Education, leadership and partnerships: nursing potential for Universal Health Coverage

Objective: to discuss possibilities of nursing contribution for universal health coverage. Method: a qualitative study, performed by means of document analysis of the World Health Organization publications highlighting Nursing and Midwifery within universal health coverage. Results: documents published by nursing and midwifery leaders point to the need for coordinated and integrated actions in education, leadership and partnership development. Final Considerations: this article represents a call for nurses, in order to foster reflection and understanding of the relevance of their work on the consolidation of the principles of universal health coverage.


Introduction
Some countries consider health care to be a fundamental right, or a commodity.For over a century, universal health coverage has represented a dream come true in most developed countries, although it is still a goal to be achieved in developing countries (1) .
The consolidation of universal health coverage is directly related to multiple, complex factors internal and external to the health system, including economic, social, political, ethical and legal aspects.In this scenario, Sustainability and Accountability in the Health Sector, approved in July 2012 (9) .They culminated in the approval by the UN of Universal Health Coverage on December 12 2012, thereby recognizing health's role in achieving the international development goals and urging countries, civil society and international organizations to include universal health coverage in the global development agenda.The resolution reaffi rmed WHO's leadership in supporting countries to respond to the challenges of the process of implementing universal coverage, considering health as a precondition, result, and indicator of three dimensions of sustainable development.
According to Margaret Chan, Director-General of WHO (10) , after the release of the 2010 Report (WHO), more than 60 developing countries requested consultation from the World Health Organization (WHO) for the implementation of universal coverage in their health systems.
Experts suggest that a minimum package of basic interventions for universal health care coverage is defi ned, prioritizing concrete low-cost actions to deal with specifi c health problems in each location, according to their specifi cities (4) .Also, in the discussions on the Millennium Development Goals (MDGs), advocates of universal health coverage envisioned the opportunity to incorporate their views on more solid and equitable health systems in the context of the post-2015 development agenda.
Thus, the proposal of the Open-Ended Working Group on Sustainable Development Goals (SDGs) included universal coverage in its pre-MDGs project (11) .Some factors must necessarily be considered by countries to achieve the universal health coverage target, including (5) : -Effi cient health care system that reaches the priority health needs by means of an integrated and focused attention on the people in order to: encourage people to become healthy and prevent diseases by facilitating access to health information; diagnose health conditions early, possessing the ability to treat diseases and help people in rehabilitation; -Affordability and access to medicines and technologies for treating health problems; and attitude (12) .
Among health professionals, nurses act as individuals, members, and coordinators of interprofessional teams, and are characterized by care centered on people that are closest to the communities where it is most required, participating in the improvement of health outcomes and cost-effective services (13) .
Nursing has features that potentiate its contribution for strengthening the quality of health systems, playing a key role in recognizing the importance of universal health coverage and its respective implementation, considering the different realities and national needs.
From this perspective, this article discusses possible nursing contributions to universal health coverage.

Method
This was a qualitative study using document analysis of WHO publications that highlight Nursing and Midwifery in Universal Health Coverage.Three documents were used: Nursing and Midwifery Services Strategic Directions -SDNM (13) , WHO Global Forum for Government Chief Nursing and Midwifery Offi cers -WGFGCNO declaration (14) and TRIAD Communiqué declaration (15) .Data were collected using a structured questionnaire applied to each document.
Data were analyzed using deductive content analysis (16) , which is a method of systematic research, whose main objective is the analysis of documents.
This analysis favors the construction of knowledge, the adoption of new perspectives, and representation of facts (17) .
Each researcher analyzed data individually and, subsequently, the results independently obtained by each investigator was juxtaposed and discussed until consensus on emerging issues was reached.It was defi ned that the interpretation process and data discussion would be based on WHO offi cial documents related to universal health coverage.

Results
The supporting each other's efforts (13) . The

Discussion
Nursing and its contribution to Universal Health

Coverage
The three emerging themes emphasize the nursing contribution as a means to achieve the Universal Health Coverage aim, considering its main pillars: access to health care, coverage, health system gateway, rightsbased approach, and protection from economic and social risk (18) .reinforced by the increasing service demand and associated with the rise in migration (19) .

The theme Continuing Education
In supporting both recruitment and retention, in addition to the active involvement of nurses and midwives in the health system development (20) .Also, as a result of this WHO movement, in 2009 the document "Global Standards for the Initial Education of Professional Nurses and Midwives" was created (21) .
Considering the diversity of nursing education programs in the world, the WHO has proposed the adoption of global standards by establishing evidencedbased criteria and expertise for nursing professional training that provides skilled care and promotes relevant health outcomes for the attended population (21) .
It is also important to highlight that the nursing professional education must consider the wider health context, including its social determinants, and the principles of sustainable development.In this backdrop, the structural iniquities also establish differences in the local health priorities, requiring the development of both competencies and specifi cs skills in the nursing health professional's education (22) .
From this perspective, the Action Plan, established by the WHO for the health system governance for universal coverage, values human resource development as a fundamental condition of the system's effectiveness (23) .
Therefore, the investment in education over the life of these valuable human resources is vital, in order to offer quality health services to the users: the possible Rev. Latino-Am.Enfermagem 2016;24: e267 health outcomes depend on its valuation.And here, Nursing deserves emphasis and special attention from governments, managers, education and health leaders: it is a profession that is considered to be the backbone of the health system, not only because of its majority representation in the health workforce, but also because of its presence, performance and permanence (24 hours) in services, coordinating care and representing the link between the members of the health team (24) .
The in the health ministries.It is recommended that in the near future they act in teams and lead nursing and midwifery processes, highlighting that the approach of talent management is adopted to put them in strategic leadership (25)(26) .
Leadership is exercised by means of support systems that promote that nurses are allowed to perform to their full ability, their contribution for improving the health outcomes, their participation in their own professional development, their satisfaction and recognition for the work they perform (19) .Nursing leadership is also expressed by means of innovating based on research results, and the entrepreneurial activities towards services` resolubility.
Leaders are important, but leadership is even more so: a single leader can make a difference and produce better than expected results, but the collective leadership brings together leaders at all organizational levels through shared and sustainable actions.With the development of leaders, their organizations also progress, becoming more capable of sustaining the changes required by them.This is a permanent commitment with personal change and the leadership cultivation culture affecting all organizational leaders, therefore, leadership sustainability (27) .
The nurse who is committed to current policies seeks constant self-improvement and the involvement of other leaders, being recognized as a leader in the healthcare system, assuming responsibility for sustainable leadership.Good leaders are believed to become even better when they are aware and convinced of the changes they know they need to make.
Thereby, nurses need to commit to the implementation of programs that contribute to the consolidation of universal health coverage.
Data from the WHO demonstrate that, despite the process already achieved, health service coverage and the protection against fi nancial risks are still far short of the goal of universal coverage, due to several factors, including diffi culties understanding the association between the service coverage and health.These gaps can be fi lled by means of development of research on the topic (28) .It is recommended, therefore, that nurses develop research focusing on improving health service coverage, protection against fi nancial risks and in outlining of indicators for data generation to monitor the progress in the universal coverage policy.
In sum, research should focus on the nursing actions for achieving universal health coverage and the effects of these interventions.
Universal health coverage represents a means for improving the health conditions of people and the promotion of their development.Studies performed on the subject can play a key role in nursing actions implemented in the context of the MDGs, as well as being a support for discussion of the post-2015 sustainable development agenda (28) .
The In a context of coping with diffi culties with the consolidation of universal health coverage by various countries, development of partnerships emerges as a viable alternative to achieving policy directives focusing on social welfare, by means of joint work which is impossible to be performed by organizations separately (29) .The seed of necessity and the potential emergence of interdependence relationships, generating effective actions to narrow the relationship of the actors involved in care for system users, are identifi ed Mendes IAC, Ventura CAA, Trevizan MA, Marchi-Alves LM, Souza-Junior VD.
in the scope of health organizations.Nurses, as links between the system services, exercise leadership which values diversity and strengthening the human power of all members, including the user (30) .Teamwork is recognized as central to the concept of partnership, both in the workplace and in the inner workings of both professions (31) .
Considering the relevance of collaborative work, in 2010, the WHO published a document highlighting the need to stimulate interprofessional collaboration in education as an innovative strategy to deal with the global crisis of the health workforce (32) .Therefore, collaborative practice in health care was defi ned as an integration of different professionals in the work with patients, their families, caregivers, and communities, aiming to offer high-quality care.The same concept can be adopted in the idealization and implementation of the partnerships for universal health coverage.

Figure 1 -
Figure 1 -Nursing Contribution to the Universal Health Coverage [KRA 3 SDNM, Strategy 2 WGFGCNO and Guideline Quantity, Quality and Relevance of Workforce Nursing and Obstetrics of TRIAD Communiqué] encompasses the basic and postbasic education, by means of curriculum with central contents, coordinated with health policies and local realities, in order to guarantee the minimum number of nurses in the health services recommended by the WHO, capable of qualifi ed professional performance and sustained education programs throughout one's working life.Nurses' education is especially important, considering the global lack of these professionals, 2001, the World Health Assembly approved Resolution 54.12, validating the WHO commitment and its member countries` with the expansion and strengthening of training of nurses and midwives.It is important to highlight that the Nursing and Midwifery Services Strategic Directions document (2002-2008) served as a guide for the implementation this national government's resolution.By meeting the needs expressed by the Member States, Resolution WHA 59.27 urges governments to implement programs to strengthen nursing and midwifery development, theme Leadership and Innovation [KRA 1, KRA 2 e KRA 4 SDNM, Strategy 1 WGFGCNO, Directive Leadership and Policy Direction for the Universal Health Coverage of the TRIAD communiqué] points to the exercise of leadership and innovative performance of nurse, focused on his/her participation in the development of health policy, management of health services, valuation of its human resources, and a favorable environment in which to work.The competencies in nursing leadership must be cultivated for leaders to develop skills to ensure nursing's contribution to universal health coverage.It is therefore important to ensure nursing participation in the establishment of policies, strategies and clear goals for access to health coverage, as advocates of individual and social rights of the population, aimed at protecting economic and social risks.The technical expertise of the nurse, the size of its contingent and especially its proximity to the health services users, daily experiencing their needs, strengths and weaknesses, legitimize the imperative of this participation.The World Health Organization recognizes the need for clearer examples of Nursing and Midwifery leadership subject, Effective Partnerships [KRA 5 SDNM, Strategy 3 WGFGCNO and Guidelines Collaborative Partnerships in the current economic and social situation and TRIAD Communiqué], reinforces the importance of nursing collaboration with different stakeholders, including the government, civil society, and professional organizations.
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