Personal Reflections on Universal Health Coverage

The foundation of resilient, healthy families and communities, universal health coverage (UHC) requires integrated, person-centered care, engagement of non-health actors, and commitment to reach all.?

In December 2021, people around the world celebrated International Universal Health Coverage (UHC) Day, with the theme to “Invest in health systems for all.” With the aspirational symbol of an all-encompassing umbrella, UHC means that everyone should be protected from adverse health events and have access to high-quality health care so that we can thrive as a healthy global society. Health systems provide essential fabric for this UHC umbrella to achieve health for all.?

We don’t always know when we will need the protection of UHC’s umbrella. Those who have been privileged to stay safe under its shield may never notice it. But for those who are pushed to the edges of the UHC umbrella, it is different. They face barriers to affordable, accessible, acceptable, and high-quality health care, whether for routine wellness visits, or when there is a health emergency. The fabric of UHC’s umbrella is not wide enough to cover them; its health system fabric is frayed at best; at worst it has gaping holes.????

What does UHC look and feel like in real life? I recently reflected on three experiences to explain how UHC has helped me and my family thrive.

This first experience is somewhat dramatic. One summer night when I was 11 years old, I broke my neck in a car accident. I was awakened as medics pried me from the car and airlifted me to Massachusetts General Hospital, one of the best in the world. Clinicians and technicians evaluated my “hangman’s fracture” using state-of-the-art technology and diagnostics, later fitting me in a stabilizing halo. My parents were holders of a comprehensive health insurance plan that did not impoverish them as I underwent surgery, rehabilitation, and completed recovery over the next year. I started my seventh-grade semester on time and kept my place on the honor roll. ?

This second experience is slightly less dramatic. As a university exchange student in Paris, France, I tripped while jogging by the Eiffel Tower, breaking my nose. With my basic insurance plan, I could quickly schedule an evaluation at a specialist clinic. I was confused in a different language and health system – especially when I was asked to pay directly for my x-ray and carry it from one floor to the next myself. I had never held nor owned my own x-rays; my parents would only see insurance bills and claims in the mail months later. Nonetheless, the French health system accommodated me and my emergency. I was back in the classroom within a few days.

Later that same year, when I got a waitressing job in Paris, I was surprised to learn that I was scheduled for a general health screening, including for tuberculosis. I was paid for the time I took to attend the appointment. This, too, was new to me. For previous waitressing jobs in the U.S., my employer never offered such health services. However, while France’s post-World War II employee-based insurance approach gradually expanded to include more types of workers, and finally undocumented immigrants by 2000, like many health systems it still struggles to cover some residing within its borders. In the U.S., we were even more behind: the Affordable Care Act would not be signed into law for nearly another decade. ?

This third experience is not dramatic at all. But it is significant, nevertheless. Every August, I take my three children for an annual check-up. A nursing assistant takes their height and weight. The family nurse practitioner greets us. My kids observe intently as she listens to their little beating hearts, looks in their eyes, ears, and throats. We discuss nutrition and developmental milestones. When my four-year-old twins were newborns, we also spent time with a lactation consultant. This last visit, they required two vaccine boosters. Against the firm and gentle hand of the lab technician, they squirmed and squeaked, but were promptly assuaged with superhero stickers. I make sure not to leave the clinic without our critical Washington, D.C. Health Form, required for all students’ school attendance. We make similar semestrial visits to the dentist. Requiring health and dental forms, including updated immunization, for all school-aged children means everyone can stay as healthy as possible as they learn. Having universal pre-kindergarten starting at age three means that more kids in Washington, D.C. are getting health physicals than if they started going to school at age five, for kindergarten. ??????

In each of these cases, how did the health system support UHC?

Between all these stories are peaceful moments of prevention and privilege. Non-emergencies are not counted. ?Strong health systems cannot count the number of non-emergencies and non-events that they have prevented, only the events to which they are resilient enough to respond.

In my work at Chemonics, health systems strengthening (HSS) is the cornerstone of our Global Health Division’s strategy. Strong and resilient health systems should be delivering high-quality preventive, promotive, curative, and palliative services for all people, with an emphasis on primary health care. ?

As a global health practitioner, I recognize health system best practices that help achieve UHC around the world:

1.?????People-centered UHC requires diverse, interprofessional teams. In the year after breaking my neck, I recovered thanks to the support of emergency medics, orthopedic surgeons, registered nurses, home health aides, physical therapists, a social worker, the school nurse, and our family doctor. Few health workers can be trained and always available to respond to the different health needs of the community. Therefore, we must strive for better coordinated teams of diversely skilled health workers who work together to respond to a broad range of health services, bridging community health with primary and tertiary care. ?

2.?????All means all. A global pandemic has shown us that health is not a zero-sum game. Your good health and wellbeing contribute to my better health and wellbeing. Reaching everyone may require additional resources, especially for providing people-centered care and addressing systemic inequities in health. For health systems, equity is paramount to efficiency. We must invest in UHC, now more than ever. ?

3.?????Health system actors must engage other sectors to address the social and systemic determinants of health. Our health and wellbeing are impacted by the health of our planet, the water we drink, the food we eat, the safety of our roads, homes, and workplaces, our education, our status in society, the equity of our justice and political systems, our ability to earn decent livelihoods, and many other areas. Biomedically-centered health systems require a paradigm shift towards greater multi-sector engagement with a fundamental focus on public health.

COVID-19 has revealed us the vulnerabilities of the UHC umbrella, but also how health system best practices – diverse, interprofessional teams, equity, and multi-sectoral approaches – can make a difference. My hope is that the pandemic will help the global community garner the momentum we need for our health systems to build back better.