*Here, a dispatch from the work of a sister project here at R4D, part of coalescing global movement for... you guessed it. This is also posted at [Blog 4 Global Health](http://blog4globalhealth.wordpress.com/2011/03/07/universal-health-cover...).*
Universal Health Coverage. Still debated in the United States, the concept is taking off in countries from [South Africa](http://www.timeslive.co.za/local/article670694.ece/Health-insurance-tax-...) to [India](http://www.thehindu.com/health/policy-and-issues/article838394.ece) to [Indonesia](http://www.thejakartaglobe.com/indonesia/wb-says-indonesia-on-course-for...). Even as I write this, governments around the world are in the midst of serious political and technical [discussions](http://www.searo.who.int/LinkFiles/RC_63_a-15-SEA-RC63-24.pdf) on how to expand health coverage and, at the same time, [move toward Universal Health Coverage (UHC)](http://www.who.int/bulletin/volumes/88/9/10-020910/en/index.html).
While this in part can be attributed to recent activities at the global level, such as the launch of the [2010 World Health Report](http://www.who.int/whr/2010/en/index.html), these movements are being drive by-and-large by growing domestic political will, technical capacity and financial fuel required to undertake reforms.
However, even as domestic political leaders and global development partners alike promote these reforms as laudable, attainable, pro-health and anti-poverty, important questions need to be asked. What is the overall impact of these reforms? Is universal health coverage attainable in lower-income settings? What is the evidence-base in support of these reforms?
Many are beginning to ask such questions, and it’s only natural given the level of attention the issue has been receiving globally. In [“What Would it Take to Get Universal Health Coverage Around the World? Lessons from Countries on the Move,”](http://www.globalhealth.org/news/article/13289) the final event in the Global Health Council and Results for Development Institute’s (R4D) series [“New Visions for Improving Global Health in Developing Countries,”](http://resultsfordevelopment.org/projects/new-visions-improving-health-d...) these issues were brought to the fore.
[Gina Lagomarsino of R4D](http://resultsfordevelopment.org/experts/gina-lagomarsino) agreed that the evidence is mixed on UHC’s results, pointing to a [new Brookings’ publication](http://www.brookings.edu/press/Books/2011/theimpactofhealthinsuranceonlo...) on the impact of certain UHC reforms that have been studied: “There is significant positive evidence on health insurance’s impact on access and use, but mixed evidence on the impact on financial protection and minimal evidence of the impact on health status.”
[Davidson Gwatkin of R4D](http://resultsfordevelopment.org/experts/davidson-gwatkin) also cautioned on the [impact of UHC on equity](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2962...), warning against a focus on better off populations while excluding or de-prioritizing poorer populations: “The poor are notoriously difficult to find, but they’ll also be the ones to suffer the most. How do we ensure that we reach the poor and avoid a situation where the gears stall and political winds shift to other issues before we have covered those who need care the most?”
However, high levels of out-of-pocket health expenditures have made it clear that domestic health financing reforms are needed to fully confront the downward spiral of sickness and poverty that disproportionately impacts the poor in many countries. In India, [76% of health spending is out-of-pocket](http://www.who.int/whosis/whostat/en/index.html). As Lagomarsino pointed out, “It’s important to consider the means of collecting revenues across the entire population, in order to secure the revenue base needed for priority interventions and populations, and help to avoid the development of two-tiered systems favoring the better off.”
All panelists agreed on the inherent technical complexity of implementing reforms that move toward Universal Health Coverage. As [Brian Latko of R4D](http://resultsfordevelopment.org/experts/brian-latko) and [Catherine Connor of the Health Systems 20/20](http://www.abtassociates.com/Page.cfm?PageID=40132&EMP=2&EPID=52) project shared, a number of countries, including China and Ghana, are in the intermediate stages of extending health coverage. Connor, in particular, cautioned that these very countries face significant technical, administrative and operational challenges in charting the right course to UHC.
The key to successful implementation is to consider the technical and political factors equally and in combination in developing a path toward UHC, and to address issues head on. The panelists recognized the importance of supporting countries in the design and implementation of reforms through initiatives such as [Providing for Health](http://www.who.int/providingforhealth/about/whatis_p4h/en/index.html) and the [Joint Learning Network](http://www.jointlearningnetwork.org/).
While many questions remain on the overall impact of reform efforts, it’s clear that sound policy choices and a marriage of political will and technical know-how are essential to successful implementation of such reforms. Countries are already moving forward. Now the international community needs to ensure that efforts to expand health coverage achieve their full potential for reducing poverty and improving health around the world.