This week we take a look at universal health coverage (UHC). This is central to the global health policy agenda and will remain so, at least until 2030, when the world evaluates its progress towards the sustainable development goals. What is really fascinating about UHC, however, is that it does not exist – it is an ideal. Even more so, it’s not a particularly well-defined one and is difficult to measure. This means that private healthcare, whose markets will be closely shaped by UHC, has little certainty. So what can we say for sure?

The first thing is that UHC, and by this we mean systems that claim to near the ideal in some form or another, is coming. For this feature, we spoke to sources from Uganda, Nigeria, Kenya, South Africa, India, Thailand, Indonesia, Colombia, Chile, Costa Rica, Mexico, UAE, Russia, and Georgia. All have either declared UHC a key goal, are at various stages of the legislative process, have enacted UHC programmes or are reforming them. It will be a long time before India or Nigeria can offer each of its citizens tertiary care out of the state purse – if ever – but basic primary care is on the way.

And that leads to the second lesson: successful governments generally choose to restrict the service package rather than the extent of coverage or the level of financial protection. Rwanda, Ethiopia and the Indian state of Kerala have all started from the bottom up in services, but gone straight for the maximum in population coverage. Universalism contains its own targeting mechanism, as elites rarely patronise basic public healthcare facilities. And many targeting systems, like below poverty line cards in India, have failed.

It’s also sadly true that there are many UHC charlatans. Indonesia and Mexico are known for their UHC programmes, but they do not stand up to scrutiny – waiting lists are pervasive in Mexico and patients face numerous hidden costs in Indonesia. But this is true far more widely. For example, just how many Russians have to pay under the counter to access services? How much do even those Americans fortunate enough to possess insurance shell out in co-payments? And how many South Africans neglect to pick up the results of their lab tests because of the cost of a bus ride to their local metropole? Once the full complexity of UHC is revealed, the failures of many healthcare systems come rapidly into focus.

Finally, UHC will present both opportunities and challenges for the private sector. We are unlikely to see NHS systems. But if the private sector wants its share of the UHC pie, it needs a seat at the table and that means first, dialogue, and then, partnership. The former should be easy as policy makers are increasingly aware of what the private sector can offer and that they need its capacity, expertise and innovation. The second is more problematic. From Mexico to India, we heard horror stories of the politicisation of contracting, reimbursement problems and lost contracts. On the other side, many operators have exploited failings in the public capacity for strategic contracting – particularly at the local level. In short, PPPs are perilous, but UHC needs them.

The way forward, as we see it, is a looser connection between the private and public sectors. Give the patients the money and let them choose public or private (including non-profit). Don’t waste your time having private operators run public facilities. If your country lacks the indigenous expertise to offer complex surgery, for example, its resources would likely be better directed to other areas of healthcare where it doesn’t. If there is to be a revolving door between public and private, far better the patients are walking through it than anyone else. You can access the full report here.