Article by Harvard School of Public HealthKaren Feldscher– September 13, 2013

September 13, 2013 — Countries that are wealthy, have less income inequality, and whose citizens have the highest educational levels are the most likely to develop universal health care systems, according to new research from Harvard School of Public Health (HSPH). The study also found that countries run by dictators or those with high levels of ethnic fractionalization are less likely than others to implement universal health care.

The new findings are part of a comprehensive analysis by first authorAndrea Feigl, a doctoral candidate in the HSPH Department of Global Health and Population, and senior author Eric Ding, research scientist in the HSPH Department of Nutrition. As part of their research, Feigl and Ding developed a standardized index for assessing universal health care coverage, and then calculated the likelihood that a particular country will successfully develop and achieve universal health care over time.

The study appeared online August 1, 2013 in Health PolicyRead the abstract.

“This new index and analysis can boost understanding of the economic, social, and political drivers of universal health care,” said Feigl. “It could be particularly useful for transitioning countries as they seek to expand health care coverage for their citizens.”

Feigl and Ding analyzed a century’s worth of data (from 1880 to 2008) from 194 countries. Using a new index dubbed the Evidenced Formal Coverage (EFC) index, they classified countries as having “evidence of formal coverage” if they had a combination of legislated universal health care, had formal coverage for 85% or more of the population, and if access to skilled attendance at birth—a widely accepted indicator of health system capacity—was 90% or higher.

The researchers found that a total of 74 out of the 194 countries had legislatively approved universal health care coverage, but only a subset of 51 out of these 74 countries had achieved universal health care according to their EFC index.

In looking at the economic, social, and political factors that can predict a country’s success over time in achieving universal health care, Feigl and Ding found that, among all of the countries they examined, a doubling in gross domestic product (GDP) per capita was associated with a 77% increase in achieving universal health care. Moreover, focusing on just middle-income countries, they found an even stronger association—a 150% increased likelihood of developing universal health care with a doubling in GDP.

Educational levels were also a major predictor of a country’s likelihood of providing universal health care. Each 20% increase in the primary school completion rate was linked with a 2.3-fold increase in the likelihood of achieving universal health care; each 20% increase in the literacy rate boosted the likelihood 22-fold. These education-related effects were independent and separate from the GDP effects.

Income equality also plays a big role in whether or not a country will achieve universal health care. Using the GINI coefficient—a measurement of unequal wealth distribution—the researchers found that for each doubling of the GINI coefficient (greater inequality), the likelihood of universal health care development decreased by 72%.

In terms of political predictors, Feigl and Ding found that both democracy and proportional political representation were major factors in determining whether or not a country was likely to achieve universal health care. If a country had proportional representation, it was nearly three times as likely to have universal health care as countries without such a system; if a country was a democracy as opposed to a dictatorship, the likelihood jumped 10-fold.

The researchers also found that, for each 25% increase in ethnic fractionalization in a country, the likelihood of achieving universal health care dropped by 49%.

Feigl’s advice for low-income countries interested in achieving universal health coverage? “It might be best to have focused health goals—such as reducing maternal mortality and improving child health—in addition to focusing on development,” she said.

She added, “However, a narrow focus on GDP growth alone is insufficient for achieving universal health care—as economic growth needs to be coupled with income equality, simultaneous educational attainment, and progress towards democracy. Each of these factors are important independently of GDP, and might be the best preconditions for a rising lower- or middle-income country to achieve universal health care in the future.”