambra State Health Insurance Scheme (ASHIS). This study analysed governance factors and practices influencing the effective implementation of ASHIS, focusing on principal-agent relationships among actors towards better social health protection performance and attainment of universal health care in Anambra state, Nigeria. Methods The study adopted a descriptive qualitative design to explore governance factors and practices influencing the implementation of ASHIS. Data were collected from three categories of actors - policymakers ( n  = 10) and health care providers (HCPs) ( n  = 10) through in-depth interviews, then focus-group discussions ( n  = 10) with 67 health insurance enrollees. Data were analyzed using a thematic analysis approach, and the principal-agent theory was adapted for data synthesis. Results Within the policymakers-clients sphere, there were positive assertions on responsiveness of the health insurance manager (as agent) on enrollee’s (as principal) needs, preferences and demands. There are established mechanisms for feedback from enrollees on service delivery, including round-the-clock customer care lines, weekly radio phone-in programs, random health facility visits, and annual town hall meetings. In the policymakers-health care provider (HCPs) sphere, the respondents stated that the insurance managers provide policies, and regulatory documents including operational guidelines, service level agreement, and resources for efficient and effective performance of the scheme. Respondents noted that HCPs as the agents deliver contracted services and instructions to their principal. However, some HCPs default through provider-induced moral hazard, and information asymmetry on matters like adequacy of provider payment mechanisms due to conflicting interests. Within the HCPs-clients sphere, while some respondents claimed that the agent uses enrollee’s (principal) inputs and oversight for improving service delivery, others rebutted the claim. Conclusions The study revealed series of governance practices supportive of progress, including the availability of regulatory policies/guidelines, feedback mechanisms and responsiveness to enrollee’s demands. Conversely, some disconnects in the principal-agent relationship were found. Addressing identified gaps will improve ASHIS’ performance and accelerate progress towards attaining UHC in Anambra state, Nigeria.

Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana. Using a pragmatic cluster randomized trial, 32 community health centers within Ghana's public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (-20.4 mm Hg; 95% CI -25.2 to -15.6) than the HIC group (-16.8 mm Hg; 95% CI -19.2 to -15.6), with a statistically significant between-group difference of -3.6 mm Hg (95% CI -6.1 to -0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI -1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group. Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost-benefit analysis. ClinicalTrials.gov NCT01802372.

Current interest in a single-payer approach to universal health care coverage in the United States has also triggered interest in alternative multipayer approaches to the same goal. An analysis of experiences in Germany, the Netherlands, Switzerland, and Israel shows how the founding of each system required a distinctive political settlement and how the subsequent timing, content, and course of the reforms were shaped by political circumstances and adjustments to the founding bargain in each nation. Although none of these systems is directly transferable to the United States, certain parallels with the American context suggest that a multipayer approach might offer a model for universal coverage that is more politically feasible than a single-payer scheme but also that issues associated with risk selection and other potential inequities would remain.

Many countries that subscribe to the Millennium Development Goals (MDGs) have committed to ensuring access to basic health services for their citizens. Health insurance has been considered and promoted as the major financing mechanism to improve access to health services, as well as to provide financial risk protection. In Africa, several countries have already spent scarce time, money, and effort on health insurance initiatives. Ethiopia, Ghana, Kenya, Nigeria, Rwanda, and Tanzania are just a few of them. However, many of these schemes, both public and private, cover only a small proportion of the population, with the poor less likely to be covered. In fact, unless carefully designed to be pro-poor, health insurance can widen inequity as higher income groups are more likely to be insured and use health care services, taking advantage of their insurance coverage. The purpose of this handbook is to provide policy makers and health insurance designers with practical, action-oriented support that will deepen their understanding of health insurance concepts, help them identify design and implementation challenges, and define realistic steps for the development and scaling up of equitable, efficient, and sustainable health insurance schemes. The handbook takes policy makers and health insurance designers through a step-by-step series of considerations and tasks that need to be achieved. The handbook's philosophy is to not be dogmatic, ideological, or prescriptive. This handbook was prepared to be used in a six-day regional workshop. Clearly, health insurance design is an intensive political and technical process that takes much longer than six days. The expectation for the workshop is that by the end of the week, each team has a clear idea of next steps that they could take back home to engage other stakeholders and move toward scaling up and improving the performance of health insurance in their country.

Background Despite the availability of evidence-based treatment, there is a substantial gap between the number of individuals in need of mental health care and those who receive treatment. The aim of this study was to assess changes in treatment coverage and barriers to mental health care among adults with depression and alcohol use disorder (AUD) before and after implementation of a district mental health care plan (MHCP) in Nepal. Methods The repeat population-based cross-sectional community survey was conducted with randomly selected adults in the baseline ( N  = 1983) and the follow-up ( N  = 1499) surveys, 3 years and 6 months apart. The Patient Health Questionnaire and Alcohol Use Disorder Identification Test were used to screen people with probable depression and AUD. Barriers to seeking mental health care were assessed by using a standardized tool, the Barriers to Care Evaluation Scale (BACE). Results The proportion of the participants receiving treatment for depression increased by 3.7 points (from 8.1% in the baseline to 11.8% in the follow-up) and for AUD by 5.2 points (from 5.1% in the baseline to 10.3% in the follow-up study), however, these changes were not statistically significant. There was no significant reduction in the overall BACE score in both unadjusted and adjusted models for both depression and AUD. The possible reasons for non-significant changes in treatment coverage and barriers to care could be that (i) the method of repeat population level surveys with a random sample was too distal to the intervention to be able to register a change and (ii) the study was underpowered to detect such changes. Conclusion The study found non-significant trends for improvements in treatment coverage and barriers to mental health care following implementation of the district mental health care plan. The key areas for improvement in the current strategy to improve treatment coverage and barriers to mental health care included change in the content of the existing community sensitization program, particularly for changing attitude and intention of people with mental illness for seeking care.