WFPHA: World federation of public health associations

Universal health coverage: contestations and the role of public health associations
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Ensuring that all people can access the health services they need – without facing financial hardship – is key to improving the well-being of a country’s population. But universal health coverage is more than that: it is an investment in human capital and a foundational driver of inclusive and sustainable economic growth and development. It is a way to support people so they can reach their full potential and fulfil their aspirations [1, page v].


Universal health coverage (UHC) is one of the targets of the 2015 sustainable development goals (SDGs) [2] and has captured the attention and imagination of the global community. The World Health Organization (WHO) has made UHC a centre piece of its 13th programme of action (POA), with the theme of “Promote Health, Keep the World Safe and Serve the Vulnerable” [2]. The POA calls on leaders throughout the world to advance the vision of UHC and to ensure that every person receives the health care services they need without facing financial hardship [3].

In this piece, I comment on the global reported progress on UHC, the contestations in the UHC discourse, and the possible role of national public health associations. I conclude with suggestions on the role of the World Federation of Public Health Associations (WFPHA), given its global reach and its vision of social justice and health equity.

Progress on UHC

The 2017 Global Monitoring Report on UHC noted the progress since 2000. Notwithstanding this progress, at least half of the world’s population do not have full coverage of essential services [1]. In 2017, coverage with essential services varied greatly among geographical regions and between countries [1], with an overall UHC service coverage index value of 64 (out of 100) globally [1]. The UHC service coverage index was highest in East Asia (77 on the index) and Northern America and Europe (also 77). Sub-Saharan Africa had the lowest index value (42), followed by Southern Asia (53). The index is correlated with under-five mortality rates, life expectancy, and human development [1]. Across the world, there was also a large unmet need for specific interventions, including treatment for hypertension, family planning, and childhood vaccination [4].

Many of these reported inequities remain, and in 2019, WHO reported that communities in low-income countries have less access to essential health services compared to their wealthier counter-parts, exacerbated by the acute shortages of health care professionals and low domestic expenditure on health [4].

UHC Contestations and the role of national public health associations

The concept of UHC means different things to different people. Although UHC combines the public health concept of services based on need, and the economic concept of financial risk protection, there are several potential dangers against which the public health community needs to guard. First, population health outcomes are influenced by structural, social-economic, and political determinants [5, 6]. The WHO Commission on Social Determinants of Health (CDSH) generated evidence on the links between population health outcomes and the social determinants of health (water and sanitation, employment, education, etc.) [7]. National public health associations (PHAs) have an important role in generating, collating and/or disseminating evidence on the relationship between these social determinants and the health of communities. These PHAs should lobby their governments to address these social and political determinants of health. In addition, national PHAs should advocate for recognition of health as a human right, and one that is in line with the WHO’s definition of health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity [8].

Second, a narrow UHC focus that only includes health care provision has the potential to ignore the full range of public health interventions needed to improve population health. National PHAs should ensure that UHC extends beyond health service provision, to include broader public health interventions, such as tobacco control legislation and taxation, and improvements in the built environment such as the construction of safe roads [9]. They should also advocate for legislation, and taxation of unhealthy commodities, and implement fiscal policies as a powerful tool to enable new investments in health and well-being.

Third, a narrow focus that limits UHC to health service provision, especially the provision of curative services, has the potential to ignore gross inequities and power dynamics associated with geographical region, class, gender, and ethnicity. Not only these, but also others are now being exacerbated by rising xenophobia, war-mongering, and intolerance—and the impact of these on population health outcomes. National PHAs should ensure that health equity, social justice, diversity, and anti-discrimination become central themes of their advocacy effort—if they are not already. Also, they should join forces with like-minded organisations to advocate for an ethical approach to UHC, social solidarity, participatory processes, and good governance [10].

The role of the World Federation

The WFPHA is the only worldwide professional society representing and serving the field of public health. The Federation has the potential through its national members to play a critical advocacy role to ensure that UHC is seen as a comprehensive concept (Table 1), rather than a narrow focus on health services.
Table 1

Definition of UHC.

Source: WHO, World Bank [1], p. xii]

UHC means that “all people receive the health services they need, including public health services designed to promote better health (such as anti-tobacco information campaigns and taxes), prevent illness (such as vaccinations), and to provide treatment, rehabilitation and palliative care (such as end-of-life care) of sufficient quality to be effective while at the same time ensuring that the use of these services does not expose the user to financial hardship”.

The WFPHA Global Charter for the Public’s Health provides a tool for national PHAs to enhance their advocacy, leadership, and operational/ programmatic capacities to enable them to have an impact on population health and health equity [11]. Other supportive activities include public health capacity building, education and training, and knowledge sharing, of which the 2020 World Congress on Public Health is an important vehicle.

Laetitia C. Rispel, Professor

President of the World Federation of Public Health Associations & DST/NRF SARChI Research Chair on the Health Workforce

School of Public Health

University of the Witwatersrand, Johannesburg, South Africa or +27 11 717 2043 


  1. 1.

    The content of The Federation’s Pages is selected and edited by the WFPHA and not sent through by JPHP’s usual process of peer review.



  1. 1.
    WHO, World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Geneva: World Health Organization and International Bank for Reconstruction and Development/The World Bank; 2017.Google Scholar
  2. 2.
    United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015.Google Scholar
  3. 3.
    WHO. Draft thirteenth general programme of work, 2019–2023. Report by the Director-General. World Health Assembly Seventy-first World Health Assembly, 71/4, Provisional agenda item 11.1. Geneva: World Health Organization; 2018.Google Scholar
  4. 4.
    WHO. World Health Statistics. Monitoring health for the SDGs. Sustainable Development Goals. Geneva: World Health Organization; 2019. p. 2019.Google Scholar
  5. 5.
    Baltussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on cost-effectiveness. Int J Health Pol Manage. 2016;5(11):615.CrossRefGoogle Scholar
  6. 6.
    Bloom DE, Khoury A, Subbaraman R. The promise and peril of universal health care. Science. 2018;361(6404):eaat9644. Scholar
  7. 7.
    Commission on Social Determinants of Health. Closing the gap in a health generation: health equity through the social determinants of health. Geneva: World Health Organization; 2008.Google Scholar
  8. 8.
    WHO. World Health Organization constitution. Geneva: World Health Organization; 1948.Google Scholar
  9. 9.
    Gopinathan U, Ottersen T. Evidence-Informed deliberative processes for Universal Health Coverage: broadening the scope: comment on “priority setting for Universal Health Coverage: We need evidence-informed deliberative processes, not just more evidence on cost-effectiveness”. Int J Health Policy Manage. 2017;6(8):473.CrossRefGoogle Scholar
  10. 10.
    Reis A. Universal Health Coverage-The Critical Importance of Global Solidarity and Good Governance: Comment on “Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage”. Int J Health Policy Manage. 2016;5(9):557.CrossRefGoogle Scholar
  11. 11.
    World Federation of Public Health Associations. A global charter for the public’s health. Geneva: WFPHA; 2016:

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