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Peer-reviewed

Research Article

Universality of universal health coverage: A scoping review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations School of Public Health, The University of Queensland, Brisbane, Australia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Roles Conceptualization, Supervision

Affiliation College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Affiliation School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Roles Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

• Aklilu Endalamaw, 
• Charles F. Gilks, 
• Fentie Ambaw, 
• Yibeltal Assefa

• Published: August 22, 2022
• https://doi.org/10.1371/journal.pone.0269507
• Reader Comments

The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC.

The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings.

Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier.

Conclusions

The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.

Citation: Endalamaw A, Gilks CF, Ambaw F, Assefa Y (2022) Universality of universal health coverage: A scoping review. PLoS ONE 17(8): e0269507. https://doi.org/10.1371/journal.pone.0269507

Editor: Wen-Wei Sung, Chung Shan Medical University, TAIWAN

Received: May 27, 2022; Accepted: August 9, 2022; Published: August 22, 2022

Copyright: © 2022 Endalamaw et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: Authors declared no conflict of interest.

Abbreviations: ANC, Antenatal Care; AR, Antiretroviral Therapy; CHI, Catastrophic Health Expenditure; FP, Family Planning; GBD2019, Global Burden Disease 2019; HIV/AIDS, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome; IDs, Infectious diseases; NCDs, Non-communicable diseases; RMNC, Reproductive, Maternal, Neonatal and Child; SCA, Service Capacity and Access; SDGs, Sustainable Development Goals; UN, United Nations; UHC, Universal Health Coverage; WB, World Bank; WHO, World Health Organization

Introduction

Universal health coverage (UHC) is a multi-dimensional concept that includes population coverage, services coverage and financial protection as its building blocks, as well as equity and quality in its integrated definition [ 1 ]. Health policy and decision makers believe UHC as a foundation to improve population’s health, facilitate economic progress, and achieve social justice [ 2 , 3 ]. It is also essential to minimize disparities, promote effective and comprehensive health governance, and build resilient health systems [ 4 ].

The United Nation’s (UN) post-2015 goals described UHC as the predominant approach to realize the 2030’s sustainable health goals [ 5 ]. It is also taken as an urgent priority in 2020 UHC high-level meeting to address global health crises, through delivering affordable essential quality healthcare services, including the pandemic COVID-19 [ 6 ]. The UN General Assembly further declared, at its 73 rd session, that global institutions and countries make healthcare accessible to one billion more people by 2023 [ 7 ] and 80 percent of the population by 2030 with no catastrophic health expenditures [ 5 ].

WHO and the WB established core tracers of health service coverage to monitor UHC [ 8 ]. These tracers are categorized under the main theme reproductive, maternal, neonatal, and child health (RMNC), infectious diseases (IDs), non-communicable diseases (NCDs), and service capacity and access (SCA). Another dimension of UHC in SDG 3.8.2 is financial risk protection, which is typically measured by catastrophic health expenditure (CHE) and impoverishment due to healthcare costs [ 8 ].

While no prior studies have been conducted to identify and map the available evidence on UHC, other related studies such as “a synthesis of conceptual literature and global debates” [ 1 ] and a scoping review of “implementation research approaches of UHC” [ 9 ] are available. In addition to these literature, another study assessed the hegemonic nature of UHC in health policy described historical background of how UHC emerged, and frequency of UHC mentioned in all fields of articles available in PubMed database [ 10 ]. None of those previous studies addressed the universality of UHC in terms of its building blocks and service types and summarized the findings from each study included in the review.

A scoping review of the studies on UHC and its dimensions is crucial to map and characterize the existing studies towards UHC. This will help to identify key concepts, gaps in the research, and types and sources of evidence to inform practice, policymaking, and research [ 11 ]. The goals of this scoping review towards universality of UHC were, first, to determine the distribution of articles across WHO and WB regions, health service types, and dimensions including major components and tracer indicators, and second, to synthesize barriers of UHC. This review provides insight that is useful in setting strategies, evaluating health service performance, and advancing knowledge on priority research questions for future studies.

Identifying a research question

The protocol of this scoping review is available elsewhere https://doi.org/10.21203/rs.3.rs-1082468/v1 . The overall activities adhered to the Arksey and O’Malley’s (2005) scoping review framework [ 12 ], which was expanded with a methodological enhancement for scoping review projects [ 13 ], and the Joanna Briggs Institute framework [ 14 ]. The review followed five steps: (1) identifying research questions, (2) identifying relevant studies, (3) study selection, (4) data charting, and (5) collation, summarization, and reporting of results. The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews were used ( S1 Checklist ) [ 15 ].

The research questions were developed by AE in collaboration with YA. The Population, Concept, and Context framework was used to determine the eligibility of research questions [ 16 ]. According to the framework, the population represented study participants to whom findings infer which includes people at any age or other important characteristics of study participants. Not all UHC expected to have population component, which is non-applicable in some research. The concept was overall UHC or financial risk protection, equity, quality, and coverage. Context includes the study settings or countries and, in this review, the global context.

Identifying relevant studies

Web of Science, PubMed and Google Scholar were used to find literature in the field. Hand search was also used to find articles from WB Library, WHO Library, UN Digital Library Collections, and Google. Using the relevant keywords and/or phrases, a comprehensive search strategy was established. Universal, health, "health care", healthcare, "health service”, quality, access, coverage, equity, disparity, inequity, equality, inequality, expenditure, and cost were search words and/or phrases. “AND” or “OR” Boolean operators were used to broaden and narrow the specific search results. Search strings were formed in accordance with the need for databases ( S1 Table ). Article search date was between 20 October 2021 and 12 November 2021, with the most recent update on 03 March 2022. The articles were imported into EndNote desktop version x7, which was used to perform an automatic duplication check. Manual duplication removal was also performed. The database search strategies are shown in the ( S1 Table ).

Study selection

In consultation with YA, AE developed and tested study selection forms (inclusion and exclusion criteria) using a random sample from collected references, which were found using search strategy. A second meeting was held to approve the study screening form and process. Then, inclusion and exclusion criteria were applied during the article screening process for all articles. Studies conducted using the English language were included. Articles on overall UHC (UHC effective service coverage and FRP), UHC effective service coverage, UHC without specification with service coverage and FRP, and which reported coverage, quality, inequity, FRP in the outcome of the study or explored UHC research objectives were included. Types of study design included were quantitative, qualitative, mixed-research, and review types. The search was narrowed to include only literature published since 2015 to find studies which addressed the SDG target 3.8 and proceeding years. Non-English language literature, abstracts only, comments or letters to the editor, erratum, corrections, and brief communications were all excluded.

Articles’ titles, abstracts, and full texts were reviewed in stages. After duplicates were removed using EndNote desktop x7 software and manual duplication removal, titles were screened. After that, abstracts were used to screen the literature. Those who passed abstract review were eligible for full-text review. Full-text articles were also screened for data charting purposes. For articles with only an abstract, contact was made with the study’s corresponding authors.

Data charting

A piloted and refined data extraction tool was initially developed to chart the results of the review from full-text literature. Data was examined, charted, and sorted according to key issues and themes. Author(s), publication year, WHO geographic category, WB group, study approach, studied domain or topic, UHC themes, and health care service types were all extracted.

Collation, summarization, and report of results

Based on years of publication, studied dimensions (interrelated objectives), WHO region, WB group, study approach, and health care service types, available articles were compiled and summarized with frequency and percentage.

A simple descriptive analysis was performed, and the results were presented in the form of tables and figure. The data reporting scheme was adjusted as needed based on the findings.

Search results

PubMed (n = 6,230) and Web of Science (n = 832) databases were searched. Google Scholar (n = 21), WB Library (n = 5), WHO Library (n = 7), UN Digital Library Collections (n = 13), and Google (n = 63) were also manually searched. A total of 7,171 records were discovered. Following title and abstract screening, 65 articles were chosen for full-text review. Finally, 47 articles were selected for scoping review ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0269507.g001

Articles characteristics

Almost one-fourth of articles were from WHO Africa region and another 25.5% were across two or more WHO regions. According to income category, 42.5% were from lower-middle-income countries followed by 29.8% across two or more WB economy groups. More than half of the articles (54.1%) followed a quantitative research approach ( Table 1 ). The countries where each article conducted are available in S2 Table .

https://doi.org/10.1371/journal.pone.0269507.t001

Health service types

Twenty articles [ 17 – 36 ] are categorized under health promotion. These articles were focused on pathways and efforts, program evaluation and change, opportunities and challenges, barriers/factors/enablers, community-based health planning and service initiative, perceived effect of health reform on UHC, health-seeking behaviour and knowledge, health security and health promotion activities, the impact of insurance on coverage, and SCA dimensions of UHC. Health promotion encompasses funding and infrastructure, health literacy, the development of healthy public policies, the creation of supportive environments, and the strengthening of community actions and skills, as well as any activities that assist governments, communities, and individuals in dealing with and addressing health challenges.

Six articles discussed treatment aspects of health services, which were access to care for illness, access to treatment for rheumatic heart diseases, neglected tropical diseases (NTDs), mental disorders and hypertension [ 37 – 42 ].

According to GBD-2019, WHO and WB tracers, FP and/or SCA components for promotion, immunization for prevention and other diseases in RMNC, IDs, NCDs for treatment aspects, nineteen articles were a combination of promotion, prevention, and treatment aspects [ 43 – 61 ].

One study looked at both the promotion and treatment of health services [ 62 ].

One study done on the quality of health care for disabled people [ 63 ] was classified as a palliative and rehabilitative care service type despite it did not adhere to palliative care assessment guidelines.

Components and dimensions of UHC

The main four components of UHC are RMNC, IDs, NCDs and SCA. Of included articles, RMNC was reported by 19 articles, 17 assessed NCDs were reported by 17 articles, CDs was assessed by 13 articles, and SCA was assessed by 9 articles. Regarding dimensions, coverage was assessed by 25 of articles; FRP by 13 articles, inequity by 10 articles and quality by 3 articles ( S2 Table ).

Tracer indicators for summary measure of UHC

Of 25 quantitative articles, 19 articles used various tracer indicators to assess UHC quantitatively; the remaining six quantitative articles assessed each empirical analysis of the potential impact of importing health services, access and financial protection of emergency cares, perceived availability and quality of care, the performance of district health systems, crude coverage and financial protection, health-seeking behaviour and OOP health expenditures, and the performance of health system.

Accessibility and affordability in China [ 64 ], as well as curative care and quality of care components in India [ 48 ] were developed as new tracers.

Ten tracers were used in RMNC component of UHC. Five tracers in IDs, seven tracers in SCA and 18 tracers were used NCDs component of UHC. Three tracers were used for FRP estimation. The iteration of tracers under four components of UHC effective service coverage and FRP is shown in Table 2 .

https://doi.org/10.1371/journal.pone.0269507.t002

Barriers/challenges of UHC

Policy, health sector and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned cross-cutting barriers ( Table 3 ).

https://doi.org/10.1371/journal.pone.0269507.t003

The purpose of this scoping review was to map existing research, and the most researched UHC dimensions, components and summarized main findings. Many articles were found in the African region and in countries with middle-income (lower and upper). Many of the studies followed a quantitative research approach. Palliative and rehabilitative health care types did not be well address in UHC research. The service coverage and financial protection dimensions were most frequently studied, followed by inequity and quality of health care services.

The current evidence found a greater number of articles than a scoping review of African implementation research of UHC [ 65 ]. This is because the former was conducted on a single continent and concentrated on UHC research approaches. Another bibliometric analysis, on the other hand, discovered a greater number of available evidence than the current scoping review [ 66 ]. Because it includes all available evidence as terminology, title, phrases, or words in policy documents, commentaries, editorials, and all frequency counts found in databases by the first search without the conditions of pre-established exclusion criteria. Aside from that, the bibliometric analysis included articles dating back to 1990. UHC is a global agenda that has improved the health of the global population through political support, funding, and active national and international collaborations [ 67 , 68 ]. The number of research output is likely increasing over time though current evidence shows that comparable numbers of articles are available in each year. An earlier bibliometric analysis discovered an increasing trend of UHC research outputs [ 66 ].

Many of the studies in this review used a quantitative approach. A prior scoping review conducted in Africa discovered that qualitative and mixed-methods studies were the commonest method to investigate UHC [ 10 ]. The former study did not consider financial protection research, UHC effective service and crude coverage, service capacity and access. UHC is intended to be quantified numerically as a summary index to track the progress of health care performance. Given the nature of UHC, fewer articles used qualitative research design to investigate its challenges, opportunities, and success of UHC. Various health systems and policies in low, middle, and high-income countries may present different barriers and facilitators to achieve UHC [ 69 – 71 ]. The current review has also identified policy, health system and cross-cutting barriers of UHC that were frequently explored by qualitative research.

Many number of countries are available in the European region and the high-income category [ 72 , 73 ]. In contrast, a substantial amount of UHC research was produced in middle-income countries, most were from African region. Trend analysis in health policy and systems research conducted on the overall research progress discovered that an increasing trend of publications in low-and middle-income countries between 2003 and 2009 [ 74 ]. This could be attributed to the nature of the health problems and the health policy in place regarding health research. Furthermore, health research budgets and clinical trial infrastructures may determine health research activities in each continent. Health budget might not always true in its effect of high research publication. For instance, evidence from a review finding indicated that nations with significant donor investment in health research may not necessarily produce a large number of research [ 75 ]. Articles available across WHO regions were comparable to frequency of articles in WHO African region. This might be due to UHC is a global strategy in monitoring the global process towards universal access to health care. The availability of UHC monitoring framework helps to conduct to conduct research at the multicounty level.

In 2019, the burden of NCDs was 63.8 percent worldwide, followed by IDs, RMNC, and nutritional disease (26.4 percent) [ 76 ]. In the summary measure of the UHC index, RMNC was the most frequently studied component followed by NCDs. This could be because many of the articles in the current review came from Africa and lower-and middle-income countries. In these countries, maternal and child morbidity and mortality were extremely high [ 77 ], making RMNC more likely to be investigated in UHC context. Similarly, a scoping review study on maternal, neonatal, and child health realized a high rate of publication in the most recent period [ 78 ].

This review provides an answer to the question of how much UHC is universal and how much UHC is covered in the current health systems and policy research. UHC tracer indicators are focused on health promotion, disease prevention, treatment, palliative, and rehabilitative health care services at the individual and population level. Promotion aspects of health services were more frequently investigated in the current review. This could be because those articles non-specific to either component of UHC were classified as health promotion. A single study was conducted on disabled population, close to palliative and rehabilitative health care types. Palliative care focuses on the physical, social, psychological, spiritual, and other issues confronting adults and children living with and dying from life-limiting conditions, as well as their families [ 79 ]. Assessment of pain and symptom management, functional status, psychosocial care, caregiver assessment, and quality of life are all part of a palliative care measurement and evaluation domains [ 80 ]. The Worldwide Hospice Palliative Care Alliance recommended research to improve palliative care coverage [ 81 ] in order to ensure equitable health care access for more than 40 million people who require palliative care each year worldwide [ 82 ]. However, UHC effective service coverage measurement indicators are appropriate only for assessing the promotion, prevention and treatment aspects of health care, even though all health care services are theoretically expected to be covered [ 54 ].

In terms of dimensions, coverage was more commonly studied. The framework for monitoring and tracking was initially established for effective service coverage and FRP. UHC’s service coverage is a collection of many individual disease indicators used to assess the performance of the health care system. Therefore, it is not surprising that many articles have been written about the coverage dimension. Aside from the usual trend of calculating the service coverage summary index, a few articles estimated UHC by combining effective service coverage and FRP indicators. In the current review, a few studies assessed the quality of care as a dimension of UHC; a single study developed a distinct quality of care measurement that integrated into the UHC matrix. Effective service coverage is predicated on the assumption that those in need receive high-quality health care services. Effective services coverage and quality are theoretically integrated. However, having a high UHC index value does not imply that high-quality care is provided for each specific disease. For example, in countries with high UHC index value [ 54 ], quality medical care services were found to be inadequate for patients with chronic diseases [ 83 ]. Quality of health care can be assessed using structure, process, and outcome indicators in the healthcare system [ 84 ].Therefore, generally, measuring the quality of care for specific disease is helpful for stakeholders, clinicians, and health policymakers working on specific health problems [ 85 ].

The UHC summary index is also useful in comparing the national and subnational progress of health system performance between countries and within a specific country. One of UHC’s primary functions is to promote health equity [ 3 ], and equity has been identified as a measurable component of UHC [ 86 ]. It is linked to social determinants that should be monitored over time, across or within different settings and populations [ 87 ]. Inequity in UHC service coverage studies was reported broadly. None of the UHC articles examined health disparities based on age, gender, race or ethnicity, residence, education level, or socioeconomic status. Moreover, range, absolute or relative difference, concentration index, and Gini coefficient were not used as equity measurement techniques in the included articles.

As implication to policy/program manager and researcher, more research is needed in settings where UHC has not been thoroughly investigated qualitatively. Future research better focus on the quality and equity dimension of UHC health care services. Given that the distinct nature of UHC tracers may limit UHC’s articles on health promotion, prevention, and treatment aspects, palliative and rehabilitative care services require attention in the future research environment. For specific health problems, additional review may be required to identify research gaps in specific tracer.

Strength and limitation

This is the first scoping review of UHC, and it is accompanied by the most recent articles. Our review identified UHC literature in each category of health service type.

In terms of limitations, this review included only articles conducted in English; articles conducted in other languages may have been missed, and geographical representation of UHC articles may have been over or underestimated for regions. When considering UHC dimensions, they may have a different level of research articles discovered if another mapping review is done for specific disease types.

Most articles were from Africa, across WHO regions and middle-income countries. Quantitative research approach has been frequently used. Equity and quality of services have got little attention in UHC research. Palliation and rehabilitation health services have also got little attention in the UHC research. Tracer indicators other than WHO and WB were developed and utilized in different countries. Policy, health sector and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common challenges of the health sector towards UHC. Lack of common understanding on UHC was frequently mentioned as cross-cutting barrier.

Supporting information

S1 checklist. items followed in conducting this review..

https://doi.org/10.1371/journal.pone.0269507.s001

S1 Table. Search strategy.

https://doi.org/10.1371/journal.pone.0269507.s002

S2 Table. Articles’ country and main findings.

https://doi.org/10.1371/journal.pone.0269507.s003

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• 16. The Joanna Briggs Institute. The Joanna Briggs Institute Reviewers’ Manual: 2014 edition/supplement. Australia: The Joanna Briggs Institute.

• Open access
• Published: 23 March 2023

Quality of care in the context of universal health coverage: a scoping review

• Bernice Yanful   ORCID: orcid.org/0000-0002-6824-6694 1 ,
• Abirami Kirubarajan 2 ,
• Dominika Bhatia 2 ,
• Sujata Mishra 2 ,
• Sara Allin 2 &
• Erica Di Ruggiero 1 , 2 , 3  

Health Research Policy and Systems volume  21 , Article number:  21 ( 2023 ) Cite this article

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Introduction

Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps.

We conducted a scoping review using the Arksey and O’Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers.

Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.’s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity.

There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC.

Peer Review reports

According to the World Health Organization, 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 ]. UHC has gained renewed attention from researchers and policymakers following its inclusion in the 2030 Agenda for Sustainable Development (SDGs). SDG target 3.8 calls for achieving ‘universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ [ 2 ].

While there is growing evidence linking UHC to different health, economic and social outcomes, recent estimates suggest that about 800 million people globally still do not have access to full financial coverage of essential health services, including but not limited to high-income countries [ 3 ]. The WHO’s well-established UHC cube identifies three dimensions of UHC: (1) population (who is covered); (2) services (services that are covered); (3) direct costs (the proportion of the costs that are covered) [ 4 ]. Absent from the cube is the explicit inclusion of quality of care. However, without attention to the quality of care provided, increasing service coverage alone is unlikely to produce better health outcomes. As such, quality of care is critical to the achievement of UHC. A high-quality health system has been defined as one ‘that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs’ [ 5 , p. e1200].

Current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries (LMICs) [ 6 ]. While the era of the Millennium Development Goals (MDGs) expanded access to essential health services in LMICs, poor quality of care remains a significant problem, and explains persistently high levels of maternal and child mortality [ 6 ]. In addition, poor quality of care is estimated to cause between 5.7 and 8.4 million deaths yearly in LMICs [ 7 ]. Low-quality services are also an issue in high-income countries (HICs), particularly for disadvantaged populations such as immigrant and Indigenous groups [ 6 , 8 ].

As such, efforts to achieve UHC focused solely on expanding access to care are insufficient. Achieving UHC will require a more deliberate focus on quality of care across its various dimensions including effectiveness, safety, people-centredness, timeliness, equity, integration of care and efficiency [ 6 ]. However, existing literature synthesizing evidence on the quality of care within the context of UHC is more limited.

The primary objective of this scoping review is to synthesize and analyse the existing conceptual and empirical literature on quality of care within the context of UHC. The secondary objective is to identify knowledge gaps on quality of care within the context of advancing UHC and highlight areas for further inquiry.

We conducted a scoping review using the five-stage scoping review framework proposed by Arksey and O’Malley [ 9 ] and further elaborated by Levac et al. with the following stages [ 10 ]: (1) formulating the research question; (2) searching for relevant studies; (3) selection of eligible studies; (4) data extraction and (5) analysing and describing the results. In addition, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines [ 11 ]. In accordance with the guidelines, our protocol is publicly available through Open Science Forum [ 12 ]. The scoping review methodology was selected due to its relevance to both identifying emerging and established content areas, and integration of diverse study methodologies [ 13 ]. As such, our methodology was well-aligned with the exploratory aims of our study.

To synthesize the existing knowledge on quality of care within the context of UHC, we focused on retrieving and analysing relevant reviews (as opposed to primary research studies). Bennett et al. [ 14 ] applied this overview of reviews approach in identifying health policy and system research priorities for the SDGs.

Information sources and search strategy

We developed the search strategy in consultation with a research librarian with expertise in public health and health systems. After finalizing our search in MEDLINE (Ovid) through an iterative process involving pilot tests, we completed a systematic search of MEDLINE (Ovid), EMBASE (Ovid), CINAHL-Plus (EBSCO), PAIS Index, ProQuest and PsycINFO (Ovid) for articles published from 1 January 1995 to 27 September 2021. The date cut-off of 1995 was selected to capture articles published during the period leading up to the adoption of the MDGs. We applied adapted search filters from the InterTASC Information Specialists’ Subgroup Search Filter Resource for each database [ 15 ].

Our searches combined terms related to the concepts of (1) UHC (e.g. universal health insurance, universal coverage) and (2) quality of care and its seven dimensions (e.g. equity, safety, people-centredness). Our search strategy is available in Appendix A. Figure  1 outlines the eligibility criteria we used to assess studies for inclusion in the review.

Eligibility and exclusion criteria

Data management

Results from database searches were managed through Covidence ( www.covidence.org ) for deduplication and screening.

Study selection

Two reviewers (BY&AK) independently assessed studies against the eligibility criteria in two phases: (1) titles and abstracts and (2) full-text articles. A pilot test of the title and abstract screening was completed for approximately the first 100 search results. The two reviewers discussed disagreements to revise eligibility criteria as required. Any disagreements were resolved via consensus and in consultation with senior co-authors.

Data extraction

BY & AK independently completed data extraction for the first 10 articles using a standardized form. Following the pilot, the full data extraction was completed by the two reviewers in parallel. We extracted data on key study characteristics and according to each domain and subcomponent identified in Kruk et al.’s [ 5 ] framework described in the following section. The process of data extraction was iterative, with the form subject to revisions. Geographic regions were classified either by WHO regions [ 16 ] or through self-identification by the articles, such as a global focus, LMICs, HICs, ‘developing’ or ‘developed’.

Data synthesis

We synthesized the results through both a descriptive summary and a qualitative, narrative synthesis. We anchored our narrative synthesis in Kruk et al.’s [ 5 ] conceptual framework for high-quality health systems. The framework draws from Donabedian’s well-known conceptual model of quality of care, which was first developed in the 1960s and identifies structures, processes and outcomes as three components of quality of care. Kruk et al. [ 5 ] offer a new evidence-based framework relevant to present-day health systems, recognizing the heterogeneity of health systems across HIC and LMIC contexts.

They define three key domains of a high-quality health system, which they argue should be at the core of implementing and advancing UHC: foundations, processes of care and quality impacts. Foundations refer to the context and resources required to lead a high-quality health system. Processes of care include competent care and systems, relating to evidence-based effective care and health systems’ ability to respond to patient needs. Quality impacts include both patient and provider-reported health outcomes and client confidence in the health system, as well as economic benefits such as a reduction of resource waste and financial risk protection. The Kruk et al. [ 5 ] framework does not explicitly address equity; however, the authors state that equity in the quality of healthcare is critical, which they define as ‘the absence of disparities in the quality of health services between individuals and groups with different levels of underlying social disadvantage [p. e1214].’ When compared with Donabedian’s model for evaluating the quality of care [ 17 ], Kruk et al. [ 5 ] offer a much more elaborated framework that explicitly names a range of subcomponents to guide quality measurement and improvement (e.g. governance, positive user experience, etc.).

As our scoping review examines the existing literature on quality of care within the context of UHC and identifies knowledge gaps, Kruk et al.’s [ 5 ] framework provided a useful analytic tool by which to organize and interpret our findings.

We organized the results from our narrative synthesis according to each component of the framework (foundations, processes of care and quality impacts), addressing equity as a cross-cutting theme across these components. Table 1 summarizes the components and subcomponents of the framework.

Description of included reviews

The database searches yielded 4128 results after deduplication. Following screening, 45 articles that met eligibility criteria were included in the review. The search results are shown in Appendix A and a summary of each article is presented in Table 2 . Narrative reviews comprised 40.0% of the studies ( n  = 18), 35.6% were systematic reviews (n = 16), while 20.0% were scoping reviews ( n  = 9), and 4.4% were overviews of systematic reviews ( n  = 2). Of the 45 reviews, 28 covered multiple WHO regions (62.2%). This included reviews with a broad global focus, reviews focused on LMICs, ‘developing’ or ‘developed’ countries, as well as reviews with an explicit focus on more than one of six WHO regions. Regarding the dimensions of quality of care, equity was the most well represented, examined by 40 of the studies (88.9%). Integration of care and safety were the least represented across the studies, each examined by 11 of the reviews (24.4%). We did not formally appraise the quality of studies included in our review, which is not required for a scoping review given its overarching aim to map the scope and size of the available literature on a given topic.

Narrative synthesis of results

Conceptualizing universal healthcare/coverage and quality of care.

The included studies highlighted varying definitions of UHC and quality of care. A common definition of UHC was that all people who require any essential healthcare services, including but not limited to promotion, prevention and treatment, are able to access services without financial stress [ 18 , 19 , 20 ]. One study further expanded this definition to include that UHC was the desired outcome of health system performance [ 18 ]. Some studies specified the definition was outlined in the Alma Ata declaration [ 21 , 22 ].

Definitions of quality of care also varied. One study distinguished between service quality (e.g. patient satisfaction, responsiveness) and technical quality (e.g. adherence to clinical guidelines) [ 23 ]. Another study defined high-quality healthcare as ‘providing the highest possible level of health with the available resources’ [ 24 , p. 142]. However, most studies did not provide a working definition of quality of care, and instead used proxy indicators such as infant mortality [ 25 ] to highlight quality-related outcomes.

Synthesis according to Kruk et al. Conceptual framework

Below, we synthesize findings from the studies according to the components of Kruk et al.’s [ 5 ] conceptual framework (foundations, processes of care and impacts). We highlight the most common themes that we identified in the literature for each domain and provide illustrative examples. Unless specified, findings were not specific to LMIC or HIC contexts.

Foundations

Governance: leaders, policies, processes and procedures providing direction and oversight of health system(s).

A common theme across the literature was health system governance at local, regional and national scales, and its relationship to quality of care within the context of UHC. Naher et al. [ 26 ] identified transparency, accountability, laws and regulations, and citizen engagement as critical components of governance. The articles discussed both poor and good governance, their underlying determinants and drivers, as well as interventions to improve governance and thus quality of care [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ].

The literature suggests that poor governance is a common issue across health systems, and is both a cause and indicator of poor-quality care. Causes and forms of poor governance include weak supervision of, and inadequate incentives and remuneration for healthcare providers; lack of transparency and accountability in decision-making; and insufficient financial capacity; in addition to fragmented regulations and policies. Poor governance has also been found to result in low patient trust and confidence in the health system, wasted resources and poor patient outcomes [ 26 , 40 , 44 ]. In contrast, the reviewed literature described strong governance as critical to effective healthcare services [ 26 ] and the basis for achieving UHC [ 32 ].

Interventions to improve governance described by the reviewed literature include decentralization, social accountability mechanisms, such as social audits, and policy reforms to strengthen provider incentives and service integration [ 26 , 28 , 31 , 45 , 47 , 53 ]. However, the evidence regarding the effectiveness of these interventions on governance and quality of care was largely inconclusive. Regarding integration, White [ 45 ] noted the need to ensure adequate leadership and organizational capacity before integrating services, as a key determinant of success.

Quality of care measures

Six studies identified measures and/or measurement instruments to assess quality of care or its various dimensions within the context of UHC [ 19 , 22 , 27 , 30 , 42 , 51 ]. These measures differed based on their service areas of focus (e.g. family planning, primary care), the geographic contexts for which they are intended and whether they assessed foundations, processes of care or quality impacts. The reviewed literature identified a lack of standardized quality assessment tools as a significant barrier to the realization of UHC [ 22 , 42 ]. However, researchers also noted the need for country-specific indicators reflective of a country’s unique social, political and economic circumstances, and population needs and expectations [ 18 , 22 , 30 , 39 , 51 ]. Studies also emphasized the importance of integrating equity as an explicit component in the measurement and monitoring of UHC through for example, disaggregation of data by key socioeconomic and demographic variables including place of residence, occupation, religion, ethnicity and migration status [ 18 , 27 , 30 , 35 ]. Table 3 maps the measures identified in the studies according to the domains and subdomains of Kruk et al.’s framework.

Skills and availability of health system workers

Several studies also identified critical health workforce shortages and inequities in the distribution of appropriately qualified staff between urban and rural areas as significant constraints to the provision of high-quality, equitable care within the context of UHC, particularly in LMIC contexts [ 21 , 23 , 25 , 29 , 31 , 38 , 40 , 43 , 44 , 46 , 47 , 48 , 49 , 50 , 53 ]. Strategies discussed to address these concerns included (i) improving recruitment and retention of health system staff for rural and remote areas [ 21 , 46 , 47 , 50 ]; (ii) recruiting and training community health workers, while increasing the skills of lay health workers [ 21 ]; (iii) training traditional medicine practitioners in conventional medicine and utilizing them as community health workers [ 49 ]; and (iv) increasing task shifting, through delegating tasks to less specialized health workers [ 21 , 31 ], for which supportive supervision and adequate training is required [ 21 ].

Processes of care

Access to competent care and systems, incentives to improve quality of care delivery.

Evidence from the reviewed studies suggests that poor provider competence across a range of health services remains an ongoing issue, particularly in LMICs, posing a considerable barrier to the provision of timely, safe and effective quality of care [ 22 , 23 , 29 , 31 , 33 , 39 , 40 , 46 , 47 , 49 ]. For example, in China, a study with standardized patients found that providers in village hospitals provided correct treatment for tuberculosis only 28% of the time [ 47 ].

Within health systems seeking to provide UHC, significant inequities remain in both LMICs and HICs regarding the quality of care received by different populations. Vulnerable populations, who are more likely to receive care from lower-level health facilities, such as health centres, are disproportionately impacted by incompetent care and systems, having already constrained access to care [ 26 ], fewer options regarding providers and being more likely to receive inappropriate referrals [ 40 ], all indicators of lower-quality care.

Four studies described organizational factors influencing provider competence, including performance appraisal, continuing education, incentives, and remuneration and payment mechanisms [ 27 , 31 , 40 , 46 ]. For example, Sanogo et al. [ 40 ] discussed how delays in provider reimbursement as observed in Ghana, can demotivate healthcare providers, which Agarwal et al. [ 27 ] noted may decrease providers’ willingness to exert maximum effort on assigned tasks, compromising the quality of care.

Regarding incentives to improve motivation and quality of care delivery, Yip et al. [ 47 ] suggested a pay-for-performance system in China, as physicians are traditionally incentivized for treatment-based care through fee-for-service. However, the systematic review from Wiysonge et al. [ 46 ] noted a lack of evidence to support whether financial incentives for healthcare providers would improve quality of care in low-income countries.

User experience: wait times and people centredness

Wait times, a core component of quality of care, were noted as ongoing concerns in HICs and LMICs [ 21 , 23 , 33 , 39 , 40 , 47 , 48 , 55 , 56 ]. In HICs such as Norway and the United Kingdom, long wait times have been found to increase the demand for duplicative voluntary private health insurance, which Kiil argues may threaten the overall quality of public-sector driven UHC and exacerbate inequities [ 56 ]. In LMICs, evidence has shown that service quality is often superior in the private sector compared with the public sector, defined in relation to shorter wait times, better hospitality and increased time spent with providers [ 23 ].

Several studies described the relationship between positive user experience and people-centred care, which focuses on the needs and preferences of populations served while engaging them in shaping health policies and services. In addition, people centredness has been linked to improved mental and physical health, and reduced health inequities among other outcomes [ 20 , 22 , 31 , 35 , 57 ].

One study presented a people-centred care partnership model intended to support the work of advanced practice nurses in sustaining UHC, identifying nine attributes of people centredness including mutual trust and shared decision-making [ 20 ].

Several studies also discussed strategies aimed at increasing patient/community voice and engagement and the people centredness of health systems. These strategies included citizenship endorsement groups in Mexico [ 34 ] and various public forums to foster accountability and transparency [ 26 ]. However, McMichael et al. [ 35 ] cautioned that approaches to increase the voice of patients and communities risk excluding the most vulnerable, as those facing the greatest barriers to participation in such initiatives are often the most disadvantaged in their access and use of health services.

Quality impacts

Quality of care outcomes.

A few of the reviewed articles reported on empirical studies that analyzed patient and population health outcomes in relation to quality of care in the context of UHC. Where reported, these outcomes were discussed in reference to (i) specific programmes intended to improve quality of care and advance UHC, (ii) the impacts of health insurance schemes or health system reforms, (iii) private versus public sector provision of healthcare and/or (iv) the effects of specific service delivery models.

Regarding programmes intended to improve the quality of care, a community health extension programme in Ethiopia was associated with increased perinatal survival and decreased prevalence of communicable diseases. Though resource constraints such as inadequate medical supplies and limited supervision of health extension workers were noted as challenges, a key success factor included strong community engagement [ 29 ].

Another six studies examined health outcomes in relation to health insurance schemes or health system reforms [ 25 , 40 , 46 , 47 , 48 , 55 ]. Some improvements in health outcomes were noted. For example, in China, health system reforms aimed at achieving UHC have been associated with decreased maternal mortality rates [ 25 ]. However, the burden of noncommunicable diseases such as diabetes is rising amid significant gaps in their detection and treatment [ 47 ].

Studies also compared patient outcomes in relation to private versus public sector healthcare provision [ 24 , 56 , 58 ]. How the private sector was conceptualized varied across the studies, both in terms of how it was categorized (e.g. for-profit versus not-for-profit), as well as its role in healthcare financing and delivery. Given this heterogeneity, whether the public or private sector leads to higher-quality care and consequently, better health outcomes, is unclear in the reviewed literature. However, the private sector, when financed through out-of-pocket payments, is more likely to exacerbate inequities in access to healthcare.

Finally, two studies examined integrated models of care and their relationship to health outcomes [ 52 , 54 ]. According to these studies, different forms of service integration may positively impact health, for example, through slowed disease progression [ 54 ] and decreased preterm births [ 52 ].

Patient-reported satisfaction and trust in health system

Reports of poor perceived quality of care and low patient satisfaction as barriers to healthcare uptake and enrollment in health insurance schemes were common across the reviewed studies [ 26 , 28 , 36 , 40 , 44 , 47 , 55 , 56 ]. For instance, Alhassan et al. [ 28 ] found that perceived low quality of care, long wait times and poor treatment by healthcare providers reduced clients’ trust in Ghana’s National Health Insurance Scheme, reducing subsequent re-enrollment rates. In Ghana, perceived quality of care was found to exert a greater influence on men’s decisions regarding care uptake than on women’s decisions [ 36 , 44 ]. O’Connell et al. [ 36 ] suggested this gendered difference may be due to men’s care being more likely to be prioritized within household financial decisions, affording them the opportunity to be more discerning regarding the quality of care.

Several studies also discussed the effects of health system reforms and different service delivery models on patient satisfaction and trust in healthcare systems [ 23 , 28 , 29 , 31 , 38 , 43 , 47 , 54 , 57 ]. Yip et al. noted that despite reforms aimed at expanding access to care across China, many patients have chosen to forgo care at primary healthcare facilities altogether due to a lack of trust and dissatisfaction with quality of care [ 47 ]. Similarly, Ravaghi et al. identified contradictory results regarding the effects of hospital autonomy reforms on patient satisfaction. Two studies in Indonesia cited in Ravaghi’s review reported improvements, while others noted decreased or no change in patient satisfaction [ 38 ]. In contrast, four reviews found that integrated, people-centred health services may positively impact patient satisfaction [ 29 , 31 , 54 , 57 ].

Efficiency of healthcare services and systems

Twenty-seven studies addressed the efficiency of healthcare systems and services, which the review by Morgan et al., defined as ‘the extent to which resources are used effectively or are wasted’ [ 23 , p. 608]. These studies discussed inefficiencies in health systems [ 22 , 26 , 28 , 29 , 44 , 48 ], the possible effects of health reforms and other interventions on efficiency [ 21 , 25 , 31 , 37 , 38 , 41 , 44 , 45 , 46 , 47 , 50 , 53 , 54 , 55 , 58 , 59 ], efficiency as a criterion in health policymaking [ 32 ], and the measurement of efficiency [ 22 , 30 , 42 , 51 ], an example of which, as cited in Rezapour et al.’s study, was the percentage of prescriptions including antibiotics in health centres and health posts [ 51 ].

Additionally, some studies compared the efficiency of public and private sector healthcare provision, reporting mixed results [ 23 , 24 , 48 , 58 , 61 ]. For example, higher overhead costs and lower quality of care outcomes, including higher death rates, have been observed in private hospitals compared with public hospitals in the United States [ 24 ]. In contrast, research on the National Health Service in England has suggested that privatization and market-oriented reforms have improved the efficiency of hospital care through cost cutting without evidence of reduced quality [ 58 ].

In LMICs, the private sector has been linked to increased service costs related to overprescribing and use of unnecessary and expensive procedures [ 23 ]. However, Morgan et al. noted that studies assessing private sector performance in LMICs have often focused on unqualified or informal small private providers, such as small drug shops, operating amid weak public health systems and poor regulation, providing an incomplete picture of the role of the private sector in progress towards UHC [ 23 ]. Table 4 captures a high-level overview of the key highlights related to each domain and subdomain of Kruk et al.’s [ 5 ] framework discussed in the studies.

Identified evidence gaps and priorities for future research

Substantial evidence gaps that were identified in the reviewed literature are grouped thematically below. Themes are ordered by how frequently they were discussed by the reviewed studies.

Gap 1: How to measure and monitor UHC, with particular attention to quality of care and equity

Several studies identified the need for additional research to inform the development, selection and use of monitoring and evaluation frameworks and measures to assess quality of care and equity in relation to UHC in various geographic contexts at multiple levels of the health system, including facility and institutional levels [ 22 , 30 , 31 , 34 , 39 , 42 ]. For example, Rodney et al. stressed that countries should select contextually relevant indicators, and pay particular attention to the measurement of equity within UHC, cautioning that measuring equity based solely on wealth quintiles may mask inequities related to other factors such as race or disability [ 39 ]. In addition, two studies discussed the lack of client-reported measurements and advocated for further research to integrate data from household surveys and user-experience surveys [ 22 , 30 ].

Gap 2: Comparative information on the efficiency and effectiveness of public and private health provision and appropriate mix of public and private healthcare

Researchers noted the need for more conclusive evidence comparing the efficiency and effectiveness of public and private health sector provision, and the role of the private sector in contributing to UHC [ 21 , 23 , 56 , 57 , 62 ]. For example, Morgan et al. highlighted the need for greater evidence on how system-level influences such as regulations, may be used to create a public–private healthcare mix that promotes high-quality care and supports the achievement of UHC [ 23 ].

Gap 3: Effects of financial and insurance schemes on quality-of-care delivery and patient outcomes

The reviewed literature identified a lack of evidence regarding the impacts of different financial and insurance schemes on quality-of-care delivery and patient outcomes, particularly for vulnerable groups including women-headed households, children with special needs and migrants [ 34 , 46 , 55 , 62 ]. For example, van Hees et al. noted a lack of evidence regarding the impacts of financial schemes, such as pooling of funds and cost sharing, on equity [ 55 ].

Gap 4: Effects of integrated service delivery models

Studies identified the need for more robust evidence related to the effects of integrated service delivery models on access to quality care, as well as patient and population health outcomes [ 22 , 37 , 52 , 54 ]. Lê et al. specifically highlighted the lack of evidence on equity outcomes related to service integration, suggesting the need for further research in this area [ 54 ].

Gap 5: Mechanisms and contexts that enable and hinder implementation of quality-related interventions

Finally, researchers called for additional evidence regarding the mechanisms and contextual factors such as societal stigma that influence the effectiveness of interventions related to quality of care in the context of UHC [ 34 , 37 , 55 ]. To this aim, van Hees et al. recommended realist evaluations to surface what works, for whom, and in what contextual circumstances [ 55 ]. For example, Palagyi et al. identified a need for further research on task shifting, particularly how the skills gained by health workers can be maintained, and its implications for team dynamics and the delivery of existing programmes [ 37 ].

This scoping review aimed to characterize the existing conceptual and empirical literature on quality of care within the context of UHC. As noted in our results, in the reviewed literature, quality of care was often ill defined or defined inconsistently. A lack of conceptual clarity compromises the development of a robust evidence base able to inform the design and implementation of effective quality-related policies and interventions.

The 45 articles we reviewed for our study reveal a heterogeneous body of literature when compared with Kruk et al.’s quality of care framework. While some framework components including governance and the efficiency of healthcare services and systems were highly represented in the included literature, others were less represented such as physical and technological resources and tools, and patient and population health outcomes.

We also noted in the reviewed literature a lack of clarity regarding how the studies distinguished between private sector involvement in financing and/or delivery of care. This lack of clarity limits our understanding of the implications of private sector engagement for the quality of care and the achievement of UHC in various geographical contexts. Research is required to provide greater clarity of the role and impacts of private sector involvement in financing and/or delivery of health services, to help inform countries’ decision-making regarding private sector engagement. In addition, further research is needed regarding the interactions between the public and private sector and their effects on the sustainability of UHC. For example, studies have noted a concern that the availability of concierge services can create downstream implications for people who cannot afford private insurance, such as an imbalance in resource distribution [ 57 ].

Overall, the identified evidence gaps pointed to the need to build a stronger evidence base about what works, for whom, and under what contextual circumstances, and with what effects on equity to improve quality of care in LMICs and HICs. This includes a need for further evidence on the effects of integrated service delivery models, as well as how regulation can be used to create a public–private healthcare mix promoting high-quality and equitable care. The literature further highlighted the urgent need for additional research to inform the creation of robust monitoring and evaluation frameworks prioritizing equity that could support improvements to quality of care. This includes further research to help support the inclusion and use of disaggregated data, such as by wealth, sex and ethnicity to monitor and inform efforts to increase equity in access, utilization and outcomes for vulnerable populations. Beyond the above-noted research priorities, we also recommend additional research comparing quality related outcomes before and after UHC implementation, and how they intersect with health equity.

Strengths of our scoping review include the use of a broad search methodology and validated search filters in consultation with an expert librarian, and the use of a conceptual framework to guide analysis of findings. Further, our search was not constrained based on country of origin. In our search of the literature, we did not find other published reviews of similar scope about quality of care within the context of UHC.

The primary limitation of our review is the small number of included studies that met our eligibility criteria. This highlights that quality-related research in UHC remains an emerging field. In addition, many of the included studies were narrative reviews, which may not have captured the full breadth of the literature. Another limitation of our review is that we included only English-language studies. Future reviews should attempt to search and synthesize evidence in additional languages to provide more global relevance. Further, the conceptual framework we applied to the analysis of findings does not consider various factors that render health systems more fragile such as pandemics, disasters and conflicts, which may compromise the quality of care and realization of UHC. As our study did not include search terms for specific vulnerable populations such as Indigenous or racialized groups, there is also need for future research related to LMICs and communities experiencing marginalization and discrimination within HICs.

In addition, there may be limited applicability of findings across studies to different geographic regions. Finally, due to the heterogeneity and qualitative nature of the included studies, meta-analysis and synthesis beyond thematic analysis were not feasible.

This review summarized the existence of available evidence on quality of care within the context of UHC, identifying strategies aimed at improving quality of care as well as diverse knowledge gaps. Further research, evaluation and monitoring frameworks including those that attend to equity are required to strengthen the existing evidence base.

Availability of data and materials

This work analyzed secondary sources, which are cited and are publicly accessible or with academic institutional credentials. Authors can confirm that all other relevant data are included in the article and/or its additional files.

Abbreviations

African Region

Region of the Americas

Community Health Worker

Eastern Mediterranean Region

European Region

High-Income Countries

Low- and Middle-Income Countries

Millennium Development Goals

National Health Insurance Scheme

National Health Service

Primary Healthcare

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Sustainable Development Goals

South-East Asian Region

Universal Health Coverage

Western Pacific Region

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This research was funded by the Canadian Institutes of Health Research (CIHR) (#407149) for the project titled ‘Towards Equitable Universal Health Coverage in a Globalized Era: A Research Agenda-Setting Workshop’.

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Yanful, B., Kirubarajan, A., Bhatia, D. et al. Quality of care in the context of universal health coverage: a scoping review. Health Res Policy Sys 21 , 21 (2023). https://doi.org/10.1186/s12961-022-00957-5

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Universal Healthcare in the United States of America: A Healthy Debate

Affiliations.

• 1 Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
• 2 Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA.
• PMID: 33143030
• PMCID: PMC7692272
• DOI: 10.3390/medicina56110580

This commentary offers discussion on the pros and cons of universal healthcare in the United States. Disadvantages of universal healthcare include significant upfront costs and logistical challenges. On the other hand, universal healthcare may lead to a healthier populace, and thus, in the long-term, help to mitigate the economic costs of an unhealthy nation. In particular, substantial health disparities exist in the United States, with low socio-economic status segments of the population subject to decreased access to quality healthcare and increased risk of non-communicable chronic conditions such as obesity and type II diabetes, among other determinants of poor health. While the implementation of universal healthcare would be complicated and challenging, we argue that shifting from a market-based system to a universal healthcare system is necessary. Universal healthcare will better facilitate and encourage sustainable, preventive health practices and be more advantageous for the long-term public health and economy of the United States.

Keywords: chronic disease; diabetes; health insurance; health promotion; hypertension; obesity; socio–economic status; universal healthcare.

• Delivery of Health Care
• Diabetes Mellitus, Type 2*
• Health Status
• United States / epidemiology
• Universal Health Care*
• Universal Health Insurance

Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?

The United States spends substantially more on health care than most developed countries, yet leaves a greater share of the population uninsured. We suggest that incremental insurance expansions focused on addressing market failures will propagate inefficiencies and are not likely to facilitate active policy decisions that align with societal coverage goals. By instead defining a basic bundle of services that is publicly financed for all, while allowing individuals to purchase additional coverage, policymakers could both expand coverage and maintain incentives for innovation, fostering universal access to innovative care in an affordable system.

Katherine Baicker is dean and Emmett Dedmon Professor, University of Chicago Harris School of Public Policy, Chicago, Illinois. Amitabh Chandra is Ethel Zimmerman Wiener Professor of Public Policy, Harvard Kennedy School, and Henry and Allison McCance Professor of Business Administration, Harvard Business School, Cambridge, Massachusetts. Mark Shepard is Associate Professor, Harvard Kennedy School, Cambridge, Massachusetts. Their email addresses are [email protected], [email protected], and [email protected]. This paper is based on a manuscript prepared for the Journal of Economic Perspectives. The authors thank the editors and Joe Newhouse for helpful feedback and suggestions, and Jason Furman and Matt Fiedler for sharing historical data on US uninsured rates. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

Baicker serves on the boards of Eli Lilly, the Mayo Clinic, the Urban Institute, the Chicago Council on Global Affairs, and NORC. Baicker and Chandra serve on the CBO Panel of Health Advisers.

Amitabh Chandra Disclosures

Congressional Budget Office (Federal Government). Panel of Health Advisors. Unpaid. Leigh Speakers Bureau, Speakers Bureau Washington Speakers Bureau, Speakers Bureau Analysis Group, Academic Affiliate Kyruus, Advisor Health Engine, Advisor SmithRx, Advisor

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Katherine Baicker & Amitabh Chandra & Mark Shepard, 2023. " Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?, " Journal of Economic Perspectives, vol 37(2), pages 99-122.

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Universal Health Coverage: The Benefits of Implementation in the United States

Colette Feghali-Behboud

Personal Statement

I am a current public health student at Lake Washington Institute of Technology. My purpose for developing this research paper is to bring awareness to the advantages and challenges of implementing a universal health coverage system in the United States. Despite the challenges, change is possible and recommended to improve health equity and increase general productivity among residents and communities. As a future public health professional, I aim to advocate for health reform in the state of Washington so that health care is accessible and affordable to all populations. Health care is a basic human right, not a privilege.

This paper aims to address how universal health coverage (UHC) could impact the quality of life for middle- to low-income households in the United States. The approaches to addressing this issue include gathering empirical data from credible sources and providing successful examples from other countries that utilize this type of system. Information on the advantages and challenges of UHC implementation in the U.S. have been collected and will be discussed. A few examples of advantages include health equity, improved quality of life for all, and decreased financial burdens for vulnerable populations. With the implementation of a UHC system in the U.S., it could foster a more productive society.

As one of the wealthiest nations in the world, the United States and its government should be able to provide Americans with universal health coverage (UHC). Many countries have successfully implemented some form of UHC and have statistically spent less money on health care services compared to the U.S. (McGough et al., 2023, para. 2). Universal health care has many benefits that could drastically transform and save lives. Based on evidence from comparably wealthy countries, once established, UHC in the U.S. would provide improved quality of life and health equity, preventive health care, affordable and cost-effective medical coverage, protection against future outbreaks and preventable deaths, and a better health care system. Quality health care should be easily accessible by all residents of the U.S.

Quality of Life and Health Equity Improvements

A common statement that many people believe, and others should acknowledge, is this: health care is a basic human right, not a privilege. According to the World Health Organization (WHO), universal health care is “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user [to] financial hardship” (Zieff et al., 2020, para. 2). Developing a UHC system in the U.S. would improve quality of life by eliminating medical costs incurred by uninsured and vulnerable populations. Additionally, a UHC system provides flexibility for people to pursue better employment as they are not tied to employer-provided insurance. A substantial portion of the U.S. population receives medical insurance through their employers and can thus face substantial hardships when losing employment. This is especially true among vulnerable populations that tend to have lower employment percentages. By providing UHC, health equity may be improved by narrowing the income-related disparities inherent in the U.S. (Schneider et al. 2021, para. 23). The quality of life for Americans can be improved by preventive care, which can diagnose and treat diseases before they become life-threatening (Galvani et al., 2020, para 19).

Advantages of Sustaining Preventive Health Care

One of the most important impacts of UHC is preventive care through access to healthcare services among middle- and low-income populations who cannot currently pay for medical costs. Patients who are at risk for developing chronic diseases and illnesses can address them at regular doctor visits and screenings. According to Zieff et al. (2020), “Accessible, affordable healthcare may enable earlier intervention to prevent—or limit risk associated with—non-communicable chronic diseases, improve the overall public health of the U.S., and decrease the economic strain associated with an unhealthy low-SES [socioeconomic status]” (para. 8). With the current costs of private insurance and unreliable employer-based health care, vulnerable populations are often underinsured or uninsured. This results in certain populations becoming unhealthy and less productive. Some examples of benefits that would be managed under UHC include behavioral and mental-health disorders, substance-use disorders, communicable diseases, and non-communicable diseases such as heart disease, diabetes, and cancer (American Academy, n.d., Benefits section). Routine preventive care can foster an environment for patients to receive ongoing care and screenings as they age, including mammograms and prostate exams. With preventive care, patients with non-communicable diseases can receive laboratory and diagnostic testing to prevent emergency room visits. Supporting this approach, Zieff et al. (2020) report that “the uninsured diabetic population is responsible for 55% more emergency room visits each year than their insured diabetic counterparts” (para. 8). If the U.S. government adopted a UHC system, these conditions could be prevented or treated without any financial burdens associated with medical costs.

Affordable and Cost-Effective Medical Coverage

Americans who are against the implementation of UHC in the U.S. claim that the financial costs do not outweigh the benefits. On the contrary, Galvani et al. (2020) state, “we predict that a single-payer healthcare system would require $3.034 trillion annually, $458 billion less than current national healthcare expenditure” (para. 12). This translates into a savings of ~$1,400 per person annually. Additionally, the existing U.S. healthcare system already spends a disproportionate amount of gross domestic product (GDP) on medical care compared to economically comparable nations. A study that analyzed the U.S. healthcare costs per GDP found that “health spending per person in the U.S. was $12,914 in 2021, which was over $5,000 more than any other high-income nation” (McGough et al., 2023, para. 4)(see Figure 1). The U.S. is spending approximately 17% of its GDP on health care compared to 8 to 12% among 10 other wealthy nations, yet the care in the U.S. is substantially worse (Schneider et al., 2021, Exhibit 4). The one aspect of the current U.S. healthcare system that is working well is the “rates of mammography screening and influenza vaccination as well as the percentage of adults who [spoke] with their provider about nutrition, smoking, and alcohol use” (Schneider et al., 2021, para. 19). When advocating for the implementation of UHC in the U.S., it will be important to preserve this aspect that is currently working well.

Further objections to the UHC system are often made by shareholders of insurance companies whose primary focus is to drive up the price value of shares. Due to the insurance companies’ fiduciary responsibility to their shareholders combined with the private insurance model that has transiently enrolled patients, long-term care is not a priority. Instead, by limiting primary care, they reduce short-term costs (Galvani et al., 2020, para. 19). Under the UHC model, “a single-payer system would be financially responsible for healthcare throughout the lifespan of all Americans, [and thus] it becomes efficient to incur a small cost in the present with the purpose of avoiding more serious and costly health conditions in the future” (Galvani et al., 2020, para. 19). Associated costs with administrative, medical-service, and other health-care fees would decrease, and can balance the initial financial burden of establishing such a system. Along these lines, vulnerable groups would be able to access primary care and potentially save their lives.

Protection Against Future Outbreaks and Preventable Deaths

During the COVID-19 pandemic, many Americans had insufficient access to medical coverage, which led to high mortality rates. Galvani et al. (2022) calculated that about 338,954 preventable deaths associated with the COVID-19 pandemic could have been averted with a UHC system (para. 11). For instance, if the uninsured populations had medical coverage and had been able to maintain health issues, it would have lowered their risk of comorbidities and death during the pandemic. According to the policy statement from the APHA, the existing employer-sponsored health insurance is subject to downturns in the economy and was predicted to cause 10 million Americans to lose their insurance from being laid off during the Covid-19 pandemic (American Public Health Association [APHA], 2020, para. 7). As a result, many Americans and family members enrolled into Medicaid/Children’s Health Insurance Program (CHIP), further straining state and federal budgets (APHA, 2020, para. 5)(see Figure 2).

When Americans lose their access to health care, they can become vulnerable to mortality due to outbreaks as their diseases and illnesses go untreated. It is unsurprising that the tragic result of the Covid-19 pandemic in the U.S. was, in the estimation of Galvani et al (2020), that “the number of lives that could have been saved in 2020 by universal healthcare from both non-COVID conditions and COVID-19 would be 211,897” (para. 12). The American Public Health Association (APHA) (2020) describes the pandemic as “a watershed moment where we can reconstruct a fractured health insurance system into a system of universal health care” (Problem Statement section, para. 15). In the words of Wesley Mantooth, a professor and department chair at Lake Washington Institute of Technology, “in terms of communicable diseases, it seems like [the case for implementing UHC] is a good argument to persuade people that all of society would be safer if currently vulnerable members had better care” (Mantooth, personal communication, March 8th, 2023). To address this issue of inequity in the U.S. healthcare system, many people advocate for a transition to UHC. For example, Senator Bernie Sanders supports the Medicare for All Act (MAA), which would lower maternal deaths, increase the rate of survival for newborns, and increase the longevity of all people in the U.S. who are currently dying without comprehensive medical care (Galvani et al., 2020, Introduction section). Unfortunately, the reform in the U.S. healthcare system is slow to evolve and is often mired in political misinformation.

Successful Coverage Among Other Comparably Wealthy Countries

Despite being one of the highest income countries, the U.S. ranks among the lowest in healthcare approaches compared to countries with UHC. A 2021 study compared healthcare systems in 11 wealthy nations: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, and the U.S. According to Schneider et al. (2021), the key differences can be summarized below:

Four features distinguish top-performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults. (para. 5)

For the U.S. to reach equal standards of care, these four features must be addressed:

• Providing affordable, universal coverage helps with three subcategories of care. First, patients would be less likely to report that insurance companies denied their claims. Secondly, patients would have fewer burdens in paying for their care. Lastly, there would be better access to same-day care as well as after-hours care. Currently, the U.S. ranks last when compared to 10 other wealthy nations in providing affordable coverage (Schneider et al., 2021, para. 14).
• The next feature is equitably available primary care, which is currently unbalanced in the U.S., with high-income patients reporting easier access to primary care, while low-income communities struggle to meet their needs. When comparing the income gap to access of care of these same 10 wealthy nations, it becomes clear that not only would low-income communities benefit from UHC, but also wealthier ones, as 27% of high-income U.S residents still report access problems (Schneider et al., 2021, Exhibit 7) (see Figure 3). To clarify, this means that even wealthy communities would gain ground with the transition to UHC.
• In the pursuit of improving administrative efficiencies, the U.S. stands to benefit from UHC implementation, as the U.S. ranks last in this category as well. Administrative efficiency is a measure of how burdensome documentation and bureaucratic tasks are that impose difficulties for patients and doctors to pursue care. Since insurance in the U.S. is so fragmented, patients can experience roadblocks to medication or treatment because their insurance does not cover it, or because a specialty clinic is out-of-network. By eliminating these inefficiencies with the implementation of UHC, the U.S. can reduce the cost of care and manage primary care efficiently and effectively.
• The final category that these other wealthy countries currently outpace the U.S. in is their investment in social services. These services include “access to nutrition, education, child care, community safety, housing, transportation, and worker benefits” (Schneider et al., 2021, Discussion section). The benefits of these services contribute to one critical aspect of health care: a healthier population that lessens the burden on health services. A metaphor can be used to illustrate this concept, where the “reduce” feature of the “reduce, re-use, and recycle” program moto aims to prevent the use of materials before they enter the production cycle. Similarly, reducing hospital and emergency room visits by promoting healthier and more equitable communities in the first place can save money and resources. In a country where a large part of the GDP is already spent on health care, saving costs by moving to UHC would benefit the whole populace. It is important that all Americans can afford medical care to achieve the best health possible.

Health care in the U.S. is lacking and should reform to universal coverage as successfully shown in other comparable countries. Although universal health coverage has its advantages and disadvantages, the disadvantages of the initial financial costs would eventually balance out over time. Many advantages include access to health care for all, prevention of chronic diseases and illnesses, reduced medical bills, and protection against future national emergencies. Universal coverage provides access to health care for those without means to currently afford the costs. It would improve the health of the general population by providing routine care, preventive care, treatment, and support and resources to maintain their current conditions. Additionally, with the elimination of financial burdens from medical fees, middle- to low-income households would be able to provide their families with basic needs such as food and housing, among other things. Eliminating employer-sponsored health coverage would allow companies to divert their insurance payments to the paychecks of their workers. While workers would need to adjust to higher taxes to cover UHC, they would still save an expected $1,400 annually, per person, which may then be used to further stimulate the economy. This change could bring about better health and better economic growth.

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Galvani, A. P., Parpia, A. S., Pandey, A., Sah, P., Colón, K., Friedman, G., Campbell, T., Kahn, J. G., Singer, B. H., & Fitzpatrick, M. C. (2022). Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic. Proceedings of the National Academy of Sciences, 119(25). https://doi.org/10.1073/pnas.2200536119

McGough, M., Telesford I., Rakshit, S., Wager, E., Amin, K., & Cox, C. (2023, February 15). How does health spending in the U.S. compare to other countries? Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/

Schneider, E. C., Shah, A., Doty, M. M., Tikkanen, R., Fields, K., & Williams II, R. D., (2021) Mirror, mirror 2021: Reflecting poorly. Commonwealth Fund. https://doi.org/10.26099/01dv-h208

Zieff, G., Kerr, Z. Y., Moore, J. B., & Stoner, L. (2020). Universal healthcare in the United States of America: A healthy debate. Medicina-Lithuania, 56(11), 580. https://doi.org/10.3390/medicina56110580

Note. This figure demonstrates the higher cost-related access problems among low- and high-income populations in the U.S. compared to other high-income countries.

Figure 1. U.S. Health Care Costs per GDP Compared to Other High-Income Nations Note. This figure shows a comparison of health-care costs per GDP between the U.S. and other high-income nations.

Figure 2. Medicaid/Children’s Health Insurance Program (CHIP) Enrollment (A, B), Excess Death (C), and Years of Life Lost (D) During Covid-19 Pandemic

Figure 3. Higher Rates of Cost-Related Access Problems in the U.S. Compared to other High-Income Nations Note. This figure demonstrates the higher cost-related access problems among low- and high-income populations in the U.S. compared to other high-income countries.

Keywords: universal health care; universal health coverage; health care; health care systems; health care debate; health care costs; health equity; universal health care benefits; universal health care advantages; access to health care

The Lion's Pride, Vol. 16 Copyright © 2022 by Colette Feghali-Behboud is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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UC Merced Undergraduate Research Journal

The Possibility of Universal Health Coverage in the United States

• Riley, Anna

Published Web Location

This research paper intends to examine the ways in which universal healthcare coverage can potentially benefit the United States population, as well as investigate the challenges of implementing it. This paper found that there are many problems within the current U.S. healthcare system that can be improved by the implementation of Universal Health Coverage (UHC). Additionally, this paper includes evidence that UHC could have many economic and public health benefits in the United States. The paper then mentions the clear plans for implementing UHC in the U.S. and that there are other countries which have successfully implemented it. Finally, the paper ends by highlighting the certain difficulties that come with implementation as well as underscoring their possible solutions.

Keywords: universal healthcare coverage, United States healthcare, health insurance

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Point Turning Point: the Case for Universal Health Care

An argument that the COVID-19 pandemic might be the turning point for universal health care.

Why the U.S. Needs Universal Health Care

As we all grapple with our new reality, it's difficult to think of anything beyond the basics. How do we keep our families safe? Are we washing our hands enough ? Do we really have to sanitize the doorknobs and surfaces every day? How do we get our cats to stop videobombing our Zoom meetings? Do we have enough toilet paper?

Win McNamee | Getty Images

The more we read the headlines, the more we feel the need to do something, or at least say something. Change is happening – ready or not. Maybe talking about some of these important issues can lead to action that will help us steer out of this skid.

Historically, Americans have found ways to meet their circumstances with intention, moving in mass to make heretofore unimaginable change that has sustained and improved our lives to this day. The Great Depression lead to the creation of the New Deal and Social Security. The Triangle Shirtwaist Factory fire brought about change in labor conditions. The Cuyahoga River fire lead to the founding of the Environmental Protection Agency.

Could the COVID-19 pandemic be the turning point for universal health care? We can't think of a more propitious time. In the first two weeks of April, 5.2 million Americans filed for unemployment. Economists believe that 30% unemployment is possible by fall. For most Americans, our health care is tied to our employment, and because of this, millions of Americans are losing their health care just when they may need it the most. Economists predict that health insurance premiums will likely increase by 40% in the next year due to less payers and more who are in need of care and the eventual collapse of private health care insurance .

Our current circumstances have illustrated the need for universal health care in a way that is obvious and undeniable. Below we have listed the most frequent arguments in opposition followed by an evidence-based rebuttal.

1. Point: "Governments are wasteful and shouldn't be in charge of health care."

Counterpoint: In 2017, the U.S. spent twice as much on health care (17.1% of GDP) as comparable Organization for Economic Co-Operation and Development countries (OECD) (8.8% of GDP), all of whom have universal health care. The country with the second highest expenditure after the U.S. is Switzerland at 12.3%, nearly 5% less. Of all these countries, the U.S. has the highest portion of private insurance. In terms of dollars spent, the average per capita health care spending of OECD countries is $3,558, while in the U.S. it's $10,207 – nearly three times as costly.

Bottom line: Among industrialized countries with comparable levels of economic development, government-provided health care is much more efficient and more economical than the U.S. system of private insurance.

2. Point: "U.S. health care is superior to the care offered by countries with universal health care."

Counterpoint: According to the Commonwealth Health Fund , in the U.S., infant mortality is higher and the life span is shorter than among all comparable economies that provide universal health care. Maternal mortality in the U.S. is 30 per 100,000 births and 6.4 per 100,000 births on average in comparable countries, which is nearly five times worse.

In addition, the U.S. has the highest chronic disease burden (e.g., diabetes, hypertension) and an obesity rate that is two times higher than the OECD average. In part due to these neglected conditions, in comparison to comparable countries, the U.S. (as of 2016) had among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

The Peterson-Kaiser Health System Tracker , which is a collaborative effort to monitor the quality and cost of U.S. health care, shows that among comparable countries with universal health care, mortality rate is lower across the board on everything from heart attacks to child birth. The U.S. also has higher rates of medical, medication and lab errors relative to similar countries with universal health care.

Bottom line: With our largely privately funded health care system, we are paying more than twice as much as other countries for worse outcomes.

3. Point: "Universal health care would be more expensive."

Counterpoint: The main reason U.S. health care costs are so high is because we don't have universal health care. Unlike other first world countries, the health care system in the U.S. is, to a great extent, run through a group of businesses. Pharmaceutical companies are businesses. Insurance companies are businesses. Hospital conglomerates are businesses. Even doctors' offices are businesses.

Businesses are driven to streamline and to cut costs because their primary goal is to make a profit. If they don't do this, they can't stay in business. It could mean that in the process of "streamlining," they would be tempted to cut costs by cutting care. Under the current system, a share of our health care dollars goes to dividends rather than to pay for care, hospitals are considered a "financial asset" rather than a public service entity and a large portion of their budgets are dedicated to marketing rather than patient care.

Given all these business expenses, it shouldn't be surprising that the business-oriented privately funded health care system we have is more expensive and less effective than a government provided universal system. In addition, for the health care system as a whole, universal health care would mean a massive paperwork reduction. A universal system would eliminate the need to deal with all the different insurance forms and the negotiations over provider limitations. As a result, this would eliminate a large expense for both doctors and hospitals.

The economist Robert Kuttner critiques the system this way: "For-profit chains … claim to increase efficiencies by centralizing administration, cutting waste, buying supplies in bulk at discounted rates, negotiating discounted fees with medical professionals, shifting to less wasteful forms of care and consolidating duplicative facilities." As he points out, "using that logic, the most efficient 'chain' of all is a universal national system."

Evidence to support these points can be found in a recent Yale University study that showed that single-payer Medicare For All would result in a 13% savings in national health-care expenditures. This would save the country $450 billion annually.

Bottom line: Universal health care would be less expensive overall, and an added benefit would be that health care decisions would be put in the hands of doctors rather than insurance companies, which have allegiances to shareholders instead of patient care.

4. Point: "I have to take care of my own family. I can't afford to worry about other people."

Counterpoint: It is in all of our best interests to take care of everyone. Aside from the fact that it is the compassionate and moral thing to do, viruses do not discriminate. When people don't have insurance, they won't go to the doctor unless they're gravely ill. Then, they're more likely to spread illness to you and your family members while they delay getting the care they need.

In addition, when people wait for care or don't get the prophylactic care then need, they end up in the emergency room worse off with more costly complications and requiring more resources than if they had been treated earlier. Taxpayers currently cover this cost. This affects everyone, insured or not. Why not prevent the delay upfront and make it easy for the patient to get treatment early and, as an added bonus, cost everyone less money?

In addition, the health of the economy impacts everyone. Healthy workers are essential to healthy businesses and thus a healthy economy. According to the Harvard School of Public Health , people who are able to maintain their health are more likely to spend their money on goods and services that drive the economy.

Bottom line: The health of others is relevant to the health of our families either through containment of infectious diseases such as COVID-19 or through the stability of the economy. Capitalism works best with a healthy workforce.

5. Point: "Entrepreneurship and innovation is what makes the U.S. a world leader."

Counterpoint: Imagine how many people in the U.S. could start their own businesses or bring their ideas to market if they didn't have to worry about maintaining health care for their families. So many people stay tethered to jobs they hate just so their family has health care. With workers not needing to stay in jobs they don't like in order to secure health insurance, universal healthcare would enable people to acquire jobs where they would be happier and more productive. Workers who wanted to start their own business could more easily do so, allowing them to enter the most creative and innovative part of our economy – small businesses.

In his book, "Everything for Sale," economist Robert Kuttner asserts that it's important to understand that businesses outside of the U.S. don't have to provide health care for their employees, which makes them more competitive. From a business point of view, American companies, released from the burden of paying employee insurance, would be more competitive internationally. They would also be more profitable as they wouldn't have to do all the paperwork and the negotiating involved with being the intermediary between employees and insurance companies.

Bottom line: Unburdening businesses from the responsibility of providing health insurance for their employees would increase competitiveness as well as encourage entrepreneurship and innovation, and allow small businesses room to thrive.

6. Point: "The wait times are too long in countries with universal health care."

Counterpoint: The wait times on average are no longer in countries with universal healthcare than they are in the U.S., according to the Peterson-Kaiser Health System Tracker . In some cases, the wait times are longer in the U.S., with insurance companies using valuable time with their requirements to obtain referrals and approvals for sometimes urgently needed treatments. On average, residents of Germany, France, UK, Australia, and the Netherlands reported shorter wait times relative to the U.S.

Bottom line: Wait times are longer in the U.S. when compared with many countries with a universal health care system.

7. Point: "My insurance is working just fine, so why change anything?"

Counterpoint: A comprehensive study conducted in 2018 found that 62% of bankruptcies are due to medical bills and, of those, 75% were insured at the time. Most people who have insurance are insufficiently covered and are one accident, cancer diagnosis or heart attack away from going bankrupt and losing everything. The U.S. is the only industrialized country in the world whose citizens go bankrupt due to medical bills. And, if you survive a serious illness and don't go bankrupt, you may end up buried in bills and paperwork from your insurance company and medical providers. All of this takes time and energy that would be better spent healing or caring for our loved ones. Besides, we don't need to abolish private health insurance. Some countries like Germany have a two-tiered system that provides basic non-profit care for all but also allows citizens to purchase premium plans through private companies.

Bottom line: Private insurance does not protect against medical bankruptcy, but universal health care does. The residents of countries with universal health care do not go bankrupt due to medical bills.

8. Point: "I don't worry about losing my insurance because if I lose my job, I can just get another one."

Counterpoint: We can't predict what will happen with the economy and whether another job will be available to us. This pandemic has proven that it can all go bad overnight. In addition, if you lose your job, there is less and less guarantee that you will find a new job that provides insurance . Providing insurance, because it is so expensive, has become an increasingly difficult thing for companies to do. Even if you're able to find a company that provides health care when you change jobs, you would be relying on your employer to choose your health plan. This means that the employee assumes that the company has his or her best interests in mind when making that choice, rather than prioritizing the bottom line for the benefit of the business. Even if they're not trying to maximize their profit, many companies have been forced to reduce the quality of the insurance they provide to their workers, simply out of the need to be more competitive or maintain solvency.

Bottom line: There are too many factors beyond our control (e.g., pandemic, disability, economic recession) to ensure anyone's employment and, thus, health care. Universal health care would guarantee basic care. Nobody would have to go without care due to a job loss, there would be greater control over costs and businesses would not have to fold due to the exorbitant and rising cost of providing health insurance to their employees.

9. Point: "Pharmaceutical companies need to charge so much because of research and development."

Counterpoint: It's usually not the pharmaceutical companies developing new drugs. They develop similar drugs that are variations on existing drugs, altered slightly so that they can claim a new patent. Or they buy out smaller companies that developed new drugs, thus minimizing their own R&D costs. Most commonly, they manufacture drugs developed under funding from the National Institutes of Health, and thus, the tax payers are the greatest funder of drug development via NIH grants provided to university labs.

Oddly, this investment in R&D does not appear to extend any discount to the tax payers themselves. In "The Deadly Costs of Insulin, " the author writes that insulin was developed in a university lab in 1936. In 1996, the cost of a vial of insulin was $21. Today, the cost of a vial of insulin could be as much as $500, causing some without insurance to risk their lives by rationing or going without. The cost of manufacturing the drug has not gone up during that time. So, what accounts for the huge increase in price? In " The Truth About Drug Companies ," the author demonstrates that drug companies use the bulk of their profits for advertising, not R&D or manufacturing. A universal health care system would not only not need to advertise, but would also be more effective at negotiating fair drug prices. Essentially, the government as a very large entity could negotiate price much more effectively as one large system with the government as the largest purchaser.

Bottom line: Taxpayers contribute most of the money that goes into drug development. Shouldn't they also reap some of the benefits of their contribution to R&D? Americans should not have to decide between their heart medication and putting food on the table when their tax dollars have paid for the development of many of these medications.

10. Point: "I don't want my taxes to go up."

Counterpoint: Health care costs and deductibles will go down to zero and more than compensate for any increase in taxes, and overall health care needs will be paid for, not just catastrophic health events. According to the New York Times , “…when an American family earns around $43,000, half of the average compensation when including cash wages plus employer payroll tax and premium contributions, 37% of that ends up going to taxes and health care premiums. In high-tax Finland, the same type of family pays 23% of their compensation in labor taxes, which includes taxes they pay to support universal health care. In France, it’s 2%. In the United Kingdom and Canada, it is less than 0% after government benefits.”

Bottom line: With a universal health care system, health care costs and deductibles will be eliminated and compensate for any increase in taxes.

11. Point: "I don't want to have to pay for health care for people making bad choices or to cover their pre-existing conditions."

Counterpoint: Many of the health problems on the pre-existing conditions list are common, genetically influenced and often unavoidable. One estimate indicates that up to 50% – half! – of all (non-elderly) adults have a pre-existing condition. Conditions on the list include anxiety, arthritis, asthma, cancer, depression, heart defect, menstrual irregularities, stroke and even pregnancy. With universal health care, no one would be denied coverage.

It's easy to assume that your health is under your control, until you get into an accident, are diagnosed with cancer or have a child born prematurely. All of a sudden, your own or your child's life may rely on health care that costs thousands or even millions of dollars. The health insurance that you once thought of as "good enough" may no longer suffice, bankruptcy may become unavoidable and you (or your child) will forever have a pre-existing condition. Some people may seem careless with their health, but who's to judge what an avoidable health problem is, vs. one that was beyond their control?

For the sake of argument, let's say that there are some folks in the mix who are engaging in poor health-related behaviors. Do we really want to withhold quality care from everyone because some don't take care of their health in the way we think they should? Extending that supposition, we would withhold public education just because not everyone takes it seriously.

Bottom line: In 2014, protections for pre-existing conditions were put in place under the Affordable Care Act. This protection is under continuous threat as insurance company profits are placed above patient care. Universal health care would ensure that everyone was eligible for care regardless of any conditions they may have.

And, if universal health care is so awful, why has every other first-world nation implemented it? These countries include: Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, United Arab Emirates and the U.K.

Changing collective minds can seem impossible. But there is precedent. Once unimaginable large-scale change has happened in our lifetime (e.g. legalization of gay marriage, election of the first black president of the U.S. and the #MeToo movement), and support for universal health care has never been higher (71% in favor, according to a 2019 Hill-HarrisX survey ).

Point: As Chuck Pagano said, "If you don't have your health, you don't have anything."

Counterpoint: If good health is everything, why don't we vote as if our lives depended on it? This pandemic has taught us that it does.

Bottom line: Launching universal health care in the U.S. could be a silver lining in the dark cloud of this pandemic. Rather than pay lip service to what really matters, let's actually do something by putting our votes in service of what we really care about: the long-term physical and economic health of our families, our communities and our country.

Photos: Hospital Heroes

Tags: health insurance , health care , Coronavirus , pandemic , New Normal

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Canada's universal health-care system: achieving its potential

Danielle martin.

a Women's College Hospital and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

b Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

Ashley P Miller

c Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada

Amélie Quesnel-Vallée

d McGill Observatory on Health and Social Services Reforms, Department of Epidemiology, Biostatistics and Occupational Health, and Department of Sociology, McGill University, Montréal, QC, Canada

Nadine R Caron

e Department of Surgery, Northern Medical Program and Centre for Excellence in Indigenous Health, University of British Columbia, Prince George, BC, Canada

Bilkis Vissandjée

f School of Nursing and Public Health Research Institute, Université de Montréal, SHERPA Research Centre, Montréal, QC, Canada

Gregory P Marchildon

g Johnson-Shoyama Graduate School of Public Policy, University of Regina, Regina, SK, Canada

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

This is the first in a Series of two papers about Canada's health system and global health leadership

Introduction

Founded on Indigenous lands and the product of Confederation that united former British colonies in 1867, Canada is a complex project. 36 million people from a rich diversity of ethnocultural backgrounds live on a vast geography bounded by the Arctic, Pacific, and Atlantic Oceans, across six time zones and eight distinct climate regions.

Canada is among the world's most devolved federations, with substantial political power and policy responsibility held by its ten provinces and three territories. The province of Quebec, with its unique French-speaking linguistic and cultural context, often charts a policy path that is independent from the rest of the country. 1 The decentralisation of the Canadian polity is expressed in its health-care system—known as Medicare—which is not a national system per se, but rather a collection of provincial and territorial health insurance plans subject to national standards. 2 , 3 These taxation-based, publicly funded, universal programmes cover core medical and hospital services for all eligible Canadians, and are free at the point of care ( figure 1 ).

Overview of the Canadian health system

Adapted from 2 , 3 .

To Canadians, the notion that access to health care should be based on need, not ability to pay, is a defining national value. This value survives despite a shared border with the USA, which has the most expensive and inequitable health-care system in the developed world. 4

Canadian Medicare is more than a set of public insurance plans: more than 90% of Canadians view it as an important source of collective pride. 5 This pride points to an implicit social contract between governments, health-care providers, and the public—one that demands a shared and ongoing commitment to equity and solidarity. 6 Such a commitment is inevitably challenged in each generation by an array of external shocks and internal problems. Currently, wait times for elective care, inequitable access to health services in both the public and private systems, and the urgent need to address health disparities for Indigenous Canadians threaten this equity and solidarity.

In this first paper of a two-part Series on Canada's health system and global health leadership, 7 we analyse the unique history and features of the Canadian health-care system and consider the key factors challenging domestic policy makers and the system's potential to be a model for the world. We then propose a renewal of the tripartite social contract in service of accessible, affordable, high-quality care for all residents of Canada in the decades to come.

Key messages

• • Canada's universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.
• • Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.
• • In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.
• • To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.
• • To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.
• • Without bold political vision and courage to strengthen and expand the country's health system, the Canadian version of universal health coverage is at risk of becoming outdated.

History: a social democratic foundation

The words health and health care were nowhere to be found in the original Canadian Constitution of 1867. However, provincial governments were given explicit authority over hospitals in the constitutional division of powers between the federal government and the provinces and territories. Over time, these subnational governments became the presumed primary authorities over most health-care services.

In the early 1900s, Thomas Clement “Tommy” Douglas, then a young boy growing up in Winnipeg (MB), nearly lost a limb to osteomyelitis because his family was unable to pay for care. When Douglas later became the Social Democratic Premier of Saskatchewan, he implemented universal public health insurance for the province, making it the first jurisdiction with universal health coverage in North America. 8 This insurance initially covered hospital care in 1947. It was expanded to medical care (mainly defined as physician services) in 1962. Services were resourced by a provincial tax-financed plan. Hospitals and physicians maintained a high degree of autonomy, billing the public plan while designing their own models of care.

The federal government played a part in the emergence of universal health coverage during that period through its spending power, which it used, and continues to use, to maintain national standards for universal health coverage. Thus, the Saskatchewan approach was adopted in the rest of the country through the encouragement of the federal government, which originally offered 50 cents for every provincial dollar spent on universal health coverage. Panel 1 outlines key events in this complex historical process that culminated in the unanimous adoption of the Canada Health Act 9 in Canada's Parliament in 1984.

An abbreviated history of Canadian Medicare

Led by Premier Tommy Douglas, the Saskatchewan Hospital Services Plan is introduced as the first universal hospital insurance programme in North America

Led by Prime Minister Louis St. Laurent, the Hospital Insurance and Diagnostic Services Act establishes 50:50 cost sharing with provincial hospital insurance plans that meet the criteria of comprehensiveness, universality, accessibility, and portability (user fees are discouraged despite no explicit prohibition)

Implementation of the Hospital Insurance and Diagnostic Services Act, with five provinces participating

Premier Tommy Douglas announces his plan for universal publicly funded medical insurance coverage (Medicare) in Saskatchewan

Organised medicine launches a large-scale campaign against Medicare

All ten provinces now participating in the Hospital Insurance and Diagnostic Services Act

July 1, 1962

The Saskatchewan Medical Care Insurance Act takes effect, establishing universal publicly funded medical insurance for Saskatchewan residents

July 1–23, 1962

Saskatchewan doctors' strike, led by the Keep our Doctors committee

July 23, 1962

Saskatoon Agreement ends the strike, establishing opt-out provisions and protections for the fee-for-service, private practice model

Led by Justice Emmett Hall, the Royal Commission on Health Services recommends comprehensive universal health coverage for all Canadians

Led by Prime Minister Lester Pearson, federal Liberals announce support for 50:50 cost sharing with provincial health plans that meet the criteria of comprehensiveness, portability, universality, and public administration

Dec 8, 1966

The Medical Care Insurance Act is passed in Parliament, legislating federal support of provincial Medicare plans that meet the criteria of comprehensiveness, portability, universality, and public administration

July 1, 1968

The Medical Care Insurance Act comes into effect

All provinces now have established comprehensive medical insurance plans that meet the federal criteria for funding eligibility

Led by Prime Minister Pierre Elliott Trudeau, federal Liberals introduce Established Programs Financing, which provides block funding transfers to provinces and lessens federal involvement in health-care provision

Led by Justice Emmett Hall, the Health Services Review raises concerns about the increase in user fees and extra billing by physicians

The Indian Health Policy is adopted, formalising the federal government's responsibility for health-care provision for Indigenous Canadians as directed by constitutional and statutory provisions, treaties, and customary practice

Prime Minister Pierre Elliott Trudeau and Queen Elizabeth II sign the Constitution Act, establishing Canadian sovereignty through patriation; previously established Constitutional convention remained unchanged, including provincial jurisdiction over health service delivery and financing, and a federal role in pharmaceutical regulation, public health, provincial oversight, and provision of services for those groups under federal Constitutional authority (such as Indigenous peoples, armed forces, veterans, inmates, and refugees)

Under Minister of National Health and Welfare Monique Bégin, the Canada Health Act is passed unanimously by Parliament, explicitly banning extra billing and establishing criteria for transfer payment eligibility (with penalties for violations): public administration, comprehensiveness, universality, portability, and accessibility

The Canada Health Act outlines the terms and conditions to which all provincial and territorial plans must adhere in order to access federal funding for health care: portability, universality, accessibility, comprehensiveness, and public administration ( panel 2 ). Three of these conditions are particularly effective in ensuring some commonality across 13 health systems: portability, universality, and accessibility. Portability allows insured residents to keep their coverage when travelling or moving within Canada. 11 Universality stipulates that access must be on uniform terms and conditions—ie, individuals do not have preferential access based on the ability to pay privately. Accessibility means that no user fees are charged for publicly insured services: when a Canadian visits a doctor or is cared for in any department of a hospital, there is no payment or deductible. Provincial and territorial governments have upheld the principles of the Canada Health Act through various laws and policies to ensure ongoing federal funding; currently, federal transfer payments amount to approximately 20% of provincial health budgets. 12

Overview of the Canada Health Act

The following criteria and conditions must be met for provinces and territories to receive federal contributions under the Canada Health Transfer.

• • Public administration: plans must be administered and operated on a non-profit basis by a public authority
• • Comprehensiveness: plans must cover all insured health services provided by hospitals, physicians, or dentists (for surgical dental procedures that require a hospital setting)
• • Universality: all insured residents must be entitled to the insured health services on uniform terms and conditions
• • Portability: insured residents moving from one province or territory to another, or temporarily absent from their home province or territory or Canada, must continue to be covered for insured health services (within certain conditions)
• • Accessibility: not to impede or preclude, either directly or indirectly, whether by user charges or otherwise, reasonable access to insured health services

Adapted from 9 , 10 .

Financing: deep public coverage of a narrow basket of services

Financing in three layers.

Expenditures on health constitute 10·4% of Canada's gross domestic product (GDP; table ). This figure increased consistently for many years and peaked in 2010, at 11·6%, but decreased steadily in the years following the 2008–09 recession. 14 Although this figure seems to have stabilised, 14 it has not yet recovered to its previous peak.

Canada versus OECD comparators by indicators of the Triple Aim

OECD=Organisation for Economic Co-operation and Development. HAQ=Health Access and Quality. NA=not available. GDP=gross domestic product. PPP=purchasing power parity.

Pundits and think tanks often claim that governments in Canada have a public monopoly on health care, but only 70·9% of total health expenditure is publicly sourced, mainly through general taxation. 15 This percentage represents a considerably lower public share than that of the UK and most other nations in western Europe ( table ). Approximately half of the 30% private expenditure comes from out-of-pocket payments by patients; the other half is covered by private supplemental health insurance plans.

The financing of health services in Canada involves three layers ( figure 1 ). Layer one comprises public services (those that Canadians recognise as Medicare): medically necessary hospital, diagnostic, and physician services. These services are financed through general tax revenues and provided free at the point of service, as required by the Canada Health Act. Coverage is universal in this single-payer system. The most important quality of this layer is relatively equitable access to physician and hospital care. 16 Another benefit is cost containment: within Canadian publicly funded insurance plans, administrative overhead is extremely low—less than 2%—because of the simplicity of the single-payer scheme. 17

Layer two services are financed through a mix of public and private insurance coverage and out-of-pocket payments, and include provision of outpatient prescription drugs, home care, and institutional long-term care. Provinces and territories each have a diverse mix of public programmes in this layer, without any national framework. For example, in some provinces, such as Ontario, all senior citizens older than 65 years have public prescription drug coverage, whereas in others, such as British Columbia, drug coverage is income tested. 18

Layer three s ervices are financed almost entirely privately and include dental care, outpatient physiotherapy, and routine vision care for adults when provided by non-physicians. 3

Approximately 65% of surveyed Canadians have private supplemental health insurance, mostly through their employers. 19 This insurance covers some or all of the costs of layer two and three services, notably outpatient prescription medicines, generally with co-payments or deductibles. 20 An additional 11% of people have access to supplemental services through government-sponsored insurance plans. 19 However, many Canadians do not have supplemental insurance, with provincial estimates ranging from a quarter to a third of the total population. 19 , 21 These individuals have to pay out of pocket for outpatient medicines, counselling services (when provided by non-physicians), and more. Such spending has been steadily increasing, particularly for low-income Canadians. 14 More than CAN$6·5 billion in household funds was spent on pharmaceuticals alone in 2014. 18 The large number of Canadians who do not have access to supplemental insurance has led to concerns about equity, fuelling calls for public coverage of a wider range of services than are currently available in layer one.

The federal government holds special responsibilities for providing health coverage and services to Canadian Forces personnel, inmates of federal prisons, eligible Indigenous people, veterans, and certain groups of refugees. 22 The federal government also has stewardship responsibilities for pharmaceutical regulation, health data collection, and health research funding ( figure 1 ).

A small number of Canadian residents do not have public insurance for layer one services. Most are newcomers experiencing provincially mandated delays in coverage, rejected refugee claimants, and temporary residents with expired work or education permits. 23 In Ontario, a province of 13·6 million people, approximately 250 000 people are non-status residents and might therefore be unable to access health-care coverage. 24 When necessary, these people often attempt to access care through emergency departments, where upfront payment is not required. 25

Decentralisation of delivery: a defining feature of Medicare

Medicare is a single-payer layer of financing that is highly decentralised in terms of service delivery. This split between financing and provision of care evolved very differently from, for example, the more centralised National Health Service in the UK.

Doctors are most commonly independent contractors, billing public insurance plans on a fee-for-service or other basis. 26 Despite the fact that they work within the boundaries of regional or provincial health authorities and in hospitals financed almost entirely publicly, few accountability relationships exist between physicians and health authorities, hospitals, or governments. 27

This structure can again be traced back to Saskatchewan, where physicians responded to the single-payer model with a province-wide strike for 23 days, demanding to preserve their ability to bill patients or private insurance plans rather than the government. 28 The strike ended with the Saskatoon Agreement, a truce whereby doctors would become part of the system as publicly paid but self-employed professionals with minimal engagement in or accountability to system-wide governance. 29

Further fragmentation is inherent in the fact that hospitals, health authorities, and other organisations often have their own independent boards and separate budgets, and thus make decisions about the kinds of services they will provide independently of other parts of the system. 9

The centralised data collection that occurs in single-payer insurance plans has great potential to support quality improvement of the health system. Currently, these data inform the strategic directions of health ministries and support excellent health services research in most provinces. Unfortunately, their use for operational purposes to drive front-line improvements has been scarce. Data are seldom provided in real time to organisations and providers delivering care because of the prioritisation of privacy, data security, and the difficulties involved in provision of just-in-time data from large administrative databases. 30

The ease of innovation scale-up that should in theory characterise a single-payer environment remains under-realised. 31 , 32 In Canada, the rate of adoption of electronic medical records increased from about 23% of health-care practitioners in 2006 to an estimated 73% in 2015. 33 Nonetheless, hospital-based systems and primary care systems are commonly designed in isolation from each other. This separation makes information sharing difficult as patients move through distinct parts of the system that use different electronic tools unlinked to each other, causing further fragmentation of care.

National bodies that could overcome fragmentation of coverage or service delivery have had varying degrees of success. The special Canadian brand of decentralisation is illustrated in the case of health technology assessment, an area in which many countries use arm's length agencies to make nationwide decisions about funding allocation (eg, the National Institute for Health and Care Excellence in the UK). The Canadian version is the Canadian Agency for Drugs and Technologies in Health (CADTH), an intergovernmental body that provides evidence-informed funding recommendations as to which drugs and technologies should be publicly covered. However, unlike most international health technology assessment organisations, CADTH's outputs are advisory only. Although regional health plans made coverage decisions consistent with these recommendations in more than 90% of cases between 2012 and 2013, manufacturers must nonetheless navigate 13 provincial and territorial labyrinthine approval processes even after receiving CADTH sanction. 32 Furthermore, 85% of private plans provide coverage for all prescriptions, including those that CADTH recommends against, with the result that evidence-informed recommendations do not necessarily cross the public–private divide. 34

The context for change

Fiscal constraints.

As Canadian governments, providers, and the public consider how to address the important health policy challenges of the day, their options are defined by several factors. Some of these factors are common across many countries in the Organisation for Economic Co-operation and Development (OECD), such as fiscal constraints, population ageing, and the social determinants of health; other factors have uniquely Canadian elements, such as geography and particular patterns of migration.

Following the recession of 2008–09, economic growth in Canada was slower than it had been throughout much of the post-World War 2 era, with GDP growth averaging just over 2% annually between 2011 and 2016. 35 In the past decade, provincial governments have increasingly focused on reducing the rate of growth in health-care spending, which constitutes 38% of provincial budgets based on the pan-Canadian average. 14

Population ageing

In demographic terms, Canada is still a younger country than many European nations. 36 The fertility rate in Canada, which was 1·6 children per woman in 2015 ( table ; data from World Data Bank Portal), has remained relatively stable over the past decade, largely because of higher rates of childbearing among Indigenous and foreign-born Canadian women than among the general population. 37

Nevertheless, ageing remains an inevitable reality as the baby boom generation enters its senior years. People aged 65 years and older represent Canada's fastest growing age group, and 85% of seniors aged 65–79 years reported having at least one chronic condition in 2012. 38 The financial burden of ageing is not expected to be catastrophic, contributing an estimated less than 1% per year to health-care spending; however, the trend is important for design of health services. 39 The traditional hospital-focused and physician-focused nature of the Canadian system must evolve to meet the growing need for home-based and community-based care, interprofessional team-based care, and institutional long-term care. 40

Social determinants of health

The Lalonde Report of 1974 ( panel 3 ) served as a catalyst for widespread recognition that health is determined more by social, cultural, economic, and gender-based determinants of health than by access to health-care services. 41 In a country where the contribution of health services to health is estimated to be only 25%, the impact of other determinants including poverty is considerable. 42 More than 13% of Canadians were living in a low-income household in 2016. 43 This hardship disproportionately affects vulnerable Canadians from particular ethnocultural backgrounds and some groups of migrants who are more than twice as likely to experience poverty than other Canadians. 44 Thus, as is the case across high-income countries, policies aimed at income redistribution, housing support, and early education and childhood development programmes will continue to be crucial to the health of the population. 45

The history of national commissions and inquiries on health care in Canada

1961–64: Royal Commission on Health Services (Hall Commission)

Led by Justice Emmett Hall, the Commission recommended comprehensive health coverage for all Canadians and development of national policy in health services, health personnel, and health-care financing.

1973–74: A New Perspective on the Health of Canadians (Lalonde Report)

Led by Marc Lalonde, Canadian Minister of National Health and Welfare, this paper introduced the public health imperative and called for the prevention of illness and promotion of good health. It called for the expansion of the health-care system beyond disease-based medical care.

1979–80: Health Services Review

Led by Justice Emmett Hall, this review reported on the progress made since the 1964 commission and sought to determine whether provinces were meeting the criteria of the Medical Care Insurance Act. This inquiry identified widespread extra billing and user fees, and served as a catalyst for the Canada Health Act.

1991–96: Royal Commission on Aboriginal Peoples

The Commission investigated the evolution of the relationship between Aboriginal and non-Aboriginal people and governments in Canada. Major recommendations included the training of 10 000 health professionals over a 10-year period.

1993–97: Commission of Inquiry on the Blood System in Canada (Krever Inquiry )

Led by Justice Horace Krever, the Commission investigated the use of contaminated blood products that infected 2000 transfusion recipients with HIV and 30 000 with hepatitis C between 1980 and 1990. This Commission led to the creation of Canadian Blood Services in 1998.

1994–97: National Forum on Health

Commissioned by Prime Minister Jean Chrétien, this group of experts from across Canada focused on broad determinants of health and the need for enhanced emphasis on evidence-based care.

1999–2002: Standing Senate Committee on Social Affairs, Science and Technology Study on the State of the Health Care System in Canada (Kirby Committee)

Led by Senator Michael Kirby, this committee conducted a comprehensive review of Canadian health care. Recommendations included a call for enhanced federal oversight to ensure effective care and efficient resource use, and highlighted poor health human resource planning as a cause of geographical inequities.

2001–02: Commission on the Future of Health Care in Canada (Romanow Commission)

Led by former Saskatchewan Premier Roy Romanow, the Commission called for a renewed commitment to the values of equity, fairness, and solidarity. The report was the catalyst for the 2003 “Accords” and the establishment of the Health Council of Canada (defunded in 2014) to monitor progress on key objectives.

2003: National Advisory Committee on Severe Acute Respiratory Syndrome (SARS) and Public Health

Led by David Naylor, this committee was established to review the circumstances of the 2003 SARS outbreak. The report identified significant issues with public health in Canada and led to the creation of the Public Health Agency of Canada.

2008–15: Truth and Reconciliation Commission of Canada

Undertaken as part of holistic and comprehensive response to the systemic abuse suffered by Indigenous Canadians under the Indian Residential School system, the commission identified calls to action to advance reconciliation. Although not specifically focused on health care, the report highlighted substantial gaps in health care for Indigenous people and outlined the substantial impact of the trauma on mental and physical health.

2015: Advisory Panel on Healthcare Innovation

Led by David Naylor, the panel's Unleashing Innovation report highlighted the need for enhanced patient engagement, workforce modernisation, technological transformation, and improved scale-up of existing innovations.

The geographical challenges to Canada's health system are enormous. Approximately 18% of Canada's population lives in rural or remote communities dispersed throughout 95% of the area of the second largest country in the world ( table ). North of the densely inhabited Canada–USA border corridor, the need for remote primary care facilities and frequent medical transport to specialised centres renders health-care delivery both challenging and expensive ( figure 2 ). 46 The distribution of health-care providers and resources does not mirror need: only 13·6% of family physicians and less than 3% of specialists live in rural and remote areas of Canada. 47 Similar distributional imbalances exist for nurses and other regulated health-care professionals.

Population density and distribution of hospitals in Canada (and the UK)

The map shows the population density and wide geographical distribution of health-care delivery. For comparison, a map of the distribution of hospitals in the UK is shown inset. Hospital data for Canada are from DMTI Spatial, 2016, and population data for Canada are from Statistics Canada, 2016. UK hospital data are from the National Health Service, 2016, and UK population data are from Eurostat.

These realities have led to the emergence of high-performing regional networks for expensive specialty care, such as trauma services, cancer care, and organ transplantation. Telemedicine—in which local providers or patients receive specialist advice via telecommunication—has facilitated rapid access to emergency subspecialty assessment and follow-up, and is gradually expanding its role in chronic disease management. 48 New curricula and legislation have allowed rural nurses, nurse practitioners, pharmacists, and primary care physicians to broaden their scopes of practice into areas such as oncology or surgery. 49 , 50 Trainees across the regulated health professions are increasingly being trained in rural or remote communities to prepare them for careers outside major cities. 51

Despite these successes, Canadians living in remote areas must often travel long distances to access anything beyond the most basic forms of health care. 52 For example, in Nunavut, a northern and largely Indigenous territory, 58% of patients needing inpatient and outpatient hospital care are transported outside the territory. 53 These geographical complexities might change in the coming decades, as Canada continues to urbanise. Census data from 2016 show that almost 60% of Canadians now live in metropolitan areas, with one in three individuals living in Toronto, Montréal, or Vancouver. 54

Ethnocultural and linguistic diversity and migration

Migration has been and remains an important force shaping Canadian demography and identity ( figure 3 ). At present, more than one in five Canadians are foreign-born. 55 Canada welcomed nearly 325 000 immigrants and refugees in 2015, representing just under 1% of the total population. 56 Most immigrants and refugees settle in one of the country's three biggest cities—Toronto, Montréal, or Vancouver. 57

Map of Canada by country of birth

The map illustrates the population density and the proportion of provincial populations based on country of birth. For comparison, a map of the UK by country of birth is shown inset. Population data for Canada are from Statistics Canada, 2012, and population data for the UK are from the UK Office of National Statistics, 2016.

Despite the Canadian commitment to multiculturalism and a general historical pattern of strong immigrant integration into Canadian society, the health status of many migrant groups often differs from that of Canadian-born patients. 58 , 59 , 60 Newly arrived economic immigrants are typically healthier than the general population, but this so-called healthy immigrant effect declines over time, partly because of the stresses of integration, and it is not found across other classes of migrants. 61

Recent immigrants are twice as likely to have difficulty in accessing care than are Canadian-born women and men, and seek primary care less often than either established immigrants or the Canadian-born population. 62 , 63 However, with longitudinal data controlling for individual propensity to seek care, immigrants are no more likely to be without a regular doctor or report an unmet health-care need than is the Canadian-born population. 64 For refugees, challenges are more prevalent and complex. 65 Language is the most commonly cited reason for difficulty in accessing care among many categories of migrants, whether they are newcomers or established. 55 Availability of interpretation services and adequate use of those services, along with appropriate training for health-care providers and increased health and legal literacy for newcomers to Canada, would pave the way for improved access to context-sensitive care ( panel 4 ). 65 , 66

Health-care experiences of vulnerable groups in Canada

Vanessa: an Indigenous health story

Vanessa is a healthy 28-year-old First Nations woman pregnant with her third child. Her two previous deliveries were uncomplicated and her pregnancy is considered low risk. On her northern First Nations reserve, primary care services are provided by nurses in the community clinic and supported by a family physician who flies in once a month. The nearest community an hour away has a small hospital, but provides no intrapartum services.

Vanessa has access to prenatal care close to home. It is important for her that such care is given within the community, increasing the ease of access and sense of cultural safety. Her medical care and prenatal vitamins are covered through public health insurance plans, as is her transportation to medical appointments outside the reserve. She worries about her partner when she is away, particularly given the deep impact of a cluster of recent suicides in the community that included his teenaged sister. The community is affected by many preventable deaths, including suicides, and trauma, but no births—the circle of life feels incomplete.

At 34 weeks' gestation, Vanessa must travel to the city, where she sits in a motel room and waits to go into labour. Neither the timing of the baby's arrival nor the potential complications that can arise can be predicted, so Vanessa waits alone. As for most women in communities like hers, the birth will occur not with a midwife in her community, but in a hospital hundreds of kilometres away from her partner and children, compromising her much-needed sense of cultural safety. Her access to health-care services free at the point of care is critical, but she wishes her care could be connected to her home, her family, and her culture. If these defects in the system are addressed, perhaps Vanessa's next generation will grow up to expect access to such vital, culturally safe health care.

Mahmoud: a migrant health story

Mahmoud is a 52-year-old Syrian dental surgeon who arrived in Canada with his wife and four children in 2016, as a government-sponsored refugee family. The children started public school while both parents enrolled in the government-funded English-language training for the first months of settlement.

Despite having publicly funded health insurance immediately on arrival, Mahmoud does not access primary care for himself or his family for many reasons, including discomfort with the English language and a lack of knowledge of where to seek care. When he begins to feel unwell, after stalling for a long time, he goes to a local community clinic. An appointment is given for him to return with interpreter services for the following week.

Unfortunately, in the meantime, Mahmoud is admitted to hospital with uncontrolled blood sugars. He is started on oral hypoglycaemics. As a refugee, his medicines are covered, but when he transitions to regular provincial health insurance he will have to pay for his medicines out of pocket.

The process associated with recognition of Mahmoud's dental credentials and skills is complex and lengthy. To take care of his family, he takes up taxi driving. With his unpredictable hours, he finds it hard to comply with his prescribed regimen and starts missing follow-up appointments.

As the Ramadan period approaches, Mahmoud knows he will fast but does not consult with the health team at the local clinic, unsure whether he would be understood as he does not know how to get an interpreter. Despite the fact that there is an increasing sensitivity to the diversity of the Canadian population by the health-care professionals, who are also becoming increasingly diverse, more work is needed to improve communication and personalisation of care, especially at the primary care level.

Policy challenges

Three urgent issues.

Canadians have a life expectancy at birth of 82·14 years ( table ), which is longer than the OECD average. Canada also outperforms the USA, the UK, and Denmark in terms of amenable mortality (ie, deaths that should not occur in the presence of timely and effective health care), as measured through the Health Access and Quality (HAQ) Index. 13 But key observations from international comparisons point to a decades-long struggle with wait times for some elective care and inequitable access to services outside the traditional Medicare strength of hospitals and doctors. 67 Average life expectancy also masks variations in vulnerable groups, most notably Indigenous populations: First Nations people have a projected life expectancy of 73–74 years for men and 78–80 years for women; for the Inuit, living in the far north, life expectancy was 64 years for men and 73 years for women as of 2017. 68

What is most distressing to many observers of the Canadian system is the persistence of its problems over time. 69 Change in Canada is often slow and incremental, by contrast with the major and rapid transformations often observed in reforms of the UK's National Health Service. 70 It is thus most accurately described not as a system in crisis, but a system in stasis. 71 Within that context, and considering the complex needs of many segments of the Canadian population, three crucial problems require action.

Wait times for elective care are too long

Urgent medical and surgical care is generally timely and of high quality in Canada, as indicated by outcomes such as acute myocardial infarction mortality ( table ). However, the timeliness of elective care, such as hip and knee replacements, non-urgent advanced imaging, and outpatient specialty visits, is problematic. 72 The proportion of Canadians waiting more than 2 months for a specialist referral is 30% ( table ), which is far greater than any OECD comparator in the Commonwealth Fund's comparison of 11 countries. 67 Similarly, the proportion of Canadians waiting more than 4 months for elective non-urgent surgery is greatest at 18%.

Governments have experimented with wait-time guarantees, focused programmes, and targeted spending in priority areas such as cancer care, cardiac care, and diagnostic imaging, with varying degrees of success. For example, all provinces achieved wait-time benchmarks in radiation oncology in 2016, but long elective MRI wait times remain largely unchanged over the past decade, despite substantial growth in the number of machines purchased and scans done. 73 , 74

The high degree of physician autonomy in Canada does little to encourage doctors to join organised programmes to reduce wait times. Successful models exist, such as the Alberta Bone and Joint Health Institute in Calgary, which reduced wait times for consultation for hip and knee replacement from 145 days to 21 days through innovations including interprofessional teams and centralised referral. 75 However, physicians have competing responsibilities, and there is no systemic support for their involvement in system change. If a government or regional health authority wants physicians to participate in such an initiative, it must often rely on exhortation or simply pay its doctors more to gain their involvement. Poor federal–provincial–territorial collaboration also hinders the ability to scale up such successful responses to wait times across provincial borders, hence the characterisation of Canada by at least one former Minister of Health as a “country of perpetual pilot projects”. 76 , 77

Canada's reasonable performance on composite quality metrics such as amenable mortality suggests that these wait times for elective care do not necessarily translate to worse health outcomes. 78 However, for the Canadian public, long wait times for elective care are a lightning rod issue and threaten to undermine support for Medicare. Some groups have turned to the courts as a means of challenging the public–private payment divide. Relying on the constitutional Charter of Rights and Freedoms, major lawsuits in Quebec and British Columbia have argued that various provisions of provincial laws, including those that prevent privately financed care, are at the root of public wait times and threaten the right to security of the person. 79 , 80 , 81 , 82

Little more than a decade ago, the Quebec government responded to the Supreme Court of Canada's Chaoulli decision by allowing private insurance for a few types of surgical procedures, but this outcome did not create a viable private market for a health insurance duplicative of Medicare. 83 A more ambitious lawsuit impugning provincial Medicare laws was launched in British Columbia in 2016. 84 Unlike the Quebec trial, which sought only to overturn limits on private duplicative insurance, the plaintiffs in the Cambie Surgeries Corporation case in British Columbia seek to also overturn restrictions on user fees and on physician dual practice. 85

In the past decade, Canadian courts have made important judgments on several other major questions of health-care delivery, including the legalisation of safe injection sites, reinstatement of insurance coverage for refugee claimants, and legalisation of medical assistance in dying. 86 , 87 , 88 These decisions have generally increased access to care for vulnerable people. However, should the court in the Cambie Surgeries Corporation case establish a legal right for Canadians of means who wish to jump the public queue, this case could fundamentally reshape Medicare laws across the country and could threaten equitable access to care. If Canadians are unable to find ways to change the system from within through clinical and political leadership, there is a risk that changes will be forced by the courts, which are a blunt instrument for making policy change.

Services outside the Medicare basket are often inaccessible

Up to a third of working Canadians do not have access to employer-based supplemental private insurance for prescription medicines, outpatient mental health services provided by professionals such as social workers or psychologists, and dental care. 21 These individuals are more likely to be women, youths, and low-income individuals. Public coverage of those services varies between provinces, but generally focuses on seniors and unemployed people receiving social assistance, leaving the working poor most vulnerable. 89 Thus, inequities in health outcomes driven by the social determinants of health are at risk of being compounded by the narrow but deep basket of publicly funded services.

Notably, Canada is the only developed country with universal health coverage that does not include prescription medications, and 57% of prescription drug spending is financed through private means. 18 , 90 Nearly one in four Canadian households reports that someone in that household is not taking their medications because of inability to pay. 91

Beyond prescription drugs, inequitable access to home-based care and institutional long-term care is pressing. In 2012, nearly 461 000 Canadians aged 15 years or older reported that they had not received help at home for a chronic health condition even though they needed it. 92 Because such layer two services receive inadequate public financing, Canadians aged 65 years or older have cited inability to pay as the main barrier to accessing the home and community care support they needed. 92 Some combination of inspired leadership, public financing, engaged governance, robust regulation, and intergovernmental cooperation seems to be needed to protect the public interest and address inequities of access to layer two services.

Indigenous health disparities are unacceptable

As in other settler societies such as Australia, New Zealand, and the USA, Indigenous populations in Canada were colonised and marginalised. In the Canadian case, marginalisation took the forms of Indian Residential Schools, government-enforced relocation, and historically segregated Indian hospitals, to name a few. 93 , 94 Three distinct and constitutionally recognised groups—First Nations, Inuit, and Métis—constitute 4·3% of the Canadian population and experience persistent health disparities relative to the non-Indigenous population, including higher rates of chronic disease, trauma, interpersonal and domestic violence, and suicide, as well as lower life expectancy and higher infant mortality rates. 95 , 96 , 97 For example, Canada's infant mortality rate dropped by 80% from more than 27 deaths per 1000 livebirths in 1960, to five per 1000 livebirths on average in 2013. 98 However, the estimated rate in Nunavut (the northern territory in which approximately 85% of the population is Inuit) was more than three times the national rate at 18 deaths per 1000 livebirths in 2013. 98

Other far-reaching inequities exist in the social determinants of health that even the best health-care systems cannot redress. Indigenous Canadians face substantial wage gaps of up to 50% compared with non-Indigenous groups, after adjustment for education and age. 99 Persistent racism and social exclusion permeate not only the health-care but also the education and justice systems, with subsequent disparities in high school education rates, incarceration rates, and other factors often driving egregious health statistics. 100

These challenges are not evenly distributed: figure 3 illustrates the proportion of the population that is Indigenous by province and territory. Due in part to higher fertility rates in the Indigenous population than in the general population, by 2036, a projected one in five people will be an Indigenous person in the western provinces of Saskatchewan and Manitoba. 101

A dizzying array of services in the health-care system, including federal programmes, provincially provided services, and highly bureaucratised add-ons, together continue to fail to meet the needs and constitutional rights of Indigenous people. 102 Indigenous people are covered by provincial Medicare plans, but some on-reserve health-care services fall under federal jurisdiction, and many Indigenous people receive supplemental insurance through the federal government.

Canada is actively grappling with its colonial history. An unprecedented Truth and Reconciliation Commission (TRC) released a report 94 in 2015 that shared the stories of Indian Residential School survivors who lost connection to family, land, culture, and language through a process intended to assimilate them into western society. Seven of the 94 calls to action in the report refer directly to steps required to address the inequities in health. From recognising and valuing traditional Indigenous healing practices to training Indigenous doctors and nurses and setting measurable goals to close gaps in access to health-care services, the TRC calls to action address crucial themes, many of which are rooted in self-governance. The newly established First Nations Health Authority in British Columbia, which is self-governed and community-driven, is an example of the type of emerging model intended to address the demand for self-governance in the administration and delivery of culturally safe and responsive services for Indigenous people in Canada. 103 The remaining TRC calls to action, should they be implemented, would help to reduce disparities in the social determinants of health, leading to better health-care outcomes.

An opportunity to renew the social contract

The role of governments: federal, provincial, and indigenous.

As Canadians observe the 150th anniversary of Confederation in the face of these three important challenges, a renewed vision of the roles of governments, providers, and the public will be required to overcome the stasis of the present and achieve the potential of single-payer Medicare. Rather than continue the Canadian tradition of slow, steady, and incremental change, governments must step forward boldly and with proactive commitment to ensure a vital and sustainable system for all Canadians.

The predominant administrative and delivery responsibilities for health care in Canada will always lie with provincial and territorial governments. The work of reorganising resources, building infrastructure, and delivering programmes for an ageing population under fiscal constraints is theirs to lead. For wait times in particular, a focus on provincial implementation of successful projects using the available financial and policy levers is long overdue.

However, provincial and territorial governments cannot succeed alone. At a few key times in Canadian history, the federal government has overcome decentralisation and fragmentation by setting a national vision for health care and investing politically and financially in that vision. In an era in which Canada is reasserting its commitment to progressive values on the international stage, 7 health care represents a key domestic opportunity to recommit to the core Canadian values of equity and solidarity. 104

The movement to expand the scope of the public basket of services is at the heart of this approach, and we support mounting calls for universal prescription drug coverage 105 as well as expanded home care, 106 long-term care, 106 and mental health services 107 to be included in layer one of the financing system. Royal Commissions as far back as the 1964 Hall Commission 108 and as recent as the 2002 Romanow Commission 109 have clearly articulated the need for this expansion. In particular, debates about a so-called Pharmacare system are gaining needed momentum, as multiple economic evaluations have suggested that improved access through an expansion of public coverage is possible at lower overall costs. 110 As the Quebec experience illustrates, it is difficult for any one province to begin alone as Tommy Douglas did in Saskatchewan—federal cost sharing and stewardship will be required at an early stage to achieve the savings as well as the coverage and quality goals of Pharmacare. 111

With respect to wait times, solutions will continue to be based in local innovations, but the infrastructure for national spread and scale-up requires active federal involvement. One possible approach, recommended by a federally commissioned panel on health innovation, would be a Healthcare Innovation Fund intended to accelerate the spread and scale-up of promising innovations. 32

A constructive partnership between the federal government and Indigenous peoples could overcome one of Canada's most difficult challenges—the very poor health outcomes of Indigenous peoples. Newly established principles guiding the relationship between the Government of Canada and Indigenous peoples, as well as the launch of a new federal Ministry of Indigenous Services established in August, 2017, could set the tone for renewed terms of engagement. 112 This commitment to self-determination will mean supporting new models of self-governance within and beyond the health-care sphere, with a particular focus on healing from intergenerational trauma and a strengths-based, wellness-focused approach to enhancing the social determinants of health. Canada's considerable experience with decentralised models of health-care delivery should allow for such innovation, and the opportunity must be seized with more urgency.

The TRC's calls to action must move from suggestions based on the courageous voices of survivors of the Indian Residential School system to non-negotiable tasks for all levels of government, all professional organisations, and all citizens. These tasks include: first, measurement and frank evaluations of health-care systems and programmes; second, creation of cultural safety and humility within a health-care system that needs to rebuild trust; and third, true representation of Indigenous Canadians within the ranks of providers and leaders of the health-care system. Mutual accountability here is essential.

The role of providers

Canadian hospital-based nurses, nurse practitioners, pharmacists, physiotherapists, and other health professionals are employed by health service delivery organisations and regional health authorities. As employees, these regulated health professionals have accountability for quality improvement and system reform, and their influence and importance in the system have been increasing steadily for decades. 113 The scope and availability of interprofessional and nurse-led care models continue to grow, as evidenced by policy outcomes such as the rapid increase in nurse practitioners in Quebec as part of that province's approach to primary care reform. 114 Given the importance of interprofessional teams in improvement of access to high-quality primary and specialty care, such teams must be accelerated to reduce wait times, work on disparities associated with social determinants of health, and improve care for vulnerable groups.

By contrast, Canadian physicians remain primarily self-employed, independent professionals. 115 Ongoing conflicts are fuelled by mounting pressure to alter this arrangement and increase professional accountability for and to the system. 116 Productive partnerships between physicians and governments at times exist, but co-stewardship of finite resources is not built into the structure of the system. The need for physician engagement, both at the individual and collective level, is crucial as Canada moves to address long wait times for elective care, because solutions so often involve the reorganisation of traditional referral models and the introduction of team-based care. Furthermore, expanded public coverage of prescription medications will necessitate a drive towards more evidence-informed and value-based prescribing. Canadian physicians are well situated to constructively contribute to such efforts to define value and help to shift behaviour. As founders of evidence-based medicine and important contributors to global medical research, Canadian physicians must help to lead the necessary research and debates on change within the health-care system. 117 They are critical partners in ensuring quality, consistency, and availability of services. 27 Medical associations in at least two provinces have recognised the importance of system stewardship in the practice of professionalism and have committed to health system reform in collaboration with governments. 118 , 119 The Canadian Medical Association's renewed strategic plan places patients at the core of its mission. 120 And leaders in medical education have embraced a social accountability mandate and are actively working to train the “right mix, distribution, and number of physicians to meet societal needs”. 121 This approach is a model with potential broad international application.

The role of the public: patients, taxpayers, and citizens

It is not yet clear what mechanisms will emerge to alter patient behaviours as the system evolves. An early example of patients being encouraged to engage directly in system stewardship is Choosing Wisely Canada. This clinician-led campaign to address overuse of tests and treatments is part of the international movement to reduce low-value care. 122 The campaign offers four questions that patients can ask to start a conversation with their health-care provider about whether a test, treatment, or procedure is necessary. 123 Users of services will also need to be willing to participate in new models of care delivery that have been shown to successfully reduce waits for specialty care. These models will include those that are more team focused than physician focused, and models centred in comprehensive primary care with expanded scopes of practice.

Public engagement and participation in health-care policy require engagement with people as taxpayers, who want value for money, and as citizens, who continue to believe in the principle of equitable access to services. At times, governments have assessed public support for various reform options through the public consultations of independent Royal Commissions or external advisory panels, many of which are listed in panel 3 . National Royal Commissions are independent inquiries, invited through the power of the Crown to investigate matters of national importance and characterised by extensive consultations with the public. 124 , 125

Such commissions produce reports that are often accused of gathering dust, but at times they can be transformative in terms of public views and judgment, eventually having a profound effect on government policy. Some commissions even produce immediate change. Despite admirable efforts by health-care providers on the ground in Ontario and British Columbia to contain the outbreak of severe acute respiratory syndrome (SARS) in 2003, a subsequent review highlighted long-ignored flaws plaguing the system that were unmasked by the outbreak and led to formation of the Public Health Agency of Canada 1 year later. 126 , 127

As in the rest of the world, other models of citizen engagement in public policy are being explored, but the value of such initiatives is not yet known. 128 Citizens' panels are becoming more common, such as one on national Pharmacare in 2016. 129 Public support for and participation in values-based, evidence-informed decision making will be crucial to ensure financial sustainability and to mitigate the risks of overprescribing in the area of pharmaceutical policy.

Public engagement in health research—as seen, for example, in the Canadian Institutes of Health Research-funded Canada's Strategy for Patient-Oriented Research— incentivises each province and territory to identify research priorities in collaboration with patients, and must continue. 130 Public input of this kind should be nurtured, since it can help policy makers to balance the need for health system investment against other social priorities.

Canadian lessons for a global world

Canada's most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians' pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.

But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.

A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.

When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. 131 His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach. 132

Acknowledgments

We acknowledge funding from the McGill Observatory on Health and Social Services Reforms and from the Canada Research Chair in Policies and Health Inequalities (AQ-V) for maps developed by Tim Elrick and Ruilan Shi at the McGill Geographic Information Centre, Montréal, QC, Canada. We thank Ian McMillan and Leah Kelley for assistance with references, formatting, and submission; Karen Palmer for assistance with copy edits, critical review of the manuscript, and expertise regarding the British Columbia court case; and Meb Rashid for his expertise regarding migrant and refugee health issues.

Contributors

All authors contributed to the formulation of the ideas in the manuscript and the writing of initial drafts. All authors contributed to the literature search and editing of the manuscript. APM, DM, and AQ-V contributed to the figures. All authors reviewed and approved the final manuscript before submission.

Declaration of interests

DM is currently an external adviser to the Government of Canada on a review of pan-Canadian health organisations. NRC is a consultant for the cancer strategy of British Columbia's First Nations Health Authority and co-director of the Centre for Excellence in Indigenous Health, University of British Columbia (Vancouver, BC, Canada). GPM was executive director of the Romanow Commission. We declare no other competing interests.