ARE THE SUS AND THE RIGHT TO HEALTH INCOMPATIBLE WITH UNIVERSAL HEALTH COVERAGE? Challenging Misconceptions Around the Concept of UHC in the Public Health Scholarship in Brazil

O SUS e o direito à saúde são incompatíveis com a cobertura universal de saúde? Críticas e equívocos a respeito da UHC na literatura em saúde pública no Brasil

DANIEL WEI LIANG WANG About the author

ABSTRACT

The literature on public health in Brazil has criticized the idea of universal health coverage (UHC), arguing that UHC is incompatible with the universal health system and the right to health. This article assesses that criticism and concludes that it creates a “strawman” argument. The idea of UHC that is being criticized in Brazil bears little similarity to the concept of UHC promoted by international organizations and discussed in the international literature.

KEYWORDS:
Universal health coverage (UHC); right to health; universal health systems; United Nations (UN) sustainable development goals (SDG); Brazil

RESUMO

A literatura sobre Saúde Coletiva no Brasil tem criticado a ideia de cobertura universal de saúde (UHC) porque UHC preconizaria um modelo de saúde incompatível com o Sistema Único de Saúde (SUS) e com o direito à saúde. Este artigo analisa os fundamentos dessa crítica e conclui que ela se sustenta em uma “falácia do espantalho”. A ideia de UHC à qual os críticos se opõem guarda pouca semelhança com a ideia de UHC defendida por organizações internacionais e discutida na literatura internacional.

PALAVRAS-CHAVE:
Cobertura universal de saúde (UHC); direito à saúde; sistemas universais de saúde; metas de desenvolvimento sustentável da Organização das Nações Unidas (MDS-ONU); Brasil

INTRODUCTION1 1 The author is grateful to Elize Massard da Fonseca, Fabíola Sulpino Vieira and Giuliano Russo for comments on previous versions of this paper. The author is also indebted to Leonardo Nochang Heck for his research assistance. This research was funded by the São Paulo Research Foundation (Grant ID: 2019/15565-0).

Half of the world’s population lack access to adequate health services, and many must sacrifice a large part of their income in order to receive them, leading millions into extreme poverty (World Health Organization, 2019______. Universal Health Coverage. WHO Fact Sheets. Geneva: WHO, 2019. Available at: <https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)>. Accessed on: Jul. 4, 2020.
https://www.who.int/news-room/fact-sheet...
). In response to this context, several international organizations have recognized the need to achieve universal health coverage (UHC).

UHC has been included in the United Nations sustainable development goals (UN-SDG), which all member countries are committed to achieving by 2030. UHC, as defined in the UN-SDG, includes “protection against financial risk, access to good quality, essential health services, and access to essential drugs and vaccines that are safe, effective, of good quality and at prices that are accessible to all”.

There is no single definition of UHC. Resolution no. 67/81 of the un General Assembly, for example, has a definition similar to that of the UN-SDG, but refers to “access to a nationally determined set of services”. The World Bank, the Organization for Economic Cooperation and Development (OECD), Unicef and the latest publications of the World Health Organization (WHO) all present a broader and simpler definition: all people receiving quality health services that meet their needs without exposing them to financial hardship in paying for them (Ottersen et al., 2014Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.; WHO, 2010; WHO; IBRD/World Bank, 2017______; International Bank for Reconstruction and Development (IBRD)/The World Bank. Tracking Universal Health Coverage: 2017. Global Monitoring Report. Geneva: WHO, 2017. Available at: <https://www.who.int/healthinfo/universal_health_coverage/report/2017/en>. Accessed on: Jul. 4, 2020.
https://www.who.int/healthinfo/universal...
; WHO et al., 2018______; Organization for Economic Co-operation and Development; The World Bank. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Geneva: WHO, 2018. Available at: <https://apps.who.int/iris/handle/10665/272465>. Accessed on: Jul. 4, 2020.
https://apps.who.int/iris/handle/10665/2...
; Unicef, 2016Unicef. Unicef Approach to Health System Strenghtening. New York: Unicef, 2016.).

Despite the differences, it can be said that all definitions of UHC present a notion of universal and equal access to health services without incurring financial risks for patients. In other words, access to health services must be disconnected from the economic means of the user so as to avoid the risk of needed care not being received in the event that an individual is unable to pay for it, or to prevent health care expenses aggravating or pushing people into poverty. This is only achievable through a system of risk sharing, social solidarity (where those with greater financial capacity subsidize the worse-off) and forms of financing that do not depend on patients paying directly for services.

The support from international organizations for UHC, creating a common agenda around this concept, has been followed by a vast academic literature (mainly in English) that brings together specialists from different fields. Despite the different ways of interpreting UHC, Abiiro and De Allegri (2015Abiiro, Gilbert Abotisem; De Allegri, Manuela. “Universal Health Coverage from Multiple Perspectives: A Synthesis of Conceptual Literature and Global Debates”. BMC International Health and Human Rights, v. 15, n. 1, 2015, p. 17.) claim that there is a “global consensus” on its importance.

However, enthusiasm for UHC at the international level appears to stand in contrast to the perceived low take up, or even rejection, of the concept in the literature on health in Brazil. In the first part of this article, I will examine this perception through a review of this literature in order to understand in which types of publication the concept appears most often and how authors perceive it. If the hypothesis of resistance to the concept of UHC is confirmed, the second part will analyse the basis of the criticisms levelled at the concept and their validity.

METHOD

The review of the literature was carried out using the databases of the Biblioteca Virtual em Saúde [Virtual Health Library, BVS] - Regional Portal, and the Scientific Electronic Library Online (SciELO). In the BVS databases, a filter was applied to only show the publications included in the Lilacs and Medline databases. Both in the BVS and in SciELO, two searches were carried out, one using the Portuguese terms “cobertura”, “universal” and “saúde” concurrently, and the other using the English equivalents: “universal”, “health” and “coverage”. In terms of where these terms were located, standard configurations were used in the searches, which in the BVS database refer to “title, abstract and subject” and, in the SciELO database, “all indexes”. In all searches, a filter was applied to limit the results to texts published in Brazil. The SciELO database offers a specific filter for this (“Collection: Brazil”), while in the BVS database the same can be achieved using the operator cp: “BRASIL”. The timeframe of the research refers to the period between 2005 (the year of the publication of Resolution 58.33 of the World Health Assembly, which launched the concept of UHC) and May 11, 2019, the date on which the results were consolidated.

The searches carried out in the BVS database with the terms in English returned 232 results, while with the terms in Portuguese returned 157. In the SciELO database, the results were 92 and 87, respectively. In total, these searches furnished 568 results, of which 379 were eliminated because they were duplicated. Subsequently, an eligibility analysis was carried out, in which the following were excluded:

  1. (I) article whose full content is not available (n = 1);

  2. (II) graduate theses/ dissertations (n = 25);

  3. (III) non-academic publication (n = 1);

  4. (IV) studies that do not explicitly address the concept of “universal health coverage” (n = 107).

The 55 results included for analysis were classified according to the year of publication, the type of publication (book or journal) and the health speciality addressed. The results were then classified into three normative positions with respect to universal health coverage. The first position is critical of the concept, understanding UHC as limiting or harming the right to health or the universal health system. The second is of endorsement, in which the authors accept universal coverage as a goal to be achieved or as a valid parameter for evaluating health systems and policies. The third position is of neutrality: the idea of universal coverage is used to describe a health system, and not as a goal to be achieved. It is possible that the works in this third position employ “universal health coverage” in the legal sense of having the right of access to a health system, and not the broader concept of UHC measured by effective access. However, for reasons of transparency, these studies were included in the analysis.

RESULTS

Although the small number of results does not allow us to draw strong conclusions about the distribution of outputs over time, it is clear that it was from 2014 onwards that the idea of UHC began to appear more intensely in the Brazilian literature on health (Table 1).

Table 1
Distribution of results according to position and year

The results show that, among the 55 studies analyzed, 35 (64%) endorsed UHC, 12 (22%) were critical of the concept, while 8 (14%) were neutral. These results would seem to indicate that the aforementioned perception that UHC is widely rejected in Brazil is mistaken. However, when the results are divided by health speciality, the picture becomes more complex.

Most of the results (84%) come from publications in the fields of “nursing” and “public health” (Table 2). It is surprising that there are more studies mentioning UHC in the field of nursing than in public health, considering UHC has greater thematic proximity to the latter and would, therefore, be expected to be more influential as a concept. Furthermore, according to data from the Coordination for the Improvement of Higher Education Personnel (Capes), there is a significantly larger number of publications in the area of public health than in that of nursing (Capes, 2017b______. “Relatório de Avaliação - Saúde Coletiva”. Avaliação quadrienal 2017. Brasília: Capes, 2017b. Available at: <https://capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-SAUDE-COLETIVA-quadrienal.pdf>. Accessed on: Jul. 3, 2020.
https://capes.gov.br/images/stories/down...
, 2017aCoordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes). “Relatório de Avaliação - Enfermagem”. Avaliação quadrienal 2017. Brasília: Capes, 2017a. Available at: <Available at: https://www.capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-ENFERMAGEM-quadrienal.pdf >. Accessed on: Jul. 3, 2020.
https://www.capes.gov.br/images/stories/...
).

Table 2
Distribution of results according to position and area

While nearly all works in the field of nursing endorse UHC, and many make direct mention of WHO studies and guidelines on the topic, almost half of those in public health are critical of the concept. It is relevant that 83% of the critical works come from the field of public health, which shows that objection to UHC is largely concentrated in this area. Furthermore, with the exception of Medici (2011Medici, André Cezar. Do global ao local: os desafios da saúde no limiar do século XXI. Belo Horizonte: Coopmed, 2011.), the works that endorse UHC do not offer more detailed analysis or defence of the concept, but rather accept it as a theoretical reference or starting point for discussion. Critical studies, meanwhile, tend to be more incisive and centered on opposition to UHC (Annex).2 2 Available at: <https://cebrap.org.br/wp-content/uploads/2020/11/Anexo-1.docx>. Therefore, in the public health literature, criticism of UHC is greater, both in frequency and intensity, than endorsement.

The data show that one cannot speak of resistance to the concept of UHC in the health literature in Brazil as a whole, although there is strong opposition to it in the field of public health. This helps to explain the relatively low number of papers in this area that mention UHC, as scholars are less likely to investigate a concept that they, and a large part of their epistemic community, are opposed to, let alone use it as a theoretical framework or engage with the literature that does.

DISCUSSION

The results of the literature review contradict the thesis of a “global consensus” around UHC. The public health literature in Brazil make relatively little use of this concept, and a significant part of it has explicitly expressed opposition to UHC. It is thus necessary to analyze the grounds for such a rejection of a concept that arouses considerable enthusiasm in the international literature and in international organizations. As well as the critical studies already identified in the literature review, the discussion will also include a paper by Ocké-Reis, which, although not included in the researched databases, deals specifically with UHC and is cited in other references.

Critics tend to counterpose UHC to universal health systems and the right to health. From this perspective, UHC is understood as offering a very limited notion of the rights of users and the duties of the state. They associate the universality of UHC with the idea of “packages” or “baskets” of services, two-tiered health care access, and financial protection against catastrophic expenditure via private health insurance. By contrast, universal health systems such as the Brazilian National Health System (Sistema Único de Saúde - SUS) promote universal, comprehensive and integrated health care joined with equality and the recognition of health as a right that entails responsibilities for the state. As stated by Castillo and colleagues (2017Castillo, Camilo Hernán Manchola; Volnei Garrafa, Thiago Cunha; Hellmann, Fernando. “El acceso a la salud como derecho humano en políticas internacionales: reflexiones críticas y desafíos contemporáneos”. Ciência & Saúde Coletiva , v. 22, n. 7, 2017, pp. 2.151-60.), the “universal health coverage mantra thus conceals exactly the opposite of its real meaning: a non-universal, non-integrated/comprehensive, non-public and non-free health program”. Therefore, promoting UHC in the Brazilian context is equated with advocating the dismantling of the sus and abandoning the idea of health as a human right in favor of expanding the private health market. Universal health coverage is thus seen as a neoliberal alternative to social rights and the SUS.

This criticism of UHC, which opposes it to universal health systems and the right to health, rests on a “strawman” fallacy: the position that is to be refuted is presented in an inaccurate or distorted way that exaggerates some aspects while ignoring others. As will be discussed in the following sections, the way critics present UHC in order to refute it has little to do with what international organizations and the specialist literature have developed and advanced.

UHC and universal health systems

The opposition between UHC and universal health systems assumes that these are two distinct and incompatible models of health system. From this perspective, UHC is presented as an alternative to universal systems because, allegedly, it advocates a reduced role for the state, exempting it from the responsibility to provide services in a universal and equal way, so that its role is reduced to merely regulate and subsidize insurance, covering a minimum basket to those unable to buy it on the market (Giovanella et al., 2018______; Mendoza-Ruiz, Adriana; Pilar, Aline de Carvalho Amand; Rosa, Matheus Cantanhêde da; Martins, Gabrieli Branco; Santos, Isabela Soares; Silva, Danielle Barata et al. “Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias”. Ciência & Saúde Coletiva, v. 23, n. 6, 2018, pp. 1.763-76.; Castillo et al., 2017Castillo, Camilo Hernán Manchola; Volnei Garrafa, Thiago Cunha; Hellmann, Fernando. “El acceso a la salud como derecho humano en políticas internacionales: reflexiones críticas y desafíos contemporáneos”. Ciência & Saúde Coletiva , v. 22, n. 7, 2017, pp. 2.151-60.; Magno, 2015Magno, Liz Duque. “Dos clamores das ruas aos rumores no congresso: uma análise da conjuntura recente da saúde no Brasil”. RECIIS, v. 9, n. 4, 2015, pp. 1-14.). Health care would thus be primarily left to the private insurance market, which inevitably grows in the absence of a public system and the injection of public resources (Giovanella; Rizzotto, 2018______; Rizzotto, Maria Lucia Frizon. “Atenção primária à saúde: da Declaração de Alma-Ata à Carta de Astana”. Saúde em Debate, v. 42, n. sp. 1, 2018, pp. 6-8.; Giovanella et al., 2018______; Mendoza-Ruiz, Adriana; Pilar, Aline de Carvalho Amand; Rosa, Matheus Cantanhêde da; Martins, Gabrieli Branco; Santos, Isabela Soares; Silva, Danielle Barata et al. “Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias”. Ciência & Saúde Coletiva, v. 23, n. 6, 2018, pp. 1.763-76.; Laurell, 2016______. “Competing Health Policies: Insurance against Universal Public Systems”. Revista Latino-Americana de Enfermagem, v. 24, n. 0, 2016, e2668.). Universal health coverage therefore would favor market mechanisms and the fragmentation of the health system, thus aggravating health inequalities (Asociación Latinoamericana de Medicina Social, 2018Asociación Latinoamericana de Medicina Social. “Declaración de Alames frente al intento de absorber la APS en la, muy cuestionada, Cobertura Universal de Salud (UHC)”. Saúde em Debate, v. 42, n. esp., 2018, pp. 431-3. ; Castillo et al., 2017Castillo, Camilo Hernán Manchola; Volnei Garrafa, Thiago Cunha; Hellmann, Fernando. “El acceso a la salud como derecho humano en políticas internacionales: reflexiones críticas y desafíos contemporáneos”. Ciência & Saúde Coletiva , v. 22, n. 7, 2017, pp. 2.151-60.; Laurell, 2016______. “Competing Health Policies: Insurance against Universal Public Systems”. Revista Latino-Americana de Enfermagem, v. 24, n. 0, 2016, e2668.; Barros; Negri Filho, 2015Barros, Fernando Passos Cupertino de; Negri Filho, Armando de. “Cobertura universal de saúde”. Cadernos de Saúde Pública, v. 31, n. 6, 2015, p. 1.333.; Ocké-Reis , 2016Ocké-Reis, Carlos Octávio. “Cobertura universal de saúde: inclusão ou exclusão?”. Boletim de Análise Político-institucional, v. 9, 2016, pp. 19-26.).

However, the relationship between universal systems and UHC is not that of competing and mutually exclusive alternatives, but of means and ends. Universal health coverage is a set of goals to be achieved, not a particular type of health system (Kutzin, 2013______. “Health Financing for Universal Coverage and Health System Performance: Concepts and Implications for Policy”. Bulletin of the World Health Organization, v. 91, n. 8, 2013, pp. 602-11.). Countries can reach UHC in several ways - including, but not limited to, a universal health system along the lines of the SUS. The UHC literature does not prescribe universal systems funded primarily or solely by taxes, but neither does it exclude them. The World Bank, acknowledging the plurality of health systems, affirms that “there is no single path to UHC” (The World Bank, 2015______. Going Universal: How 24 Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up. Washington, DC: The World Bank, 2015.). In the same vein, the WHO also does not identify a single, nor best, type of health system to reach UHC, and considers that this choice must be made according to the economic, sociocultural and political context of each country (WHA, 2015World Health Assembly (WHA). Resolution 58.33, Ninth Plenary Meeting. Geneva: WHA, 2015.).

This consensus on the goals and agnosticism on the means of attaining them is reasonable. It is possible to offer universal and equal access to quality health services without exposing people to financial risks through universal tax-financed systems (eg, Canada and the United Kingdom), through public insurance funded by social contributions on the payroll with state support for those outside the formal labour market (eg, Germany and France), or through highly regulated private insurance with compulsory membership and public and cross-subsidization (eg, Holland and Switzerland). The only type of health system incompatible with UHC is one based on voluntary health insurance (Jamison et al., 2013Jamison, Dean T.; Summers, Lawrence H.; Alleyne, George; Arrow, Kenneth J.; Berkley, Seth; Binagwaho, Agnes; Bustreo, Flavia et al. “Global Health 2035: A World Converging within a Generation”. The Lancet , v. 382, n. 9.908, 2013, pp. 1.898-955.; Oxfam, 2013Oxfam. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxford: Oxfam, 2013.). Although such a system is preferable to direct (out-of-pocket) payments, the literature does not regard it as a long-term solution, and its existence should not be reason to reduce public investment in health (Kutzin, 2012Kutzin, Joseph. “Anything Goes on the Path to Universal Coverage? No”. Bulletin of the World Health Organization, v. 90, n. 11, 2012, pp. 867-8.).

Universal health coverage by no means imply that the role of state should be reduced to make way for market mechanisms. On the contrary, to avoid fragmentation of the system and achieve greater efficiency and equity, it requires state action to create compulsory contributions and risk-sharing mechanisms (either through single universal systems or public or private compulsory insurance) (Kutzin, 2013______. “Health Financing for Universal Coverage and Health System Performance: Concepts and Implications for Policy”. Bulletin of the World Health Organization, v. 91, n. 8, 2013, pp. 602-11.; WHO, 2010aWorld Health Organization (WHO). The World Health Report - Health Systems Financing: The Path to Universal Coverage. Geneva: WHO, 2010a.).

Universal tax-financed public systems are not the only arrangement capable of fostering UHC, although their examples are often mentioned as models to be followed (Martin et al., 2018Martin, Danielle; Miller, Ashley P.; Quesnel-Vallée, Amélie; Caron, Nadine R.; Vissandjée, Bilkis; Marchildon, Gregory P. “Canada’s Universal Health-Care System: Achieving Its Potential”. The Lancet , v. 391, n. 10.131, 2018, pp. 1.718-35.; Oxfam, 2013Oxfam. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxford: Oxfam, 2013.). Brazil is, in fact, considered one of the pioneers in recognising UHC as a human right for having constitutionalized the right to health and created the sus (The World Bank, 2014The World Bank. Universal Health Coverage for Inclusive and Sustainable Development - Country Summary Report for Brazil, 2014.). Therefore, it is possible to adopt the concept of UHC and, at the same time, argue that universal systems such as sus are, in the Brazilian context or in general, the best way to achieve UHC. It can also be argued, as Kutzin and Oxfam have, that the existence of private or public insurance segmented by groups creates inefficiencies and inequality and, therefore, are an obstacle to UHC (Kutzin, 2013______. “Health Financing for Universal Coverage and Health System Performance: Concepts and Implications for Policy”. Bulletin of the World Health Organization, v. 91, n. 8, 2013, pp. 602-11.; Oxfam, 2013Oxfam. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxford: Oxfam, 2013.). What does not make sense is to start from the premise that UHC and universal systems are conceptually incompatible or contradictory.

UHC and access and use of health services

Some authors also criticize UHC based on the distinction between “universal coverage”, the goal of UHC, and “universal access”, to which universal systems are committed. “Coverage”, according to critics, means a formal link to an organization that has responsibility for providing some kind of health care. However, the argument goes, this formal recognition does not necessarily mean the possibility of “access” and “use” of services that adequately meet the needs of patients (Buss et al., 2014Buss, Paulo Marchiori; Magalhães, Danielly de Paiva; Faraoni Freitas Setti, Andréia; Gallo, Edmundo; Franco Netto, Francisco de Abreu; Machado, Jorge Mesquita Huet; Buss, Daniel Forsin. “Saúde na agenda de desenvolvimento pós-2015 das Nações Unidas”. Cadernos de Saúde Pública , v. 30, n. 12, 2014, pp. 2.555-70.; Noronha, 2013Noronha, José Carvalho de. “Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios”. Cadernos de Saúde Pública , v. 29, n. 5, 2013, pp. 847-9.; Ocké-Reis, 2016Ocké-Reis, Carlos Octávio. “Cobertura universal de saúde: inclusão ou exclusão?”. Boletim de Análise Político-institucional, v. 9, 2016, pp. 19-26.). In other words, a population may be formally covered by a system, but unable to access and use the services it needs.

True, formal coverage does not necessarily guarantee access and use. However, “coverage” does not need to have such a narrow meaning. There are other uses of the term that also comprise access and use. This is the meaning of “access”, for example, when talking about vaccination coverage, which is calculated as the ratio between the number of people effectively immunized and the total population. Or in analyses of the coverage of the Family Health Strategy (FHS), a key primary care programme in Brazil, measured by variables such as the percentage of households registered in local health centres and receiving visits from health agents (Malta et al., 2016Malta, Deborah Carvalho; Santos, Maria Aline Siqueira; Stopa, Sheila Rizzato; Vieira, José Eudes Barroso; Melo, Eduardo Alves; Reis, Ademar Arthur Chioro dos. “A cobertura da estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013”. Ciência & Saúde Coletiva , v. 21, n. 2, 2016, pp. 327-38.). Even when critics recognize the multiplicity of meanings of “coverage”, they are suspicious that such an ambiguous term could hide the real intentions behind the idea of UHC (Laurell, 2011Laurell, Asa Ebba Cristina. “Los seguros de salud mexicanos: cobertura universal incierta”. Ciência & Saúde Coletiva , v. 16, n. 6, 2011, pp. 2.795-806.).

It is not clear, however, why critics consider that when used in connection with UHC the term “coverage” should refer to its most restrictive, formal sense, which distances itself from the concepts of “access” and “use”. In reality, the evidence points in the opposite direction, with international organizations defining UHC using the terms “access to service” or “receiving/obtaining services” (Ottersen et al., 2014Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.; WHO, 2010b______. World Health Report 2010 - Health Systems Financing: the Path to Universal Coverage. Geneva: WHO, 2010b. Available at: <https://www.who.int/whr/2010/en>. Accessed on: Jul. 3, 2020.
https://www.who.int/whr/2010/en...
; WHO; IBDR/The World Bank, 2017______; International Bank for Reconstruction and Development (IBRD)/The World Bank. Tracking Universal Health Coverage: 2017. Global Monitoring Report. Geneva: WHO, 2017. Available at: <https://www.who.int/healthinfo/universal_health_coverage/report/2017/en>. Accessed on: Jul. 4, 2020.
https://www.who.int/healthinfo/universal...
; General Assembly of the United Nations, 2012General Assembly of the United Nations. Resolution 67/81. Geneva, 2012. Available at: <Available at: https://undocs.org/en/A/RES/67/81 >. Accessed on: Jul. 6, 2020.
https://undocs.org/en/A/RES/67/81...
; WHO, 2015______. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: WHO, 2015.). Furthermore, the understanding of coverage as “effective coverage” is explicit: the percentage of people WHO need a given service and actually receive it (De Paz et al., 2017De Paz, C.; Valentine, N. B.; Hosseinpoor, A. R.; Koller, T. S.; Gerecke, M. Intersectoral Factors Influencing Equity-Oriented Progress towards Universal Health Coverage: Results from a Scoping Review of Literature. Geneva: World Health Organization, 2017.). Indicators adopted to measure countries’ progress towards UHC also focus on the proportion of people WHO actually receive the services they need (WHO; IBDR/The World Bank, 2017______; International Bank for Reconstruction and Development (IBRD)/The World Bank. Tracking Universal Health Coverage: 2017. Global Monitoring Report. Geneva: WHO, 2017. Available at: <https://www.who.int/healthinfo/universal_health_coverage/report/2017/en>. Accessed on: Jul. 4, 2020.
https://www.who.int/healthinfo/universal...
; De Paz et al., 2017De Paz, C.; Valentine, N. B.; Hosseinpoor, A. R.; Koller, T. S.; Gerecke, M. Intersectoral Factors Influencing Equity-Oriented Progress towards Universal Health Coverage: Results from a Scoping Review of Literature. Geneva: World Health Organization, 2017.; Hogan et al., 2018Hogan, Daniel R.; Stevens, Gretchen A.; Hosseinpoor, Ahmad Reza; Boerma, Ties. “Monitoring Universal Health Coverage within the Sustainable Development Goals: Development and Baseline Data for an Index of Essential Health Services”. The Lancet - Global Health , v. 6, n. 2, 2018, e152-68.). Other UHC indicators go even further than simple access to include data on whether the treatments received produce the expected health outcomes. For example, instead of just measuring the hiv-positive population WHO received antiretrovirals, the proportion of those WHO saw a reduction in viral load is also measured (WHO; IBDR /The World Bank, 2017______; International Bank for Reconstruction and Development (IBRD)/The World Bank. Tracking Universal Health Coverage: 2017. Global Monitoring Report. Geneva: WHO, 2017. Available at: <https://www.who.int/healthinfo/universal_health_coverage/report/2017/en>. Accessed on: Jul. 4, 2020.
https://www.who.int/healthinfo/universal...
).

Therefore, the distinction between “coverage”, “access” and “use” makes no difference in the context of debates about UHC. International organizations and the specialist literature unequivocally use “coverage” to also mean “access” and “use”.

UHC and service packages

Universal health coverage is also criticized for its supposedly limited reach, by seeking to guarantee coverage for only a “minimum package” or a “limited basket” of services for the poorest (Giovanella et al., 2018______; Mendoza-Ruiz, Adriana; Pilar, Aline de Carvalho Amand; Rosa, Matheus Cantanhêde da; Martins, Gabrieli Branco; Santos, Isabela Soares; Silva, Danielle Barata et al. “Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias”. Ciência & Saúde Coletiva, v. 23, n. 6, 2018, pp. 1.763-76.). These packages (or baskets) are understood to generate inequality because the poor are offered only the minimum, while the wealthy have access to more services via the market. Critics also disapprove the idea that these packages should be determined using cost-effectiveness criteria (Uribe-Gómez, 2017Uribe-Gómez, Monica. “Nuevos cambios, viejos esquemas: las políticas de salud en México y Colombia en los años 2000”. Cadernos de Saúde Pública , v. 33, n. 2, 2017, e00112616.). Universal systems, by contrast, are supposedly guided by the principles of equality and integrated care in which there are no limited baskets, and services are offered according to the needs of patients.

Criticisms of service packages are closely linked to the idea that UHC advocates a segmented health insurance system in which access is primarily gained via market mechanisms. As we have seen, this is a mistaken view of UHC. However, the idea of determining a set of services to be offered to the population does appear in discussions about UHC and stems from the correct assumption that no system in the world can provide all services to the entire population for free and, therefore, choices must be made (Ottersen et al., 2014Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.; Horton, 2018Horton, Richard. “UHC - One Promise and Two Misunderstandings”. The Lancet , v. 391, n. 10.128, 2018, p. 1.342.).

The mismatch between the population’s health demands and the capacity of systems to meet them creates limits to what is offered to the population, both in practice and in law. In Brazil, despite the existence of the SUS, there is a large supplementary private health system that covers about 30% of the population and a high proportion of out-of-pocket payments, which forces families to spend a significant part of their income on health care (Organization for Economic Co-operation and Development, 2016Organization for Economic Co-operation and Development. Universal Health Coverage and Health Outcomes - Final Report, 2016.). Discussions around the Mais Médicos [More Doctors], a program to reduce the shortage of general practitioners in deprived areas of Brazil, show the challenges for the sus to universalize even primary care (Campos; Pereira Júnior, 2016Campos, Gastão Wagner de Sousa; Pereira Júnior, Nilton. “A atenção primária e o Programa Mais Médicos do Sistema Único de Saúde: conquistas e limites”. Ciência & Saúde Coletiva, v. 21, n. 9, 2016, pp. 2.655-63.). Even much better funded universal systems have limitations. Canada, which provides universal access to hospital care, lacks a national pharmaceutical policy. There are regional variations in the public funding of medicines and a significant part of expenditure on drugs is made through complementary private insurance or by out-of-pocket payments (Martin et al., 2018Martin, Danielle; Miller, Ashley P.; Quesnel-Vallée, Amélie; Caron, Nadine R.; Vissandjée, Bilkis; Marchildon, Gregory P. “Canada’s Universal Health-Care System: Achieving Its Potential”. The Lancet , v. 391, n. 10.131, 2018, pp. 1.718-35.). In the United Kingdom, whose health system inspired the SUS, effective drugs may not be provided or access may be rationed for reasons of cost-effectiveness or budget impact (National Institute for Health and Care Excellence, 2012National Institute for Health and Care Excellence. The Guidelines Manual, 2012.; 2018______. Guide to the Processes of Technology Appraisal, National Institute for Health and Care Excellence, 2018.).

The literature on UHC accepts that the scarcity of resources constrains health systems, but what UHC aspires to is ambitious. The famous WHO cube (Figure 2), which specifies the three dimensions to be considered by UHC, shows that the ultimate goal is for all people to be covered (maximum universality), to access all the services they need (maximum coverage) without having to pay for the service used (maximum financial protection). All countries start somewhere (represented by the smaller grey cube) and the UHC goal is to fill the larger cube, but scarcity imposes choices about priorities along the way. Although the aim should be to offer an increasing number of health services over time, decisions about which services should be guaranteed to the population initially, and which should be added later, are based on the circumstances of each population and their health needs, public opinion, budget etc. (Watkins et al., 2017Watkins, David A.; Jamison, Dean T.; Mills, Anne; Atun, Rifat; Danforth, Kristen; Glassman, Amanda; Horton, Susan; Jha, Prabhat; Kruk, Margaret E.; Norheim, Ole F.; Qi, Jinyuan; Soucat, Agnes; Verguet, Stéphane; Wilson, David; Alwan, Ala. “Universal Health Coverage and Essential Packages of Care”. In: Jamison, Dean T.; Gelband, Hellen; Horton, Susan; Jha, Prabhat; Laxminarayan, Ramanan; Mock, Charles N.; Nugent, Rachel (Eds.). Disease Control Priorities: Improving Health and Reducing Poverty. The World Bank, 2017.).

Figure 1
Results of searches in databases and papers selected for analysis

Figure 2
The three dimensions to be considered on the path to UHC

Every health expenditure is a distributive choice with opportunity costs (of what could be gained from an alternative use of resources). Therefore, these choices must consider scientific evidence and the policy objectives of reducing health inequalities, giving preference to the worst-off, and maximizing efficiency in public spending by prioritizing treatments that bring large health gains at low cost (Ottersen et al., 2014Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.; Jamison et al., 2013Jamison, Dean T.; Summers, Lawrence H.; Alleyne, George; Arrow, Kenneth J.; Berkley, Seth; Binagwaho, Agnes; Bustreo, Flavia et al. “Global Health 2035: A World Converging within a Generation”. The Lancet , v. 382, n. 9.908, 2013, pp. 1.898-955.).

Systems reluctant to make such choices about priorities will end up spending a lot on expensive treatments that produce limited health benefits, probably at the expense of interventions that can have a major impact at population level at a proportionally low cost (Rumbold et al., 2017Rumbold, Benedict; Baker, Rachel; Ferraz, Octavio; Hawkes, Sarah; Krubiner, Carleigh; Littlejohns, Peter; Norheim, Ole F. et al. “Universal Health Coverage, Priority Setting, and the Human Right to Health”. The Lancet , v. 390, n. 10.095, 2017, pp. 712-4.). It is consistent with the goal of achieving UHC that countries begin their packages seeking sustainable and effective universal access to this second group of interventions (if they have not already done so) and progressively expand their coverage to include treatments in the first group. However, it would be unfair and counterproductive if the order of priorities was reversed (Ottersen et al., 2014Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.).

The identification of packages also brings transparency by making explicit the choices made by health systems. Users will know what their health care system have committed to providing. Transparency also allows accountability over what and how decisions are made and over spending plans and variations in the provision of services within a system. This all facilitates rights claims and reduces risks of favoritism, arbitrariness, corruption and discrimination in access.

The argument that explicit packages would violate SUS principles fails to acknowledge that Law 8.080/90, the SUS basic law, clarifies that the duty to providing “comprehensive care” is limited to the provision of drugs and services selected in clinical protocols and drugs lists prepared by sus itself. Such limitations do not violate the principles of universality and comprehensiveness; on the contrary, lists such as the Relação Nacional de Medicamentos Essenciais [National List of Essential Medicines, Rename] organize service provision, make public what the sus should offer to the population, and promote access and the rational use of health services. Therefore, delimiting the services offered is neither theoretically nor empirically incompatible with universal health systems.

UHC and the right to health

Alongside the criticisms of UHC already discussed, there is also an argument that UHC contradicts the idea of health as a human right (Castillo et al., 2017Castillo, Camilo Hernán Manchola; Volnei Garrafa, Thiago Cunha; Hellmann, Fernando. “El acceso a la salud como derecho humano en políticas internacionales: reflexiones críticas y desafíos contemporáneos”. Ciência & Saúde Coletiva , v. 22, n. 7, 2017, pp. 2.151-60.). This stems from the idea that the right to health, unlike UHC, presupposes the existence of a universal system along the lines of the sus; recognizes the right to access, rather than mere coverage; and guarantees the provision of services according to the needs of patients, and not those defined by limited service packages (Laurell, 2016______. “Competing Health Policies: Insurance against Universal Public Systems”. Revista Latino-Americana de Enfermagem, v. 24, n. 0, 2016, e2668.).

The argument that UHC runs counter to the human right to health is surprising, given that UHC publications closely link it to the right to health. UN General Assembly Resolutions 67/81 (2012) and 72/28 (2017), which propose and advocate UHC, affirm “the right of every human being to enjoy the highest attainable level of physical and mental health”, which is a direct reference to Article no. 12 of the United Nations Convention on Economic, Social and Cultural Rights (Chapman, 2016Chapman, Audrey R. “Assessing the Universal Health Coverage Target in the Sustainable Development Goals from a Human Rights Perspective”. BMC International Health and Human Rights , v. 16, n. 1, 2016, p. 33.). The most recent UN Sustainable Development Goals report emphasizes access to health care services as a fundamental right (UN, 2018______. Sustainable Development Goals Report 2018. New York: UN, 2018.).

The WHO states that UHC “is a practical expression of the concern for health equity and the right to health” (WHO, 2012______. Positioning Health in the Post-2015 Development Agenda - WHO Discussion Paper. Geneva: WHO, 2012.; Ooms et al., 2014______; Latif, Laila A.; Waris, Attiya; Brolan, Claire E.; Hammonds, Rachel; Friedman, Eric A.; Mulumba, Moses; Forman, Lisa. “Is Universal Health Coverage the Practical Expression of the Right to Health Care?”. BMC International Health and Human Rights, v. 14, n. 1, 2014.) and that “to support the goal of universal health coverage is […] honouring everyone’s right to health” (WHO, 2013______. The World Health Report 2013: Research for Universal Health Coverage. Geneva: WHO, 2013.). Tedros Ghebreyesus, Director-General of the WHO, is emphatic: UHC is a fundamental right (Ghebreyesus, 2017Ghebreyesus, Tedros Adhanom. “All Roads Lead to Universal Health Coverage”. The Lancet - Global Health, v. 5, n. 9, 2017, e839-40.). The same statement was made in a World Bank report (The World Bank, 2015______. Going Universal: How 24 Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up. Washington, DC: The World Bank, 2015.). There is also a vast literature on the proximity and overlap between UHC and the right to health. Although protecting the right to health may require more than UHC, it is unlikely that this right will be realized without removing financial barriers to universal access to health services (Chapman, 2016Chapman, Audrey R. “Assessing the Universal Health Coverage Target in the Sustainable Development Goals from a Human Rights Perspective”. BMC International Health and Human Rights , v. 16, n. 1, 2016, p. 33.; Gostin et al., 2019aGostin, Lawrence O.; Meier, Benjamin M.; Thomas, Rebekah; Magar, Veronica; Ghebreyesus, Tedros A. “70 Years of Human Rights in Global Health: Drawing on a Contentious Past to Secure a Hopeful Future”. The Lancet, v. 392, n. 10.165, 2019a, pp. 2.731-5.; Yamin; Maleche, 2017Yamin, Alicia Ely; Maleche, Allan. “Realizing Universal Health Coverage in East Africa: The Relevance of Human Rights”. BMC International Health and Human Rights , v. 17, n. 1, 2017, p. 21.; Ooms et al., 2013Ooms, Gorik; Brolan, Claire; Eggermont, Natalie; Eide, Asbjørn; Flores, Walter; Forman, Lisa; Friedman, Eric A. et al. “Universal Health Coverage Anchored in the Right to Health”. Bulletin of the World Health Organization , v. 91, n. 1, 2013, pp. 2-2A.). Furthermore, the recognition of the right to health in legislation has been defended as an important instrument for achieving UHC (Gostin et al., 2019b______; Monahan, John T.; Kaldor, Jenny; DeBartolo, Mary; Friedman, Eric A.; Gottschalk, Katie; Kim, Susan C. et al. “The Legal Determinants of Health: Harnessing the Power of Law for Global Health and Sustainable Development”. The Lancet, v. 393, n. 10.183, 2019b, pp. 1.857-910.).

The perceived opposition between UHC and the right to health is the result of a misunderstanding not only of UHC, but also of the right to health itself. General Comment no. 14 of the UN Commission for Economic, Social and Cultural Rights (UN/CESCR, 2000United Nations (UN), Committee on Economic, Social and Cultural Rights (CESCR). “General Comment n. 14: The Right to the Highest Attainable Standard of Health”. Geneva: UN, 2000. Available at: <Available at: https://digitallibrary.un.org/record/425041 >. Accessed on: Jul. 2, 2020.
https://digitallibrary.un.org/record/425...
) includes under the right to health availability and access without discrimination to affordable, quality health goods and services. This document also clarifies that, due to the scarcity of resources, health is a right subject to “progressive realization” and recommends that countries seek to identify the most cost-effective ways of using these resources in order to “not disproportionately favour expensive curative health services which are often accessible only to a small, privileged fraction of the population, rather than primary and preventive health care benefiting a far larger part of the population”. Therefore, UHC and the right to health in international law are very close in substance and language.

It could be argued that, although the UHC is compatible with the international right to health, it goes against the Brazilian Constitution, which recognizes the right to health based on a universal health system. However, as already discussed, the SUS model of universal health system is compatible with priority-setting. Although there are judicial interpretations that see the right to health as absolute and unlimited (Wang, 2013Wang, Daniel W. L. “Courts and Health Care Rationing: The Case of the Brazilian Federal Supreme Court”. Health Economics, Policy and Law, v. 8, n. 1, 2013, pp. 75-93.), the simple reading of Article no. 196 of the Federal Constitution shows that the principle of universality guarantees universal and equal access to health actions and services, but does not give SUS the duty to provide any and all treatment. The actions and services that should be provided by SUS are defined by infraconstitutional legislation (like Rename). Moreover, when establishing the principle of comprehensive and integrated care (Art. 198, II), the Constitution determines priority for preventive measures, explicitly recognizing the gradual realization of this right and the need to establish priorities.

CONCLUSION

There is no antagonism between UHC, the right to health and a universal health system. If this misconception persists, the public health scholarship in Brazil will deprive itself of the opportunity to participate in constructive debates around UHC that discuss, for example, the advantages and disadvantages of different types of health system for guaranteeing effective access, universality and protection from catastrophic expenditure; metrics, standards and methodologies for assessing and comparing the performance of different health systems; decision-making processes for accruing technical knowledge and social participation in decision-making; right-to-health and accountability mechanisms; and distributive justice in the funding of health care and in selecting health priorities.

This is a global dialogue to which Brazilian public health scholar have much to contribute, with its accumulated expertise after decades of constructing the sus. It is also a dialogue that can help it face a scenario of underfunding of the sus coupled with a huge increase in the price of private health insurance, which will force more and more people to choose between not receiving services or incurring catastrophic costs. This is exactly what a universal system, the right to health and UHC seek to avoid.3 3 Translated into English by Matthew Richmond. [E.N.]

REFERENCES

  • Abiiro, Gilbert Abotisem; De Allegri, Manuela. “Universal Health Coverage from Multiple Perspectives: A Synthesis of Conceptual Literature and Global Debates”. BMC International Health and Human Rights, v. 15, n. 1, 2015, p. 17.
  • Alonso, Nivaldo; Massenburg, Benjamin B.; Galli, Rafael; Sobrado, Lucas; Brolini, Dario. “Cirurgia no sistema brasileiro de saúde: financiamento e distribuição de médicos”. Revista do Colégio Brasileiro de Cirurgiões, v. 44, n. 2, 2017, pp. 202-7.
  • Anjali, Singh; Maulik, Choksi. “A realização do direito à saúde por meio da cobertura universal de saúde”. Revista de Direito Sanitário, v. 15, n. 2, 2015, p. 13.
  • Asociación Latinoamericana de Medicina Social. “Declaración de Alames frente al intento de absorber la APS en la, muy cuestionada, Cobertura Universal de Salud (UHC)”. Saúde em Debate, v. 42, n. esp., 2018, pp. 431-3.
  • Barros, Fernando Passos Cupertino de; Negri Filho, Armando de. “Cobertura universal de saúde”. Cadernos de Saúde Pública, v. 31, n. 6, 2015, p. 1.333.
  • Blanco, Silvana; Laurino, Carolina González; Toassi Ramona Fernanda Ceriotti; Abegg, Claides. “Assistência odontológica em programas sociais para populações socialmente vulneráveis na perspectiva do Programa Uruguay Trabaja”. Saúde e Sociedade, v. 27, n. 4, 2018, pp. 1.164-73.
  • Bonfim, Daiana; Laus, Ana Maria; Leal, Ana Emilia; Fugulin, Fernanda Maria Togeiro; Gaidzinski Raquel Rapone. “Application of the Workload Indicators of Staffing Need Method to Predict Nursing Human Resources at a Family Health Service”. Revista Latino-Americana de Enfermagem, v. 24, n. 0, 2016, e2683.
  • Bryant-Lukosius, Denise; Valaitis, Ruta; Martin-Misener, Ruht; Donald, Faith; Peña, Laura Morán; Brousseau, Linda. “Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health”. Revista Latino-Americana de Enfermagem , v. 25, n. 0, 2017, e2826.
  • Buss, Paulo Marchiori; Magalhães, Danielly de Paiva; Faraoni Freitas Setti, Andréia; Gallo, Edmundo; Franco Netto, Francisco de Abreu; Machado, Jorge Mesquita Huet; Buss, Daniel Forsin. “Saúde na agenda de desenvolvimento pós-2015 das Nações Unidas”. Cadernos de Saúde Pública , v. 30, n. 12, 2014, pp. 2.555-70.
  • Campos, Gastão Wagner de Sousa; Pereira Júnior, Nilton. “A atenção primária e o Programa Mais Médicos do Sistema Único de Saúde: conquistas e limites”. Ciência & Saúde Coletiva, v. 21, n. 9, 2016, pp. 2.655-63.
  • Cassiani, Silvia Helena de Bortoli. “Strategy for Universal Access to Health and Universal Health Coverage and the Contribution of the International Nursing Networks”. Revista Latino-Americana de Enfermagem , v. 22, n. 6, 2014, pp. 891-2.
  • ______; Bassalobre-Garcia, Alessandra; Reveiz, Ludovic. “Universal Access to Health and Universal Health Coverage: Identification of Nursing Research Priorities in Latin America”. Revista Latino-Americana de Enfermagem, v. 23, n. 6, 2015, pp. 1.195-208.
  • ______; Wilson, Lynda Law; Mikael, Sabrina de Souza Elias; Peña, Laura Morán; Grajales, Rosa Amarilis Zarate; McCreary, Linda L.; Theus, Lisa et al. “The Situation of Nursing Education in Latin America and the Caribbean towards Universal Health”. Revista Latino-Americana de Enfermagem, v. 25, n. 0, 2017, e2913.
  • Castillo, Camilo Hernán Manchola; Volnei Garrafa, Thiago Cunha; Hellmann, Fernando. “El acceso a la salud como derecho humano en políticas internacionales: reflexiones críticas y desafíos contemporáneos”. Ciência & Saúde Coletiva , v. 22, n. 7, 2017, pp. 2.151-60.
  • Chan, Wai Yee; Fung, Ita M.; Chan, Eric; Chan, Wai Yee. “Universal Health Coverage through Community Nursing Services: China vs. Hong Kong”. Revista Latino-Americana de Enfermagem , v. 25, n. 0, 2017, e2838.
  • Chapman, Audrey R. “Assessing the Universal Health Coverage Target in the Sustainable Development Goals from a Human Rights Perspective”. BMC International Health and Human Rights , v. 16, n. 1, 2016, p. 33.
  • Conselho Nacional de Secretários de Saúde (CONASS). Caminhos da saúde no Brasil. Brasília: CONASS, 2014.
  • Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes). “Relatório de Avaliação - Enfermagem”. Avaliação quadrienal 2017. Brasília: Capes, 2017a. Available at: <Available at: https://www.capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-ENFERMAGEM-quadrienal.pdf >. Accessed on: Jul. 3, 2020.
    » https://www.capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-ENFERMAGEM-quadrienal.pdf
  • ______. “Relatório de Avaliação - Saúde Coletiva”. Avaliação quadrienal 2017. Brasília: Capes, 2017b. Available at: <https://capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-SAUDE-COLETIVA-quadrienal.pdf>. Accessed on: Jul. 3, 2020.
    » https://capes.gov.br/images/stories/download/avaliacao/relatorios-finais-quadrienal-2017/20122017-SAUDE-COLETIVA-quadrienal.pdf
  • Covre, E. R.; Melo, W. A.; Tostes, M. F. P. “Tendência de internações e mortalidade por causas cirúrgicas no Brasil, 2008 a 2016”. Revista do Colégio Brasileiro de Cirurgiões , v. 46, n. 1, 2019, e1978.
  • Crews, Deidra C.; Bello, Aminu K.; Saadi, Gamal. “Burden, Access, and Disparities in Kidney Disease”. Nephron, v. 141, n. 4, 2019, pp. 219-26.
  • Crossetti, Maria da Graça Oliveira; Goes, Marta Georgina Oliveira de. “Revista Gaúcha de Enfermagem: contribuição ao acesso universal à saúde e cobertura universal de saúde”. Revista Gaúcha de Enfermagem, v. 37, n. 4, 2016, e70485.
  • De Paz, C.; Valentine, N. B.; Hosseinpoor, A. R.; Koller, T. S.; Gerecke, M. Intersectoral Factors Influencing Equity-Oriented Progress towards Universal Health Coverage: Results from a Scoping Review of Literature. Geneva: World Health Organization, 2017.
  • Dussault, Gilles. “A ligação em falta no caminho para a cobertura universal de saúde: a gestão”. Ciência & Saúde Coletiva , v. 20, n. 10, 2015, p. 2.930.
  • Fernandes, Ananda Maria; Mendes, Aida Maria de Oliveira Cruz; Leitão, Maria Neto da Cruz; Gomes, Maria Neto da Cruz; Amaral, António Fernando Salgueiro; Bento, Maria da Conceição Saraiva da Silva Costa et al. “The Contribution of Portuguese Nursing to Universal Health Access and Coverage”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2671.
  • França, Viviane Helena de; Modena, Celina Maria; Confalonieri, Ulisses Eugenio Cavalcanti. “A Multiprofessional Perspective on the Principal Barriers to Universal Health Coverage and Universal Access to Health in Extremely Poor Territories: The Contributions of Nursing”. Revista Latino-Americana de Enfermagem , v. 24, v. 0, 2016, e2795.
  • Gaudenzi, Paula; Schramm, Fermin Roland. “A transição paradigmática da saúde como um dever do cidadão: um olhar da bioética em saúde pública”. Interface: Comunicação, Saúde, Educação, v. 14, n. 33, 2010, pp. 243-55.
  • General Assembly of the United Nations. Resolution 67/81. Geneva, 2012. Available at: <Available at: https://undocs.org/en/A/RES/67/81 >. Accessed on: Jul. 6, 2020.
    » https://undocs.org/en/A/RES/67/81
  • ______. Resolution 72/28. Geneva, 2017. Available at: <https://undocs.org/en/A/RES/72/28>. Accessed on: Jul. 6, 2020.
    » https://undocs.org/en/A/RES/72/28
  • Ghebreyesus, Tedros Adhanom. “All Roads Lead to Universal Health Coverage”. The Lancet - Global Health, v. 5, n. 9, 2017, e839-40.
  • Giovanella, Lígia; Feo, Oscar; Faria, Mariana; Tobar, Sebastián. Sistemas de salud en Suramérica: desafíos para la universalidad, la integralidad y la equidad. Rio de Janeiro: ISAGS, 2012.
  • ______; Mendoza-Ruiz, Adriana; Pilar, Aline de Carvalho Amand; Rosa, Matheus Cantanhêde da; Martins, Gabrieli Branco; Santos, Isabela Soares; Silva, Danielle Barata et al. “Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias”. Ciência & Saúde Coletiva, v. 23, n. 6, 2018, pp. 1.763-76.
  • ______; Rizzotto, Maria Lucia Frizon. “Atenção primária à saúde: da Declaração de Alma-Ata à Carta de Astana”. Saúde em Debate, v. 42, n. sp. 1, 2018, pp. 6-8.
  • ______; Stegmüller, Klaus. “The Financial Crisis and Health Care Systems in Europe: Universal Care under Threat? Trends in Health Sector Reforms in Germany, the United Kingdom, and Spain”. Cadernos de Saúde Pública, v. 30, n. 11, 2014, pp. 2.263-81.
  • Gostin, Lawrence O.; Meier, Benjamin M.; Thomas, Rebekah; Magar, Veronica; Ghebreyesus, Tedros A. “70 Years of Human Rights in Global Health: Drawing on a Contentious Past to Secure a Hopeful Future”. The Lancet, v. 392, n. 10.165, 2019a, pp. 2.731-5.
  • ______; Monahan, John T.; Kaldor, Jenny; DeBartolo, Mary; Friedman, Eric A.; Gottschalk, Katie; Kim, Susan C. et al. “The Legal Determinants of Health: Harnessing the Power of Law for Global Health and Sustainable Development”. The Lancet, v. 393, n. 10.183, 2019b, pp. 1.857-910.
  • Guerrero-Núñez, Sara; Valenzuela-Suazo, Sandra; Cid-Henríquez, Patricia. “Effective Universal Coverage of Diabetes Mellitus Type 2 in Chile”. Revista Latino-Americana de Enfermagem , v. 25, n. 0, 2017, e2871.
  • Heimann, Luiza Sterman; Ibanhes, Lauro Cesar; Boaretto, Roberta Cristina; Nascimento Castro, Iracema Ester do; Telesi Júnior, Emilio; Cortizo, Carlos Tato; Rodrigues Fausto, Márcia Cristina; Nascimento, Vânia Barbosa do; Kayano, Jorge. “Atenção primária em saúde: um estudo multidimensional sobre os desafios e potencialidades na região metropolitana de São Paulo (SP, Brasil)”. Ciência & Saúde Coletiva , v. 16, n. 6, 2011, pp. 2.877-87.
  • Hogan, Daniel R.; Stevens, Gretchen A.; Hosseinpoor, Ahmad Reza; Boerma, Ties. “Monitoring Universal Health Coverage within the Sustainable Development Goals: Development and Baseline Data for an Index of Essential Health Services”. The Lancet - Global Health , v. 6, n. 2, 2018, e152-68.
  • Horton, Richard. “UHC - One Promise and Two Misunderstandings”. The Lancet , v. 391, n. 10.128, 2018, p. 1.342.
  • Jamison, Dean T.; Summers, Lawrence H.; Alleyne, George; Arrow, Kenneth J.; Berkley, Seth; Binagwaho, Agnes; Bustreo, Flavia et al. “Global Health 2035: A World Converging within a Generation”. The Lancet , v. 382, n. 9.908, 2013, pp. 1.898-955.
  • Kamei, Tomoko; Takahashi, Keiko; Omori, Junko; Arimori, Naoko; Hishinuma, Michiko; Asahara, Kiyomi; Shimpuku, Yoko; Ohashi, Kumiko; Tashiro, Junko. “Prática avançada de enfermagem e a parceria de cuidados centrados nas pessoas para a cobertura de saúde universal sustentável e o acesso universal à saúde”. Revista Latino-Americana de Enfermagem , v. 25, 2017, e2839.
  • Kelles, Silvana Márcia Bruschi; Machado, Carla Jorge; Barreto, Sandhi Maria. “Ten-Years of Bariatric Surgery in Brazil: In-Hospital Mortality Rates for Patients Assisted by Universal Health System or a Health Maintenance Organization”. ABCD - Arquivos Brasileiros de Cirurgia Digestiva, v. 27, n. 4, 2015, pp. 261-7.
  • Kutzin, Joseph. “Anything Goes on the Path to Universal Coverage? No”. Bulletin of the World Health Organization, v. 90, n. 11, 2012, pp. 867-8.
  • ______. “Health Financing for Universal Coverage and Health System Performance: Concepts and Implications for Policy”. Bulletin of the World Health Organization, v. 91, n. 8, 2013, pp. 602-11.
  • Laurell, Asa Ebba Cristina. “Los seguros de salud mexicanos: cobertura universal incierta”. Ciência & Saúde Coletiva , v. 16, n. 6, 2011, pp. 2.795-806.
  • ______. “Competing Health Policies: Insurance against Universal Public Systems”. Revista Latino-Americana de Enfermagem, v. 24, n. 0, 2016, e2668.
  • Maaitah, Rowaida Al; AbuAlRub, Raeda Fawzi. “Exame das ações prioritárias para o fortalecimento do papel das enfermeiras para conseguir a cobertura universal em saúde”. Revista Latino-Americana de Enfermagem , v. 25, 2017, e2819.
  • Magno, Liz Duque. “Dos clamores das ruas aos rumores no congresso: uma análise da conjuntura recente da saúde no Brasil”. RECIIS, v. 9, n. 4, 2015, pp. 1-14.
  • Malta, Deborah Carvalho; Santos, Maria Aline Siqueira; Stopa, Sheila Rizzato; Vieira, José Eudes Barroso; Melo, Eduardo Alves; Reis, Ademar Arthur Chioro dos. “A cobertura da estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013”. Ciência & Saúde Coletiva , v. 21, n. 2, 2016, pp. 327-38.
  • Martin, Danielle; Miller, Ashley P.; Quesnel-Vallée, Amélie; Caron, Nadine R.; Vissandjée, Bilkis; Marchildon, Gregory P. “Canada’s Universal Health-Care System: Achieving Its Potential”. The Lancet , v. 391, n. 10.131, 2018, pp. 1.718-35.
  • Marziale, Maria Helena Palucci. “Universal Access to Health and Universal Health Coverage: Nursing Contributions”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2667.
  • Medici, André Cezar. Do global ao local: os desafios da saúde no limiar do século XXI. Belo Horizonte: Coopmed, 2011.
  • Mendes, Isabel Amélia Costa; Ventura, Carla Aparecida Arena; Trevizan, Maria Auxiliadora; Marchi-Alves, Leila Maria; Souza-Junior, Valtuir Duarte de. “Education, Leadership and Partnerships: Nursing Potential for Universal Health Coverage”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e267.
  • Mendoza-Parra, Sara. “Coverage, Universal Access and Equity in Health: A Characterization of Scientific Production in Nursing”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2669.
  • Mishima, Silvana Martins; Campos, Ana Carolina; Matumoto, Silvia; Fortuna, Cinira Magali. “Client Satisfaction from the Perspective of Responsiveness: Strategy for Analysis of Universal Systems?”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2674.
  • Mitano, Fernando; Ventura, Carla Aparecida Arena; Lima, Mônica Cristina Ribeiro Alexandre d’Auria de; Balegamire, Juvenal Bazilashe; Palha, Pedro Fredemir. “Right to Health: (In)Congruence between the Legal Framework and the Health System”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2679.
  • National Institute for Health and Care Excellence. The Guidelines Manual, 2012.
  • ______. Guide to the Processes of Technology Appraisal, National Institute for Health and Care Excellence, 2018.
  • Noronha, José Carvalho de. “Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios”. Cadernos de Saúde Pública , v. 29, n. 5, 2013, pp. 847-9.
  • Ocké-Reis, Carlos Octávio. “Cobertura universal de saúde: inclusão ou exclusão?”. Boletim de Análise Político-institucional, v. 9, 2016, pp. 19-26.
  • Ooms, Gorik; Brolan, Claire; Eggermont, Natalie; Eide, Asbjørn; Flores, Walter; Forman, Lisa; Friedman, Eric A. et al. “Universal Health Coverage Anchored in the Right to Health”. Bulletin of the World Health Organization , v. 91, n. 1, 2013, pp. 2-2A.
  • ______; Latif, Laila A.; Waris, Attiya; Brolan, Claire E.; Hammonds, Rachel; Friedman, Eric A.; Mulumba, Moses; Forman, Lisa. “Is Universal Health Coverage the Practical Expression of the Right to Health Care?”. BMC International Health and Human Rights, v. 14, n. 1, 2014.
  • Organization for Economic Co-operation and Development. Universal Health Coverage and Health Outcomes - Final Report, 2016.
  • Ottersen, Rygve; Norheim, Ole F.; Chitah, Bona M.; Cookson, Richard; Daniels, Norman; Defaye, Frehiwot B.; Eyal, Nir et al. Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage, 2014.
  • Oxfam. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxford: Oxfam, 2013.
  • Pilotto, Luciane Maria; Celeste, Roger Keller. “Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013”. Cadernos de Saúde Pública , v. 34, n. 4, 2018, e00052017.
  • Rovere, Mario. “La atención primaria en la encrucijada: desplegar su potencial transformador o quedar instrumentados en una nueva ofensiva privatizadora”. Saúde em Debate , v. 42, special issue, 2018, pp. 315-27.
  • Rumbold, Benedict; Baker, Rachel; Ferraz, Octavio; Hawkes, Sarah; Krubiner, Carleigh; Littlejohns, Peter; Norheim, Ole F. et al. “Universal Health Coverage, Priority Setting, and the Human Right to Health”. The Lancet , v. 390, n. 10.095, 2017, pp. 712-4.
  • Santana, Vilma Sousa; Araújo, Gustavo Ribeiro de; Espírito-Santo, Jônatas Silva do; Araújo-Filho, José Bouzas de; Iriart, Jorge. “A utilização de serviços de saúde por acidentados de trabalho”. Revista Brasileira de Saúde Ocupacional, v. 32, n. 115, 2007, pp. 135-44.
  • Schveitzer, Mariana Cabral; Zoboli, Elma Lourdes Campos Pavone; Vieira, Margarida Maria da Silva. “Nursing Challenges for Universal Health Coverage: A Systematic Review”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2676.
  • Scochi, Carmen Gracinda Silvan; Gelbcke, Francine Lima; Ferreira, Márcia de Assunção; Alvarez, Ângela Maria. “Mestrado profissional: potencial contribuição para a enfermagem de prática avançada”. Revista Brasileira de Enfermagem, v. 68, n. 6, 2015, pp. 1.186-9.
  • Sena, T. S.; Costa, M. L. “Reflexões sobre a inserção da temática gestão da clínica na formação profissional em saúde”. Revista Brasileira de Educação Médica, v. 40, n. 2, 2016, pp. 278-85.
  • Soranz, Daniel; Pisco, Luís Augusto Coelho. “Reforma dos cuidados primários em saúde na cidade de Lisboa e Rio de Janeiro: contexto, estratégias, resultados, aprendizagem, desafios”. Ciência & Saúde Coletiva , v. 22, n. 3, 2017, pp. 679-86.
  • The World Bank. Universal Health Coverage for Inclusive and Sustainable Development - Country Summary Report for Brazil, 2014.
  • ______. Going Universal: How 24 Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up. Washington, DC: The World Bank, 2015.
  • Tostes, Maria Fernanda do Prado; Covre, Eduardo Rocha; Fernandes, Carlos Alexandre Molena. “Access to Surgical Assistance: Challenges and Perspectives”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2677.
  • Tung, Fabian Ling Ngai; Yan, Vincent Chun Man; Tai, Winnie Ling Yin; Chen, Jing Han; Chung, Joanne Wai-yee; Wong, Thomas Kwok Shing et al. “Nurses’ Knowledge of Universal Health Coverage for Inclusive and Sustainable Elderly Care Services”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2670.
  • Uchôa, Severina Alice da Costa; Arcêncio, Ricardo Alexandre; Fronteira, Inês; Coêlho, Ardigleusa Alves; Martiniano, Claudia Santos; Brandão, Isabel Cristina Araújo; Yamamura, Mellina et al. “Potential Access to Primary Health Care: What Does the National Program for Access and Quality Improvement Data Show?”. Revista Latino-Americana de Enfermagem , v. 24, n. 0, 2016, e2672.
  • Unicef. Unicef Approach to Health System Strenghtening. New York: Unicef, 2016.
  • United Nations (UN), Committee on Economic, Social and Cultural Rights (CESCR). “General Comment n. 14: The Right to the Highest Attainable Standard of Health”. Geneva: UN, 2000. Available at: <Available at: https://digitallibrary.un.org/record/425041 >. Accessed on: Jul. 2, 2020.
    » https://digitallibrary.un.org/record/425041
  • ______. Sustainable Development Goals Report 2018. New York: UN, 2018.
  • Uribe-Gómez, Monica. “Nuevos cambios, viejos esquemas: las políticas de salud en México y Colombia en los años 2000”. Cadernos de Saúde Pública , v. 33, n. 2, 2017, e00112616.
  • Vieira Junior, Wilson Marques; Martins, Mônica. “Idosos e planos de saúde no Brasil: análise das reclamações recebidas pela Agência Nacional de Saúde Suplementar”. Ciência & Saúde Coletiva , v. 20, n. 12, 2015, pp. 3.817-26.
  • Wang, Daniel W. L. “Courts and Health Care Rationing: The Case of the Brazilian Federal Supreme Court”. Health Economics, Policy and Law, v. 8, n. 1, 2013, pp. 75-93.
  • Watkins, David A.; Jamison, Dean T.; Mills, Anne; Atun, Rifat; Danforth, Kristen; Glassman, Amanda; Horton, Susan; Jha, Prabhat; Kruk, Margaret E.; Norheim, Ole F.; Qi, Jinyuan; Soucat, Agnes; Verguet, Stéphane; Wilson, David; Alwan, Ala. “Universal Health Coverage and Essential Packages of Care”. In: Jamison, Dean T.; Gelband, Hellen; Horton, Susan; Jha, Prabhat; Laxminarayan, Ramanan; Mock, Charles N.; Nugent, Rachel (Eds.). Disease Control Priorities: Improving Health and Reducing Poverty. The World Bank, 2017.
  • World Health Assembly (WHA). Resolution 58.33, Ninth Plenary Meeting. Geneva: WHA, 2015.
  • World Health Organization (WHO). The World Health Report - Health Systems Financing: The Path to Universal Coverage. Geneva: WHO, 2010a.
  • ______. World Health Report 2010 - Health Systems Financing: the Path to Universal Coverage. Geneva: WHO, 2010b. Available at: <https://www.who.int/whr/2010/en>. Accessed on: Jul. 3, 2020.
    » https://www.who.int/whr/2010/en
  • ______. Positioning Health in the Post-2015 Development Agenda - WHO Discussion Paper. Geneva: WHO, 2012.
  • ______. The World Health Report 2013: Research for Universal Health Coverage. Geneva: WHO, 2013.
  • ______. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: WHO, 2015.
  • ______. Universal Health Coverage. WHO Fact Sheets. Geneva: WHO, 2019. Available at: <https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)>. Accessed on: Jul. 4, 2020.
    » https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)
  • ______; International Bank for Reconstruction and Development (IBRD)/The World Bank. Tracking Universal Health Coverage: 2017. Global Monitoring Report. Geneva: WHO, 2017. Available at: <https://www.who.int/healthinfo/universal_health_coverage/report/2017/en>. Accessed on: Jul. 4, 2020.
    » https://www.who.int/healthinfo/universal_health_coverage/report/2017/en
  • ______; Organization for Economic Co-operation and Development; The World Bank. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Geneva: WHO, 2018. Available at: <https://apps.who.int/iris/handle/10665/272465>. Accessed on: Jul. 4, 2020.
    » https://apps.who.int/iris/handle/10665/272465
  • Yamin, Alicia Ely; Maleche, Allan. “Realizing Universal Health Coverage in East Africa: The Relevance of Human Rights”. BMC International Health and Human Rights , v. 17, n. 1, 2017, p. 21.
  • Zug, Keri Elizabeth; Cassiani, Silvia Helena De Bortoli; Pulcini, Joyce; Bassalobre Garcia, Alessandra; Aguirre-Boza, Francisca; Park, Jeongyoung. “Enfermagem de prática avançada na América Latina e no Caribe: regulação, educação e prática”. Revista Latino-Americana de Enfermagem , v. 24, 2016, e2807.

  • 1
    The author is grateful to Elize Massard da Fonseca, Fabíola Sulpino Vieira and Giuliano Russo for comments on previous versions of this paper. The author is also indebted to Leonardo Nochang Heck for his research assistance. This research was funded by the São Paulo Research Foundation (Grant ID: 2019/15565-0).
  • 2
  • 3
    Translated into English by Matthew Richmond. [E.N.]

Publication Dates

  • Publication in this collection
    15 Jan 2021
  • Date of issue
    Sep-Dec 2020

History

  • Received
    19 June 2019
  • Accepted
    04 June 2020
Centro Brasileiro de Análise e Planejamento Rua Morgado de Mateus, 615, CEP: 04015-902 São Paulo/SP, Brasil, Tel: (11) 5574-0399, Fax: (11) 5574-5928 - São Paulo - SP - Brazil
E-mail: novosestudos@cebrap.org.br