The Long Road to Universal Health Coverage: Historical Analysis of Early Decisions in Germany, the United Kingdom, and the United States.

Abstract-Over the last several years the once-obscure idea of Universal Health Coverage (UHC) has blossomed into a movement embraced by leading authorities in global health. Both the World Bank and the World Health Organization have designated UHC as a core objective, but many details of this concept have yet to be specified, including the political economy process by which countries can increase financial protection to move toward UHC. Using an analysis of historical literature, this paper examines the development of the two common mechanisms for providing financial risk protection: national social health insurance as developed in Germany, and general tax revenue as used by the United Kingdom to launch the National Health Service. Because of the prominence of organized labor groups in demanding increased financial protection in these two cases, the paper then considers a comparison case from the Progressive Era in the United States where labor groups were far less engaged. Based on the categories used in the historical literature, I develop a framework for comparing the cases in six areas: related legal and cultural heritage; macro-historical conditions; demand for increased social protection; politics of expanding government role in health; financing and delivery systems; and UHC-related outcomes. The paper concludes with some reflections from this analysis for low- and middle-income countries attempting to move toward UHC.