In a viewpoint published Online First and in a future edition of The Lancet, Laurie Garrett, Pulitzer Prize winner and best-selling author, and her colleagues from the Council on Foreign Relations, New York City, USA state that accomplishment of Universal Health Coverage is not connected to a country's Gross Domestic Product (GDP). They cite a number of examples of countries much poorer than the USA who have achieved more in that field. As the debate on health reform in the USA raves on, the nation must deal with the reality that, despite its wealth, an estimated 47 million of its citizens have no health coverage at all.

Besides those totally uncovered American citizens, the USA has another 25 to 45 million citizens who have insurance so unsuitable that a major medical event may lead to family bankruptcy. Studies report that about half of all bankruptcies filed by American families in 2005 were caused by medical events disastrous to the family's finances.

However several countries with low GDPs, such as Costa Rica, Cuba, Gambia, and Gabon have reached remarkable prepaid coverage compared with wealthier countries such as China, India, and the USA. Many low-income countries battle with the evident problem of shortage of money. Several do not spend the minimum of US$34 per person per year on healthcare which is estimated necessary by the WHO Macroeconomic Commission. A few countries are well beneath this figure: Bangladesh ($12) and Ethiopia ($4). Out-of-pocket expenses can financially impair families. As a result, they are forced to use funds intended for something else, such as withdrawing their children from school.

Garrett and colleagues note that this is a 'perverse economic trend' in which the poorest people have the most costly care, as a percentage of personal income and without the benefits of health insurance or social protection. This in turn is a major contributor to maternal mortality and to parental decisions denying education to girls. On the other hand, introduction of universal health financing schemes improves performance in other social sectors such as education and reduces bankruptcy and other financial emergencies.

The authors explain that the countries which have been more successful with universal health care strategies have been able to respond to three questions at the highest political levels:

• What are the role and responsibilities of the state for the health of its people?
• What are responsibilities for the individual for his/her health?
• What third parties are acceptable, and what are their roles/responsibilities?

For example, Mexico is a nation that has answered all three questions by increasing its spending on health from 4.8 percent of GDP in 2003 to 6.5 percent in 2006. Ground-breaking programs were created to organize taxation, employer contributions, and individual payments. In 2007 there was a 20 percent increase in the number of Mexicans covered. The use of health services rose, and the numbers of households facing impoverishment dropped. Mexico is on its way to reach its goal of universal health coverage by 2010. This is also true for the whole of Latin America. This will give the hope to Africa, the Middle East and Asia that they can make comparable positive steps.

The introduction of universal health coverage through insurance schemes that initially target special groups is a strategic approach that is acquiring traction, explain the authors. The target groups include women and children, the very poor, and people with catastrophic illnesses. For instance, a new global campaign linked to the Millennium Development Goals promotes "Free quality services for women and children at the point of use and other access barriers removed". This year, United Nations Secretary-General Ban Ki-Moon in his address to the Global Health Forum in New York, USA, gave undeniable support to the universal health coverage objective, and to near-term targeting of poor and helpless populations.

They write in conclusion: "It is prudent for the world community to accelerate efforts aimed at ensuring health coverage for all, linking the goal with all donor, non-governmental organisation, and country health aspirations and targets related to health, rights, and poverty. This effort will need working on many fronts, starting with the political will of governments and civil societies."

"All for universal health coverage"
Laurie Garrett, A Mushtaque R Chowdhury, Ariel Pablos-Méndez
DOI: 10.1016/S0140-6736(09)61503-8
The Lancet

Written by Stephanie Brunner (B.A.)