Universal Health Coverage, Equity and Ethics

Introduction and Context

Universal health coverage (UHC) means that all people can obtain the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, without suffering financial hardship. It is both a health-system aspiration and a policy commitment. UHC does not mean that every possible service is provided free of charge, nor does it imply identical treatment for every person. Rather, it requires deliberate decisions about which services are covered, who is protected, how services are financed and how competing claims are ethically prioritised.

UHC has become central to global health policy because illness and health-care costs reinforce poverty, while unequal access reflects social, economic, geographic and political disadvantage. The Sustainable Development Goals place UHC within the broader aim of achieving health and well-being for all. However, progress is uneven. Countries may expand insurance enrolment while leaving people exposed to co-payments, medicine costs, informal payments or poor-quality care. Consequently, coverage must be assessed in terms of access, quality, equity and financial protection rather than enrolment alone.

For health-care managers, UHC is a strategic problem involving resource allocation, purchasing, provider organisation, regulation, workforce planning, data governance and public accountability. For policy-makers, it raises questions of distributive justice: which needs should receive priority when resources are limited, and what constitutes a fair process for making those choices?

Learning Objectives

By the end of this chapter, students should be able to:

1. Explain the dimensions and policy significance of UHC.
2. Distinguish equality from equity and relate both to health-system design.
3. Evaluate benefit packages, financing arrangements and catastrophic expenditure.
4. Analyse the needs of vulnerable populations, including women, migrants and people facing discrimination.
5. Apply ethical theories and priority-setting frameworks to coverage decisions.
6. Design governance arrangements that respect human rights, transparency and accountability.
7. Assess managerial strategies for advancing equitable coverage.

1. The Architecture of Universal Health Coverage

UHC is commonly represented through three dimensions:

• Population coverage: who is entitled to services.
• Service coverage: which interventions are included and at what level of quality.
• Financial protection: the extent to which people are protected from direct payment and economic hardship.

These dimensions are interdependent. A country can achieve broad population enrolment but provide a narrow package. It can offer a generous package on paper but fail to make medicines, staff or facilities available. It can provide services without fees but still impose substantial transport, accommodation, diagnostic or opportunity costs.

A useful policy question is therefore not simply “How many people are insured?” but “Who receives which effective services, with what financial consequences, and with what degree of dignity and quality?”

Coverage and effective coverage

Nominal coverage refers to legal entitlement or registration. Effective coverage refers to receipt of services that improve health and meet acceptable quality standards. The distinction is important for rural populations, people with disabilities, migrants, and groups facing language or cultural barriers. A person may possess an insurance card yet be unable to obtain a specialist referral, essential medicine or respectful maternity care.

Health-system performance should therefore be examined along a chain:

Need → access → use → quality → health benefit → financial consequence

Failure at any stage can produce inequitable outcomes. Monitoring should disaggregate results by income, sex, age, disability, residence, ethnicity, migration status and other relevant characteristics, while protecting privacy.

2. Equality, Equity and Social Justice

Equality means treating people in the same way or distributing resources equally. Equity means responding fairly to differences in need and disadvantage. Equal funding per person may be inequitable if remote communities have higher transport costs, greater disease burdens or fewer health professionals. Equity may require additional resources for those facing greater barriers.

Three distinctions are especially useful:

1. Horizontal equity: people with equal health needs should receive comparable access and treatment.
2. Vertical equity: people with unequal needs should receive appropriately different support.
3. Health equity: avoidable and unfair differences in health outcomes or access should be reduced.

Equity is not the same as equal outcomes in every circumstance. Health is influenced by education, housing, employment, nutrition, environment and discrimination. Health policy can reduce unfair differences, but health systems cannot alone eliminate all social inequality.

Proportionate universalism

A practical approach is proportionate universalism: provide universal services while allocating intensity and resources in proportion to disadvantage. For example, a national primary-care programme may be available to everyone, while remote areas receive enhanced staffing, transport support and outreach. This avoids the exclusion that can arise from narrowly targeted schemes while recognising unequal need.

Intersectionality

People may experience overlapping disadvantages. A migrant woman with a disability, insecure employment and limited language proficiency may face barriers that are not captured by considering migration, gender or disability separately. Intersectional analysis asks how institutions and policies interact to produce cumulative disadvantage. It is particularly important in eligibility rules, communication, safeguarding and service design.

3. Benefit-Package Design and Priority Setting

A benefit package defines the services, medicines, diagnostics and forms of care to which a population is entitled. It is a central instrument of health policy because no country can provide every beneficial intervention immediately and without limits.

Principles for designing a benefit package

A credible package should be:

• Evidence-informed: based on effectiveness, safety and quality evidence.
• Needs-responsive: aligned with population disease burden and unmet need.
• Cost-conscious: attentive to opportunity costs and fiscal sustainability.
• Equity-oriented: designed to avoid worsening disparities.
• Acceptable: consistent with public values and legitimate participation.
• Administratively feasible: capable of being delivered and monitored.
• Explicit: clear about entitlements, exclusions and appeal routes.

Benefit design should consider the complete care pathway. Covering diagnosis without treatment, or hospital surgery without rehabilitation, may create an incomplete and inequitable entitlement. Medicines and transport can be decisive components of effective coverage.

Health technology assessment

Health technology assessment (HTA) systematically evaluates the clinical, economic, ethical, organisational and social consequences of technologies. It may examine medicines, devices, diagnostics, procedures or service models. Cost-effectiveness is relevant but should not be the sole criterion. A technology with a favourable average cost-effectiveness ratio may benefit mainly affluent urban groups, while a less efficient intervention may address severe disadvantage or a neglected condition.

The incremental cost-effectiveness ratio is commonly expressed as:

Here, C₁ and C₀ are the costs of a new and comparator intervention, respectively, and E₁ and E₀ are their corresponding health outcomes, such as quality-adjusted life-years (QALYs) or disability-adjusted life-years (DALYs) averted. Costs must use the same currency and time basis, and effects must use the same outcome measure. The ratio is meaningful only when the comparator, perspective, time horizon, discounting and uncertainty are specified. It should not be interpreted as an automatic coverage decision.

For example, if a new programme costs $12 million and the existing programme costs $8 million, while outcomes are 50,000 and 40,000 QALYs respectively:

This result describes additional cost per additional QALY; it does not by itself establish that the programme is affordable, equitable or ethically acceptable.

Priority-setting frameworks

Common approaches include:

• Utilitarianism: maximise total health benefit.
• Prioritarianism: give greater moral weight to benefits for the worst-off.
• Egalitarianism: reduce unjust inequalities or secure equal opportunity.
• Sufficientarianism: ensure everyone reaches a minimum threshold of health or access.
• Rights-based approaches: protect legally and morally recognised entitlements, including non-discrimination and emergency care.
• Fair process: emphasise transparency, relevant reasons, reviewability and participation.

In practice, countries use pluralistic frameworks. A transparent multi-criteria decision process may consider severity, effectiveness, cost, equity, financial risk protection, feasibility and public values.

Accountability for reasonableness

A legitimate priority-setting process should satisfy four conditions:

1. Publicity: decisions and reasons are publicly accessible.
2. Relevance: reasons are based on evidence and principles that fair-minded people can accept.
3. Revision and appeal: decisions can be challenged when evidence or circumstances change.
4. Enforcement: an authority ensures that the process is followed.

This framework recognises that disagreement is unavoidable. Ethical legitimacy depends not on eliminating disagreement but on ensuring that decisions are reasoned, inclusive and contestable.

4. Financing and Catastrophic Expenditure

Health financing has three principal functions: revenue raising, pooling and purchasing. Prepayment and pooling spread risk across people and time. Tax-funded systems, social health insurance and regulated compulsory insurance can support solidarity more effectively than fragmented voluntary schemes, particularly where informal employment is widespread.

Out-of-pocket payment at the point of care can deter needed use and expose households to hardship. Financial protection includes protection against both immediate medical payment and indirect economic consequences such as transport, lost wages and long-term care.

A simplified measure of household out-of-pocket spending is:

where OOP is total out-of-pocket expenditure and i indexes each health-care episode. The measure should specify whether it includes medicines, transport, accommodation, informal payments and foregone income.

Catastrophic expenditure is commonly assessed by comparing out-of-pocket spending with a household’s capacity to pay. One formulation is:

where CFPᵢ is the financial-burden ratio for household i, OOPᵢ is out-of-pocket spending, Tᵢ is total household resources and Sᵢ is spending required for basic subsistence. A household is classified as experiencing catastrophic expenditure when CFPᵢ exceeds a specified threshold. The threshold is a policy convention, not a universal natural constant; analysis should report the threshold, resource definition and data limitations.

A household with monthly resources of $1,000, subsistence needs of $700 and health spending of $120 has:

If the selected threshold is 40%, the household is at the threshold. The result does not indicate whether the household delayed care, borrowed money or sold assets. Therefore, financial-protection monitoring should combine incidence with impoverishment, unmet need and coping strategies.

Policy instruments for financial protection

Effective instruments include progressive taxation, risk-adjusted pooling, exemptions for low-income households, free essential medicines, maximum co-payment limits, transport support and strategic purchasing. Exemptions must be simple to claim and automatically applied where possible. Complex means testing can exclude eligible people and increase administrative costs.

5. Vulnerable and Underserved Populations

Vulnerability is not an inherent characteristic of a group; it is produced or intensified by exposure to risk, limited resources, discrimination and weak institutional protection. Policies should identify barriers rather than label populations as intrinsically vulnerable.

Gender and sex

Gender affects exposure to illness, control over resources, safety, health-seeking behaviour and treatment by institutions. Women may face financial dependence, unpaid care burdens, reproductive health risks and gender-based violence. Men may experience occupational risks, norms discouraging care-seeking and higher exposure to certain injuries. Transgender and gender-diverse people may encounter stigma, administrative exclusion and clinically inappropriate systems.

Equitable policy requires confidential and respectful services, reproductive and maternal care, violence-response pathways, gender-sensitive data, protection from discrimination and attention to unpaid caregiving. Gender-responsive budgeting can examine whether resource allocation meets different needs rather than assuming that equal spending produces equal benefit.

Children, older people and persons with disabilities

Children require preventive care, immunisation, nutrition support and safeguards against exploitation. Older people may require chronic disease management, medicines, rehabilitation, mental health services and long-term care. Persons with disabilities need accessible buildings, communication, assistive technologies, reasonable accommodation and protection against assumptions that disability reduces the value of a life.

Migrants, refugees and displaced populations

Migrants may face uncertain legal status, language barriers, fear of authorities, interrupted records and exclusion from insurance. Refugees and displaced people may have high needs but limited continuity of care. Restricting access to essential services can increase avoidable illness and public-health risk.

A rights-consistent approach separates health-care access from immigration enforcement where possible, provides interpretation, recognises equivalent documentation, maintains continuity of medicines and ensures emergency and essential primary care. Policy must also distinguish between entitlement, financing responsibility and operational delivery: a person may be legally entitled to care even when reimbursement arrangements between jurisdictions remain unresolved.

6. Human Rights and Ethics in Coverage Policy

The right to health does not mean an unlimited right to every medical intervention. It requires states and institutions to pursue available resources progressively, without discrimination, and to ensure essential services and fair processes. Human-rights principles relevant to UHC include dignity, equality, participation, accountability, privacy, informed consent and non-discrimination.

Ethical analysis should address at least five questions:

1. What benefits and harms are likely?
2. Who gains and who bears the costs?
3. Are affected groups able to participate meaningfully?
4. Are restrictions necessary, proportionate and evidence-based?
5. Can people challenge decisions or seek remedy?

Public participation is not simply consultation after a decision has been made. It should influence problem definition, criteria, package design and review. Participation must be accessible, including for people with disabilities, low literacy and limited digital access.

Tensions in ethical decision-making

Several tensions recur:

• maximising health versus prioritising the worst-off;
• national solidarity versus obligations to non-citizens;
• individual choice versus population-level benefit;
• innovation access versus affordability;
• privacy versus data needed to identify inequity;
• rapid emergency action versus deliberative legitimacy.

No single ethical principle resolves every conflict. Managers should document the values involved, evidence considered, alternatives rejected and safeguards adopted.

7. Governance, Measurement and Digital Systems

UHC requires governance across ministries, insurers, providers, regulators, civil society and communities. Core governance functions include stewardship, regulation, purchasing, quality assurance, complaints handling and protection against corruption.

Useful indicators should cover:

• service coverage for tracer interventions;
• quality and patient safety;
• unmet need and delayed care;
• out-of-pocket expenditure and catastrophic spending;
• impoverishment due to health costs;
• distribution by income, geography, sex, age, disability and migration status;
• patient-reported experience and respect.

Averages can conceal inequity. Managers should use distributional analysis, not only national means. For instance, a policy that improves average coverage but widens the rural–urban gap may require redesign.

Digital tools can support enrolment, claims management, referral continuity and equity dashboards. Artificial intelligence may help identify missed appointments or predict service demand, but it introduces risks of biased training data, opaque decisions, privacy breaches and exclusion of people with limited digital access. AI should not determine eligibility or ration care without human oversight, explainability, auditability, data minimisation and an appeal mechanism. Digital transformation must complement, not replace, accessible non-digital channels.

8. Applied Case: Designing an Equitable Essential Health Package

The following is an illustrative fictional case.

Background

The middle-income country of Lumeria has a compulsory national health fund covering 78% of residents. Registration is lower among informal workers, migrants and remote communities. Public hospitals provide free inpatient care, but households commonly pay for medicines, diagnostics and transport. A fiscal review has found that the existing package includes several high-cost interventions with limited evidence while omitting hypertension medicines and community mental-health care.

Problem

The Ministry of Health must revise the package within a fixed budget. Hospital specialists argue that removing low-volume procedures will reduce clinical choice. Community organisations argue that the current package is urban-centred and disproportionately benefits households able to travel. Migrant representatives report that documentation requirements cause delayed care.

Analysis

The ministry establishes an independent priority-setting committee. It maps disease burden, unmet need, current expenditure, geographic access and distributional effects. It finds that:

• hypertension treatment is inexpensive and prevents stroke and renal disease;
• transport costs are a major reason remote patients abandon referrals;
• mental-health services are scarce and concentrated in cities;
• some covered procedures have high opportunity costs and weak evidence;
• migrant exclusion is partly administrative rather than financial.

The committee does not rank interventions solely by cost per QALY. It also considers severity, population disadvantage, financial risk protection, feasibility and human-rights obligations.

Approach and solution

The revised package:

1. guarantees primary care, essential medicines for chronic disease, immunisation, maternity care, emergency care and community mental-health services;
2. introduces transport vouchers for low-income remote households;
3. simplifies registration and permits temporary identifiers for people lacking standard documents;
4. uses risk-adjusted payments to prevent providers from avoiding high-need populations;
5. applies evidence and review requirements to expensive procedures;
6. establishes public hearings, published reasons and an appeal process;
7. monitors outcomes by income, region, gender, disability and migration status.

The ministry protects a small contingency budget for emergencies and commits to reassessment after two years.

Outcome

In the first year, enrolment increases modestly, but effective coverage improves more substantially in remote areas because medicine availability and transport support are addressed together. Complaints initially rise because the appeal system becomes visible; after process improvements, resolution times fall. Specialist opposition remains, but transparent criteria and an independent review reduce perceptions of arbitrary rationing.

Learning points

The case demonstrates that equitable UHC is not achieved by expanding a package indiscriminately. It requires attention to delivery capacity, indirect costs, administrative barriers, distributional effects and legitimate decision processes. It also illustrates that explicit limits can be more ethical than hidden rationing, provided that limits are evidence-informed, publicly justified and revisable.

9. Strategic and Managerial Implications

Health-care leaders should translate national entitlement into operational capability. This involves aligning budgets, workforce, procurement, referral pathways, medicines, information systems and quality standards. A benefit package without implementation funding creates nominal rather than effective coverage.

Managers should:

• use equity impact assessments before major reforms;
• stratify performance data and investigate unexplained gaps;
• involve affected communities early;
• design services around care journeys rather than institutional boundaries;
• protect confidentiality and establish clear complaints mechanisms;
• train staff in cultural safety, disability inclusion and non-discrimination;
• use contracts that reward quality and access, not merely activity volume;
• audit algorithms and automated eligibility systems;
• plan for shocks such as epidemics, conflict and climate-related displacement.

Strategic purchasing is especially important. Purchasers can direct resources toward providers that serve high-need populations, use quality-linked payments, negotiate prices and require continuity of care. However, performance measures must avoid penalising providers serving complex patients whose outcomes may require more time and resources.

10. Challenges and Limitations

UHC reforms face fiscal constraints, fragmented governance, informal employment, weak data and political resistance. Benefit-package decisions may be influenced by lobbying, media pressure or judicial demands. Cost-effectiveness evidence may be unavailable for neglected populations, and global evidence may not transfer directly across settings.

Equity measurement also has limitations. Household surveys may miss homeless people, undocumented migrants and institutionalised populations. Averages can mask severe deprivation, while a single inequality index cannot capture dignity, quality or political exclusion. Quantitative evidence should therefore be combined with qualitative research, community testimony and implementation analysis.

There is also a risk of “financialisation”: treating health solely as an insurance product. UHC is broader than coverage cards and claims. It depends on public health, prevention, competent workers, reliable infrastructure, trust and social protection. Finally, ethical analysis must remain attentive to power. A process can appear participatory while affected communities lack the information, time or authority necessary to influence the outcome.

Contemporary Developments and Best Practices

Current policy development increasingly emphasises primary health care, integrated services, essential public-health functions and resilience. Climate change is expanding needs related to heat, infectious disease, displacement and disaster response. Ageing populations are increasing demand for long-term and palliative care. Global medicine shortages and supply-chain disruptions make procurement resilience part of financial and clinical protection.

Best practice is characterised by:

• explicit and periodically reviewed entitlements;
• progressive pooling and reduced reliance on point-of-service payment;
• equity-sensitive HTA and budget impact analysis;
• strong primary health care and referral continuity;
• automatic protection for people at high risk of hardship;
• inclusive participation and accessible appeals;
• disaggregated monitoring of effective coverage;
• independent oversight and public reporting;
• ethical, secure and non-discriminatory use of data.

Chapter Summary

Universal health coverage is a commitment to effective, quality health services and financial protection for all, not merely insurance enrolment. Its three dimensions—population coverage, service coverage and financial protection—must be assessed together. Equity requires more than equal treatment: it requires proportionate responses to unequal need and attention to intersectional disadvantage.

Benefit packages should be evidence-informed, financially sustainable, feasible, explicit and publicly legitimate. HTA and cost-effectiveness analysis can support decisions, but they must be balanced with severity, rights, equity, financial risk protection and public values. Catastrophic expenditure measures help identify financial harm, although their interpretation depends on definitions, thresholds and data quality.

Gender, disability, age, migration status, geography and poverty shape access. Human-rights principles require dignity, non-discrimination, participation, privacy, accountability and remedy. Fair priority setting depends on transparent reasons, relevant evidence, revision and enforcement. Managers are responsible for converting formal entitlements into effective services through strategic purchasing, inclusive design, quality management, ethical data use and continuous monitoring.

Key Terms

Universal health coverage: Access to needed quality health services without financial hardship.

Effective coverage: Receipt of services that are accessible, good quality and capable of producing health benefit.

Equality: Treating people in the same way or distributing resources equally.

Equity: Fairly responding to differences in need and disadvantage.

Horizontal equity: Comparable treatment for people with comparable needs.

Vertical equity: Differentiated support for people with different needs.

Benefit package: Defined set of covered health services, medicines and interventions.

Health technology assessment: Systematic evaluation of the consequences of a health technology.

Cost-effectiveness analysis: Comparison of incremental costs and health outcomes between alternatives.

ICER: Incremental cost-effectiveness ratio, measuring additional cost per additional unit of health outcome.

Financial protection: Protection from direct and indirect economic hardship caused by health care.

Catastrophic expenditure: Health spending that exceeds a defined share of household capacity to pay.

Risk pooling: Combining financial contributions to distribute health-care cost across a population.

Distributive justice: Ethical concern with the fair allocation of benefits, burdens and opportunities.

Accountability for reasonableness: A framework requiring publicity, relevance, revision and enforcement in priority setting.

Intersectionality: Analysis of overlapping social positions and systems of disadvantage.

Proportionate universalism: Universal provision with intensity of support proportionate to disadvantage.

Strategic purchasing: Deliberate allocation of pooled funds to influence provider behaviour and outcomes.

Effective participation: Meaningful involvement of affected people in decisions that influence their entitlements.

Review Questions

Short Answer Questions

1. Define universal health coverage and identify its three principal dimensions.
2. Distinguish equality from equity using a health-care example.
3. What is the difference between nominal and effective coverage?
4. State the four conditions of accountability for reasonableness.
5. Why can out-of-pocket expenditure cause financial hardship even when insurance enrolment is high?

Long Answer Questions

1. Explain how a national benefit package can be designed using evidence, ethics, equity and fiscal sustainability.
2. Critically compare utilitarian, prioritarian and rights-based approaches to health-care priority setting.
3. Analyse the relationship between risk pooling, user charges and catastrophic expenditure.
4. Discuss how gender, migration and disability should influence UHC policy design.
5. Evaluate the managerial requirements for converting formal health-care entitlement into effective coverage.

Analytical / Application Questions

1. A government can fund either an urban tertiary procedure benefiting 1,000 people or primary hypertension treatment benefiting 20,000 people, including many low-income rural residents. Develop a transparent framework for deciding between them, identifying relevant evidence and ethical criteria.
2. A national insurance scheme reports 95% enrolment, but rural households report medicine shortages and high transport costs. Design an evaluation plan that distinguishes population coverage, effective coverage and financial protection.
3. An algorithm denies subsidy applications disproportionately among migrants because training data contain few migrant records. Analyse the ethical and governance failures and propose corrective safeguards.

Multiple Choice Questions with Answers

Question 1

Which combination best describes the three dimensions of universal health coverage?

A. Population coverage, service coverage and financial protection

B. Hospital ownership, medical licensing and pharmaceutical patents

C. Taxation, migration control and employment protection

D. Disease surveillance, research funding and health promotion

Correct Answer: A. Population coverage, service coverage and financial protection

Question 2

What is the main distinction between equality and equity in health policy?

A. Equality concerns clinical quality, whereas equity concerns hospital finance

B. Equality treats people identically, whereas equity responds fairly to differences in need

C. Equality applies only to private care, whereas equity applies only to public care

D. Equality measures outcomes, whereas equity measures expenditure only

Correct Answer: B. Equality treats people identically, whereas equity responds fairly to differences in need

Question 3

In the illustrative ICER example, a new programme costs $12 million and the comparator costs $8 million, producing 50,000 and 40,000 QALYs respectively. What is the ICER?

A. $40 per QALY gained

B. $250 per QALY gained

C. $400 per QALY gained

D. $4,000 per QALY gained

Correct Answer: C. $400 per QALY gained

Question 4

Which condition is part of accountability for reasonableness?

A. All decisions must maximise hospital revenue

B. Reasons for decisions should be publicly accessible

C. Only clinical specialists may participate in decisions

D. Decisions must never be revised

Correct Answer: B. Reasons for decisions should be publicly accessible

Question 5

What does risk pooling primarily achieve?

A. It eliminates all health-care expenditure

B. It distributes financial risk across people and time

C. It guarantees equal health outcomes

D. It replaces the need for primary care

Correct Answer: B. It distributes financial risk across people and time

Question 6

A household has total monthly resources of $1,000, subsistence needs of $700 and health spending of $120. Using CFP = OOP ÷ (T − S), what is its financial-burden ratio?

A. 12%

B. 30%

C. 40%

D. 70%

Correct Answer: C. 40%

Question 7

Which policy best illustrates proportionate universalism?

A. Providing services only to people below an income threshold

B. Providing the same resource allocation to every district

C. Providing universal primary care with additional resources for highly disadvantaged areas

D. Restricting essential care to citizens with formal employment

Correct Answer: C. Providing universal primary care with additional resources for highly disadvantaged areas

Question 8

Why should cost-effectiveness analysis not be the sole basis for a benefit-package decision?

A. It cannot compare costs and outcomes

B. It may overlook equity, severity, rights and financial protection

C. It applies only to medicines

D. It always produces politically neutral decisions

Correct Answer: B. It may overlook equity, severity, rights and financial protection

Question 9

Which safeguard is most appropriate when artificial intelligence is used in subsidy eligibility decisions?

A. Remove all human review to increase efficiency

B. Keep the model proprietary and provide no appeal route

C. Use auditability, human oversight, privacy protection and an appeal mechanism

D. Exclude people without digital access from the programme

Correct Answer: C. Use auditability, human oversight, privacy protection and an appeal mechanism

Question 10

Why is insurance enrolment alone an insufficient measure of UHC?

A. Enrolment always overestimates population size

B. Enrolled people may still lack available, quality services or financial protection

C. Insurance has no relationship to health services

D. Enrolment measures only mortality

Correct Answer: B. Enrolled people may still lack available, quality services or financial protection