Mapping Progress: What Universal Health Coverage Looks Like Across the Global South
Dr Shambhavi Vashist, MBBS
Dr Krish Kherajani, MBBS
Keywords: UHC, health access, financial protection, India, Ayushman Bharat, Japan, Thailand, Vietnam, Brazil, Chile, Rwanda, Ghana, innovation, primary care, public health, health financing, equity.
Universal health coverage (UHC) in a country means everyone, everywhere, can access the health services they need, without being pushed into financial hardship. It stands on the four pillars of prevention, promotion, treatment and rehabilitation, and palliative care. It is a promise that a country’s system makes to its citizens, the delivery of which however remains somewhat diabolical. Across the global South, UHC is built and provided through different routes. Let’s map out where things stand in different parts of the South.
India: Looking at The Brighter Side
India being a diverse, populous nation, demands a UHC that is accessible and affordable. The four key financing strategies to achieve UHC are by increasing taxation efficiency, increasing government budgets for health, innovating health financing methods and by increasing development assistance for health. Over the years, National Health Mission (NHM) was created, to strengthen both rural and urban public health infrastructure and was complemented by other key innovative programs including Janani Suraksha Yojana and Mission Indradhanush and Rashtriya Swasthya Bima Yojana (RSBY), aiming towards coverage for women, children and financial risk to poor families. With a goal to achieve public health expenditure to 2.5% of Gross Domestic Product (GDP), the National Health Policy launched the flagship scheme Ayushman Bharat. It mainly encompasses two components- the Pradhan Mantri Jan Arogya Yojna (PM-JAY), which provides health insurance to vulnerable families, offering free secondary and tertiary care in empaneled hospitals, and the Ayushman Arogya Mandirs (AAMs), which aims to strengthen primary healthcare services, including preventative and promotive care.
Asia: Building on Experience, Pushing for Expansion
Japan: Japan offers a long-running example of universal coverage with strong cost control. UHC in Japan follows Free Access and Freedom of Practice wherein patients are essentially free to receive care from the facility of their choosing. It includes mandatory coverage for all permanent citizens. Enrollees have no choice of health insurance programs, plans are designated according to the enrollee’s employment status, age, and residence. Benefit packages and copayments are essentially the same across all plans. An out-of-pocket threshold protects enrollees from catastrophic costs. Patients face coinsurance but with income-linked caps that prevent medical bills from spiraling. This single, transparent, and standard aspect of UHC in Japan is a key takeaway.
Thailand: The “30 Baht” Universal Coverage Scheme (2001–2002), funded by the Thai government, extended health coverage to the uninsured and informal workers, aiming towards equitable access to high quality healthcare services, irrespective of individual’s income or socioeconomic status, requiring only a token 30 Baht (≈US$1) copayment per visit, whether outpatient or inpatient care. Thailand’s UHC achieved broad access on limited resources by funding through a single national purchaser (NHSO), with a population-based budget.
Vietnam: It continues to make progress on addressing the needs of vulnerable populations, including the “missing middle.” The system manages costs and chronic diseases by promoting first contact at the commune health station. UHC of Vietnam rests on the foundation of strengthening primary health care, especially after the rise of non-communicable diseases and increasing ageing population. The takeaway from Vietnam’s UHC is their consistency in expanding the insured base by investing in local capacity.
South America: Converging goals, Distinct Models
Brazil: The Health Care Law that organizes the Unified Health System (Sistema Único de Saúde or SUS), guarantees UHC and tackles health inequity. The primary health model of SUS is the Family Health Strategy (FHS, Estratégia da Saúde da Família), which provides comprehensive health care and coordinates the coverage at the primary, secondary as well as tertiary levels. Brazil’s decentralized, universal public health system is funded with tax revenues and contributions from federal, state, and municipal governments. All residents and visitors, including undocumented individuals, can access free, comprehensive services. UHC in Brazil also demonstrates an exemplary track record on vaccination coverage. The country’s strong, team-based primary care, scaled nationally, is a key to its successful coverage.
Chile: The health system in Chile has a dual financing scheme. The public system is financed with state funds called the National Health Fund (Fonasa) and the private system with direct financing from families through contracting health plans (Isapre). Additionally, there is a public system of the armed forces (FFAA). The primary financing source comes from the mandatory health contributions that workers and pensioners provide. In Chile, only 6% of the population accessed complementary health insurance in 2021, as it is fully user-financed and limited to higher-income groups. Despite policy efforts, catastrophic diseases remain a major risk for vulnerable populations.
How UHC in Brazil differs from the rest of South America?
Brazil’s SUS is unique in providing free, universal access to the entire population, while nations like Chile and Colombia rely more on insurance-based models by operating on dual health systems, leaving gaps in coverage. UHC in Brazil is more equitable and inclusive. However, vast geography and limited resources in Brazil and systems facing rising costs and court-imposed limits on health plan pricing in Chile are challenges these countries face.
Africa: Innovation at the Grassroots
Rwanda: When I first read about Rwanda myself, all I could think of is the place Wakanda from the Avenger’s Black Panther. Rwanda is currently positioning itself as an active hub for innovation through strategic government policies, the establishment of an entire city of innovation known as the Kigali Innovation City, and by making huge investments in technology. Some really cool stuff innovated by them includes a drone delivery for medical supplies by Zipline (something which I would love to see in my hospital), smart city initiatives like the Smart Rwanda Master Plan, intelligent traffic systems, and support for electric vehicle adoption. They have set up the Rwanda Innovation Fund, which further supports innovative companies and entrepreneurs, reflecting a broad vision to unlock a fast-growing innovation economy and become a leader in Africa’s digital transformation. This makes us think- Is Rwanda the Real Wakanda?
Ghana: If you’re someone looking to invest in a start-up, I’d definitely recommend considering investing in Ghana for its Innovation and Startups Bill, which has not only promoted new businesses, but is also enhancing a super-famous sector of the world- AI.
Similarly, South Africa, Madagascar and other places in Africa have much more to them than the wildlife that we see in movies and on National Geographic. It is remarkable that such places have so much potential that not us and not even AI can predict the amount of innovation these places hold in the future.
India: The Way Forward
There definitely isn’t one right way to universal health coverage. Every country has its own sets of hurdles. India needs to increase its investment in public health as a percentage of GDP. Reforms are needed to build more primary care infrastructure. Improving technology can improve access to healthcare, especially in remote areas. India needs to prioritize primary care staffing, digital claims, fraud control, and district hospital upgrades, as the impact would be greater. Japan’s outstanding price-setting, Vietnam’s gradualism, Thailand’s limited resource development, Rwanda’s community power, Brazil’s primary-care muscle and Chile’s public-private partnership are all viable paths, for they fit their politics, economies, and delivery legacies.
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Rwanda Leverages Technology to Become Africa’s Innovation Hub: https://borgenproject.org/africas-innovation-hub/
