Nurses' knowledge of universal health coverage for inclusive and sustainable elderly care services

Objectives: to explore nurses' knowledge of universal health coverage (UHC) for inclusive and sustainable development of elderly care services. Method: this was a cross-sectional survey. A convenience sample of 326 currently practicing enrolled nurses (EN) or registered nurses (RN) was recruited. Respondents completed a questionnaire which was based on the implementation strategies advocated by the WHO Global Forum for Governmental Chief Nursing Officers and Midwives (GCNOMs). Questions covered the government initiative, healthcare financing policy, human resources policy, and the respondents' perception of importance and contribution of nurses in achieving UHC in elderly care services. Results: the knowledge of nurses about UHC in elderly care services was fairly satisfactory. Nurses in both clinical practice and management perceived themselves as having more contribution and importance than those in education. They were relatively indifferent to healthcare policy and politics. Conclusion: the survey uncovered a considerable knowledge gap in nurses' knowledge of UHC in elderly care services, and shed light on the need for nurses to be more attuned to healthcare policy. The educational curriculum for nurses should be strengthened to include studies in public policy and advocacy. Nurses can make a difference through their participation in the development and implementation of UHC in healthcare services.


Introduction
Universal health coverage (UHC) is defi ned as the entire spectrum of health services, ranging from health promotion, disease prevention, acute care and treatment, rehabilitation, to palliative care, and it should be fi nancially affordable and geographically accessible to everyone in need (1) . The defi nition embraces two key concepts: inclusiveness of the coverage and the sustainable development of the services provided.
Despite many political and resource constraints, the initiatives for UHC have been reinforced again in 2000, in many countries, since the establishment of Millennium Development Goals (MDGs) following the United Nations Millennium Summit (1) . One hundred and ninety-one United Nations members have committed to achieve the MDGs by 2015. In response to the MDGs, the WHO

Global Forum for Governmental Chief Nursing Offi cers
and Midwives (GCNOMs) has declared a commitment to develop a competent nursing workforce at all levels of healthcare delivery systems to support the initiatives for UHC (2) . A set of implementation strategies was subsequently recommended for countries to follow. To succeed, it requires the contribution of nurses who are involved in policy making, management, education and clinical service.
The WHO has been advocating UHC over the past few decades to ensure all human beings are able to seek health services and are not deprived of services because of fi nancial hardship (3) . The elderly population is one of the most vulnerable groups that require extra effort in order to achieve UHC. This is partly because of the loss of gainful employment and partly because of the increased incidence of co-morbidity in this group of people. As expected, demands for health and social care will increase by many folds due to the trending rise in the aging population. Thus, the rights of elderly in accessing healthcare may face unprecedented levels of threat; Hong Kong is no exception (4) . In Hong Kong, the healthcare system, including elderly services, relies on both public sector and private sector. While 88% of the secondary and tertiary healthcare services were provided by the public sector, nearly 70% of the primary healthcare services were provided by the private sector (5) . All Hong Kong citizens are eligible to seek medical services from the public sector at a very low fee. This fee may also be waived if the person covered by the comprehensive social security scheme (CSSA).

The development of the nursing profession in Hong
Kong is considered relatively more mature than in many Asian countries, yet the level of nurses' participation in politics was reported to be low (6) . More often than not, nurses were perceived to be apathetic to political decisions, even if they were healthcare related (7) . Heavy workloads, a sense of powerlessness, gender bias, lack of understanding of the political and policy making process, and ethical confl icts between professional and political values may account for this. Nurses, as one of the major healthcare providers, are the key members in the provision of quality healthcare services, and advocate for health choices and health policies (8)(9) . It is important for them to be knowledgeable of the implementation strategies for UHC, even if they do not fully understand.
Healthcare services for elderly in Hong Kong are far from adequate, despite many new initiatives have been implemented (10)(11)(12) . Many institutions, such as day centers, skilled nursing facilities and infi rmaries want to support the initiatives; however, they cannot fi nd enough nurses to do so. The goal of achieving UHC for elderly healthcare services is moving farther away. The situation does not appear to have any impact on nurses.
This is rather unusual, as nurses have been very devoted to vulnerable people in Hong Kong. Hence, the research team decided to look into the fundamental problem that leads to this phenomenon. Are nurses aware of these initiatives which were purposely developed to support UHC for elderly healthcare services in Hong Kong?
The UHC movement was fi rst initiated in 1941. Over the last few decades, the focus of the movement has been reviewed and changed, for example, from poverty to gender equality, and to child welfare. However, the impact of UHC is yet to be seen. Engagement of various agencies, government offi cials, political leaders and relevant stakeholders is crucial in the course of implementation (13) .
For engagement to succeed, knowledge of every party is crucial.
The sample size provided reasonable protection against Type II error, given a minimum 5% of precision with 5.41% of alpha error, whereas the confi dence interval was 95%. Table 1 shows the demographic characteristics of the respondents. The ratio between registered nurse and enrolled nurse (RN/EN) was comparable to that of the proportional distribution in Hong Kong (14) . The majority of them were young (aged 35 or below), baccalaureate prepared, and working in clinical settings.  About two-thirds of the participants indicated that dispensing and prescribing were separate systems (Q4), which was wrong. Forty percent of respondents incorrectly indicated that the government did not cover elderly who could not afford health services (Q5) and tertiary care (Q6c). In Hong Kong, the Government was not the major provider for primary care (Q6a), however, 88.3% thought it was.  (Table 3). This is reasonable because ENs were mostly HD holders while RNs held degrees. It may also refl ect the reality that many ENs work in the elderly care sector, where many care providers belong to the new category of licensed elderly care workers.

Sustainable development of UHC for elderly healthcare services
This study revealed that nurses showed low political involvement and powerlessness in the process of policy making, which was consistent with the fi ndings from previous studies (7,(16)(17)(18)  well in this area. There is an urgent need to involve more nurse educators in the political process leading to decision-making (22) .
The survey uncovered a considerable knowledge gap in nurses' knowledge of UHC in elderly care services, but care must be taken in interpreting the fi ndings from such a nonrandom sample. Having collected the data on nurses' perceived contribution and importance to policy-making across clinical, management and education sectors, the research team believes that, with the increase of the aged population, nurses could do more to enhance their capacity at various fronts to support the government's initiatives to provide UHC for elderly healthcare services (23) .

Conclusion
Universal health care evolves from the 'Health for All' movement advocated by the WHO in the 1970s.
Since then, the Hong Kong government has launched many initiatives in order to achieve UHC, particularly for inclusive and sustainable elderly healthcare services.
Although the outcomes of these initiatives are yet to be seen, the research team considered it to be appropriate to conduct the reported survey to identify nurses' knowledge of and involvement in the process, including policy-making and implementation. It was hoped that the fi ndings would inform major stakeholders of some issues which may possibly affect the success of these initiatives.
The survey has revealed some knowledge gaps among nurses. Their knowledge of healthcare fi nancing, including health insurance, drug-dispensing, and human resource policy needs to be enhanced.
The low perceived importance and contribution to the sustainable development of elderly healthcare services are deterrents to their possible involvement in the initiatives. After all, nurses constitute a major work force in healthcare. They should be better prepared to participate with policy-making knowledge for the benefi t of the population that they serve.