Health Policy

Universal health coverage – The ultimate prize

By - World Healthcare Journal

Universal health coverage - The ultimate prize

The pace with which the world’s major emerging economies are getting behind the drive towards universal health coverage (UHC) is breathtaking.

2018 saw another wave of countries announce major reforms to achieve ‘health for all’: India’s Ayushman Bharat scheme to cover some 500m of the poorest citizens, Egypt’s passing of a social health insurance bill and Mexico’s new president’s announcement to unify the existing patchwork of insurers under a single payer.

This comes on top of major reforms already underway in Indonesia, Kenya and China among others. Smaller countries are making similar moves, as documented by KPMG’s recent report Islands of Progress on the remarkable changes underway across the Caribbean region.

As the turbulent progress of my own nation of South Africa’s National Health Insurance (NHI) reforms show, however, realising these grand ambitions is
an enormous political and technical challenge. The design and implementation of a country’s UHC model involves some of the most complex, contested and momentous decisions that any nation may ever make. A plethora of difficult and inter-connected choices face civil servants, politicians, business leaders and communities.

The scale of change required can lead to paralysis, but through our work implementing UHC reforms in countries from the small (NHI Bahamas) to the large (Ayushman Bharat for five states in India), KPMG has learned that success is more than possible. Three lessons, in particular, stand out from our experience and research.

On the financing side, from our global review of UHC models, One Place Many Paths, it is clear that the role of the state is critical. Mandatory (i.e. non-voluntary) coverage has been essential to every global example of rapid progress towards UHC, and some public mechanism – either through a single dominant public payer, a public option alongside private insurers or a powerful public regulator of insurance – is likewise critical. Countries that have pursued a ‘breadth then depth’ strategy have seen much greater success than the reverse –this means starting with a shallow layer of coverage for everyone and improving it, rather than trying to get full UHC for a particular group or community then spreading it out.

“Skillful politicians such as Presidents Kenyatta in Kenya and Jokowi in Indonesia have successfully converted commitments to UHC into powerful electoral mandates” 

On the care delivery side, the second lesson is the vital role of private sector provision and investment. With up to 70 per cent of outpatient and 50 per cent of inpatient care provided by private providers in low and middle-income countries, partnerships with governments can create significant short-cuts on the journey to UHC, while opening up huge commercial opportunities for well-placed businesses. KPMG’s recent global survey of 20 of the largest provider chains in emerging markets for our report ‘Healthy Returns’ showed that many large chains do not currently understand the scale of threat or promise posed by UHC. However, the research also revealed considerable interest among international investors to pivot their investments towards ‘UHC-ready’ private providers.

KPMG’s Center for Universal Health Coverage

KPMG’s Center for Universal Health Coverage is committed to helping governments and businesses to navigate the difficult journey to UHC. On this issue, history is on the side of the bold. To find out more, visit

Finally, just as important as any of these technical policy questions is to focus on generating and maintaining political will and momentum. Skilful politicians such as Presidents Kenyatta in Kenya and Jokowi in Indonesia have successfully converted commitments to UHC into powerful electoral mandates. But UHC is a 10-year journey at best, and political determination cannot be allowed to wane over this time.

One route towards this is to focus on UHC as a value, and not a cost to society. There are important arguments for UHC around the human right to health, but just as powerful is the language of poverty alleviation and economic growth.

In many countries, such as India, healthcare spending is the leading cause of families falling back into poverty and reforms are as much framed as a form of financial protection than public health. Likewise in the Bahamas, the government commissioned KPMG to project the economic benefits of universal access to primary care, which concluded that the policy would have wide-ranging positive economic multipliers - producing seven times its costs in additional GDP over the long run.

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