Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare

Document Type : Original Article


1 Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, SA, Australia

2 College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia

3 The George Institute for Global Health, Sydney, NSW, Australia

4 RegNet School of Regulation and Global Governance, Australian National University, Canberra, ACT, Australia


Universal health coverage (UHC) is central to current international debate on health policy. The primary healthcare (PHC) system is crucial to achieving UHC, in order to address the rising incidence of non-communicable diseases (NCDs) more effectively and equitably. In this paper, we examine the Australian case as a mature system of UHC and identify lessons for UHC policy to support equity of access to PHC and reduce NCDs.
Our qualitative research used policy mapping and monitoring and 30 key informant interviews, and applied policy theory, to investigate the implementation of Australian PHC policy between 2008 and 2018.
Although the Australian PHC system does support equity of access to primary medical care, other ideational, actor-centred and structural features of policy detract from the capacities of the system to prevent and manage NCDs effectively, deliver equity of access according to need, and support equity in health outcomes. These features include a dominant focus on episodic primary medical care, which is a poor model of care for NCDs, and an inequitable distribution of these services. Also, a mixed system of public and private insurance coverage in PHC contributes to inequities in access and health outcomes, driving additional NCD demand into the health system.
Countries aiming to achieve UHC to support health equity and reduce NCDs can learn from strengths and weaknesses in the Australian system. We recommend a range of ideational, actor-centred and structural features of UHC systems in PHC that will support effective action on NCDs, equity of access to care according to need, and equity in health outcomes across geographically and ethnically diverse populations.



Commentaries Published on this Paper  


  • Universal Health Coverage, Non-communicable Disease, and Equity: Challenges to Implementation; Comment on “Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

         Abstract | PDF


  • Which UHC? Features for Equity and Universalism; Comment on “Universal Health Coverage for Non-Communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

          Abstract | PDF


  • Learning by Doing: Accelerate Towards the NCD Target in SDG Through Primary Healthcare; Comment on “Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

         Abstract | PDF


  • Aiming for Health Equity: The role of Public Health Policy and Primary Healthcare; Comment on “Universal Health Coverage for Non-Communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare

        Abstract | PDF


  • Primary Healthcare Policy Research: Including Variables Associated With the Social Determinants of Health Matters; Comment on “Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

        Abstract | PDF


  • Universal Health Coverage for Non-communicable Diseases and Health Equity: Reflections on the Role of Ideas and Democratic DecisionMaking; Comment on “Universal Health Coverage for NonCommunicable Diseases and Health Equity: Lessons from Australian Primary Healthcare”

        Abstract  | PDF


  • Reiterating the Importance of Publicly Funded and Provided Primary Healthcare for Non-communicable Diseases: The Case of India; Comment on “Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

         Abstract  | PDF


  • Changing the Discourse in Ambitions Towards Universal Health Coverage: Lessons From Australian Primary Healthcare; Comment on “Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare”

         Abstract  | PDF


Authors' Response to the Commentaries


  •  Universal Health Coverage for Health Equity: From Principle to Practice

         Abstract | PDF



  1. Binagwaho A, Adhanom Ghebreyesus T. Primary healthcare is cornerstone of universal health coverage. BMJ. 2019;365:l2391. doi:10.1136/bmj.l2391
  2. Sanders D, Nandi S, Labonté R, Vance C, Van Damme W. From primary health care to universal health coverage-one step forward and two steps back. Lancet. 2019;394(10199):619-621. doi:10.1016/s0140-6736(19)31831-8
  3. World Health Organization (WHO). WHO Director-General Calls on World Leaders to Support Universal Health Coverage High-Level Meeting. Geneva: WHO; 2019.
  4. World Health Organization (WHO). Universal Health Coverage. Geneva: WHO; 2019.
  5. Sengupta A. Universal Health Coverage: Beyond rhetoric. Ottawa: Municipal Services Project, International Development Research Centre; 2013.
  6. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
  7. Galea S, Kruk ME. Forty years after Alma-Ata: at the intersection of primary care and population health. Milbank Q. 2019;97(2):383-386. doi:10.1111/1468-0009.12381
  8. Giovanella L, Mendonça MHM, Buss PM, et al. From Alma-Ata to Astana. Primary health care and universal health systems: an inseparable commitment and a fundamental human right. Cad Saude Publica. 2019;35(3):e00012219. doi:10.1590/0102-311x00012219
  9. Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387(10020):811-816. doi:10.1016/s0140-6736(15)60002-2
  10. World Health Organization (WHO). Primary Health Care on the Road to Universal Health Coverage. Geneva: WHO; 2019.
  11. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. New York: The Commonwealth Fund; 2017.
  12. Hurley C, Baum F, Johns J, Labonté R. Comprehensive primary health care in Australia: findings from a narrative review of the literature. Australas Med J. 2010;1(2):147-52. doi:10.4066/amj.2010.201
  13. Whitehead M. The concepts and principles of equity and health. Health Promot Int. 1992;6(3):217-228. doi:10.1093/heapro/6.3.217
  14. Harris MF, Harris E, Roland M. Access to primary health care: three challenges to equity. Aust J Prim Health. 2004;10(3):21-29. doi:10.1071/py04043
  15. Thiede M, Akweongo P, McIntyre D. Exploring the dimensions of access. In: McIntyre D, Mooney G, eds. The Economics of Health Equity. Cambridge: Cambridge University Press; 2007.
  16. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254-258. doi:10.1136/jech.57.4.254
  17. Australian Institute of Health and Welfare (AIHW). Health Expenditure Australia 2013-2014. Canberra: AIHW; 2015.
  18. Jackson H, Shiell A. Preventive Health: How Much does Australia Spend and is it Enough? Canberra: Foundation for Alcohol Research and Education; 2017.
  19. Windle A, Fisher M, Freeman T, et al. Increased Private Health Fund involvement in Australia’s Primary Health Care: Implications for health equity. Aust J Soc Issues. 2018;53:338-354. doi:10.1002/ajs4.45
  20. Bywood P, Katterl R, Lunnay B. Disparities in Primary Health Care Utilisation: Who are the Disadvantaged Groups? How are They Disadvantaged? What Interventions Work? Adelaide: Primary Health Care Research & Information Service; 2011.
  21. Baum F, Freeman T, Sanders D, Labonté R, Lawless A, Javanparast S. Comprehensive primary health care under neo-liberalism in Australia. Soc Sci Med. 2016;168:43-52. doi:10.1016/j.socscimed.2016.09.005
  22. World Health Organization (WHO). WHO Report on the Global Tobacco Epidemic 2019: Offer Help to Quit Tobacco Use. Geneva: WHO; 2019.
  23. Australian Bureau of Statistics (ABS). National Health Survey: First Results, 2017-2018. Canberra: ABS; 2019.
  24. Australian Institute of Health and Welfare (AIHW). Australia’s Health 2018. Canberra: AIHW; 2018.
  25. Australian Institute of Health and Welfare (AIHW). Overweight and Obesity: An Interactive Insight. Canberra: AIHW; 2019.
  26. Baum FE, Bégin M, Houweling TA, Taylor S. Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health. Am J Public Health. 2009;99(11):1967-1974. doi:10.2105/ajph.2008.154856
  27. Fisher M, Baum F, MacDougall C, Newman L, McDermott D. To what extent do Australian health policy documents address social determinants of health and health equity? J Soc Policy. 2016;45(3):545-564. doi:10.1017/s0047279415000756
  28. Baum F, Ziersch A, Freeman T, Javanparast S, Henderson J, Mackean T. Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia. Soc Sci Med. 2020;248:112824. doi:10.1016/j.socscimed.2020.112824
  29. Spies-Butcher B. Marketisation and the dual welfare state: Neoliberalism and inequality in Australia. Econ Labour Relat Rev. 2014;25(2):185-201. doi:10.1177/1035304614530076
  30. Yin RK. Case Study Research: Design and Methods. 4th ed. London: SAGE Publications; 2009.
  31. Labonté R, Sanders D, Baum F, et al. Implementation, effectiveness and political context of comprehensive primary health care: preliminary findings of a global literature review. Aust J Prim Health. 2008;14(3):58-67. doi:10.1071/py08037
  32. Hill M, Hupe P. Implementing Public Policy: An Introduction to the Study of Operational Governance. 2nd ed. London: SAGE Publications; 2009.
  33. Howlett M, Ramesh M, Perl A. Studying Public Policy: Policy Cycles and Policy Subsystems. Toronto: Oxford University Press; 2009.
  34. Cairney P. Standing on the shoulders of giants: how do we combine the insights of multiple theories in public policy studies? Policy Stud J. 2013;41(1):1-21. doi:10.1111/psj.12000
  35. Carstensen MB, Schmidt VA. Power through, over and in ideas: conceptualizing ideational power in discursive institutionalism. J Eur Public Policy. 2016;23(3):318-337. doi:10.1080/13501763.2015.1115534
  36. Hooghe L, Marks G. Unraveling the central state, but how? types of multi-level governance. Am Polit Sci Rev. 2003;97(2):233-243. doi:10.1017/s0003055403000649
  37. Fisher M, Baum F, Kay A, Friel S. Are changes in Australian national primary health care policy likely to promote or impede equity of access? A narrative review. Austr J Prim Health. 2017;23(3):209-215. doi:10.1071/PY16152
  38. Primary Health Care Advisory Group. Better Outcomes for People with Chronic and Complex Health Conditions. Canberra: Australian Government; 2015.
  39. Hajizadeh M, Connelly LB, Butler JRG. Health policy and horizontal inequities of health-care utilization in Australia: 1983–2005. Appl Econ Lett. 2012;19(18):1765-1775. doi:10.1080/13504851.2012.659337
  40. Korda RJ, Banks E, Clements MS, Young AF. Is inequity undermining Australia's 'universal' health care system? Socio-economic inequalities in the use of specialist medical and non-medical ambulatory health care. Aust N Z J Public Health. 2009;33(5):458-465. doi:10.1111/j.1753-6405.2009.00430.x
  41. Duckett S, Swerissen H, Moran G. Building Better Foundations for Primary Care. Melbourne: Grattan Institute; 2017.
  42. Twetman S. Prevention of dental caries as a non-communicable disease. Eur J Oral Sci. 2018;126 Suppl 1:19-25. doi:10.1111/eos.12528
  43. Sharma S, Traeger AC, Mishra SR, Sharma S, Maher CG. Delivering the right care to people with low back pain in low- and middle-income countries: the case of Nepal. J Glob Health. 2019;9(1):010304. doi:10.7189/jogh.09.010304
  44. Alsharif AT, Kruger E, Tennant M. Disparities in dental insurance coverage among hospitalised Western Australian children. Int Dent J. 2014;64(5):252-259. doi:10.1111/idj.12116
  45. Demaio A, Jones A. The true price of sugar-sweetened disease: political inertia requires renewed, strategic action. Med J Aust. 2018;209(2):60-61. doi:10.5694/mja18.00223
  46. Australian Institute of Health and Welfare (AIHW). Australian Health Expenditure by Remoteness: A Comparison of Remote, Regional and City Health Expenditure. Canberra: AIHW; 2011.
  47. Department of Health. Health Care Homes: Reform of the Primary Health Care System. Canberra: Australian Government; 2016.
  48. Biggs A. Health Care Homes: An Update. Parliament of Australia; 2018.
  49. Department of Health. Primary Health Networks: Grant Programme Guidelines. Canberra: Australian Government; 2014.
  50. Dwyer J, O'Donnell K, Lavoie J, Marlina U, Sullivan P. The Overburden Report: Contracting for Indigenous Health Services - Summary. Darwin: Cooperative Research Centre for Aboriginal Health, Department of Health Management Flinders University; 2009.
  51. Administrator National Health Funding Pool. Glossary Canberra: ANHFP; 2019. https://www.publichospitalfunding.gov.au/Glossary.  Accessed June 10, 2020.
  52. Menadue J, McAuley I. Private Health Insurance: High in Cost and Low in Equity. Sydney: Centre for Policy Development; 2012.
  53. Freeman T, Baum F, Lawless A, et al. Case study of an aboriginal community-controlled health service in Australia: universal, rights-based, publicly funded comprehensive primary health care in action. Health Hum Rights. 2016;18(2):93-108.
  54. Baum F, Fry D, Lennie I. Community Health: Policy and Practice in Australia. Sydney: Pluto Press Australia; 1992.
  • Receive Date: 29 June 2020
  • Revise Date: 09 November 2020
  • Accept Date: 09 November 2020
  • First Publish Date: 23 November 2020