Márcia Costa, Research Manager and Karen Taylor, Director, Deloitte Centre for Health Solutions
Universal Health Coverage (UHC) means ‘all people have access to the full range of quality health services they need, when and where they need them, without financial hardship’. Yet today, half the world’s population still does not have access to essential health services and two billion people face financial hardship or are impoverished due to out-of-pocket health spending.1 UHC Day on 12 December is an official United Nations (UN) day, marking the UN’s unanimous endorsement of UHC in 2012. UHC was subsequently included as a Sustainable Development Goal (SDG) in 2015 making it a major goal of health system reform.2 All countries reaffirmed this commitment at the UN’s General Assembly on UHC in 2019.3 While progress in achieving the UHC SDG was faltering before the COVID-19 pandemic, progress has since stalled. This year’s UHC Day campaign, Health for All, Time for action, is calling for specific actions to invest in building health system resilience.4 In this blog, we explore the progress on delivering UHC and the steps needed to help deliver the UHC SDG by 2030.
Progress towards UHC
The World Health Organisation (WHO) was established 75 years ago on the conviction that health is a human right and that the best way to realise that right is UHC. The WHO also believes that strong primary health care (PHC), is the most inclusive, equitable and cost-effective path towards UHC. However, many countries vary in their provision of UHC, the resources they commit to healthcare and the services provided, including PHC.5
The inclusion of UHC in the SDGs in 2015 presented an opportunity to promote a comprehensive and coherent approach to health, focusing on strengthening health systems.6 Indeed, the goal of UHC is expressed in SDG Goal 3.8 as to: ‘achieve UHC, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.’ It is divided in two parts: SDG 3.8.1 tracks the progress on coverage of essential health services and SDG 3.8.2 tracks the extent of catastrophic health spending.7
In 2019, at the UN General Assembly High Level Meeting on UHC, countries reaffirmed that health is a precondition for and an outcome and indicator of, the social, economic and environmental dimensions of sustainable development. At the time, however, progress towards UHC was faltering. Progress seen prior to 2015 had slowed, with the SDG 3.8.1 increasing by only three points between 2015 and 2019. The portion of the population incurring catastrophic out-of-pocket health spending (SDG 3.8.2) increased continuously from 9.6 per cent in 2000 to 13.5 per cent in 2019 with out-of-pocket health spending dragging 344 million people further into extreme poverty and 1.3 billion into relative poverty with two billion people facing some form of financial hardship (catastrophic, impoverishing or both). Moreover, inequalities remained a fundamental challenge for UHC.8
Monitoring progress towards the UHC SDG
On 11 December, the WHO and World Bank published its annual Universal Health Coverage Global Monitoring Report (UHC GMR). This is the official monitoring tool of the SDG target 3.8.1 and 3.8.2 and sheds light on the evolution of global healthcare spending at the height of the COVID-19 pandemic. It also illustrates once again that while global spending on health increased and reached a high of US$ 9.8 trillion (10.3 per cent of gross domestic product (GDP)) in 2021, the distribution of spending remained grossly unequal, with public spending on health increasing across the world except in low-income countries, where spending actually decreased.9 The report also highlights that the scale of growth in health spending is unlikely to continue as countries face other economic priorities such as inflation and increased debt service obligations.
Importantly, the 2023 monitoring report presents an ‘alarming picture’ on the state of UHC around the world, with the expansion of UHC largely stalled and financial protection for those who do receive health services worsening. Consequently, the world is off track to meet the UHC SDG target 3.8 by 2030. Specifically:
- in 2021, 4.5 billion people (some 57 per cent of the world population) were still not fully covered by essential health services
- two billion people facing financial hardship of which 1 billion are experiencing catastrophic out-of-pocket health spending
- inequalities continue to be a fundamental challenge for UHC. Even where there is national progress, the aggregate data mask inequalities within-countries. For example, coverage of reproductive, maternal, child and adolescent health services tends to be higher among those who are richer, more educated, and living in urban areas. On financial hardship, catastrophic out-of-pocket health spending is more prevalent among people living in households with older members. People living in poorer households, rural areas and in households with older family members are more likely to be dragged further into poverty by out-of-pocket spending.10
Accelerating progress towards UHC
A new UN declaration on UHC in September 2023, saw world leaders committing to redouble their efforts to achieve UHC by 2030. This commitment now needs to be turned into investments in resilient health systems. This year’s UHC Day campaign focuses on five main proposals to help achieve this commitment:
- invest in UHC: as shown, UHC can have a positive impact on health outcomes and other social determinants
- strengthen health systems - building more resilient systems will be crucial in helping countries who are struggling to emerge from the impact of the pandemic, in the face of increasingly complex challenges such as geopolitical unrest, climate change, environmental degradation, unplanned urbanisation and other shocks impacting the health of the population. This is particularly important because countries most at risk of these threats (mainly sub-Saharan, Latin American and south Asian countries) are also those lagging most behind in UHC and have the highest population growth rates
- expand PHC - the main focus continues to be on expanding PHC, including health promotion and disease prevention, especially with the rise on non-communicable disease (NCDs) PHC is the best hope to prevent them or reduce their burden
- work across sectors and communities - associated with PHC, there has been a welcome shift towards working more closely with local communities (e.g., at local clinics and pharmacies); recruiting from these communities can also be an excellent strategy to reduce local unemployment and poverty and increase productivity as locals know best the needs of the populations they serve and consequently have their trust
- promote innovation to reach everyone - innovation is essential, not only in terms of new diagnostics and treatments, but also funding models, health system and population health management, and decision making.11,12
To mark UHC Day 2023, the WHO Youth Council, together with UHC2030 and the Inter-Parliamentary Union hosted a virtual town hall bringing together parliamentarians, youth advocates and UHC campaigners to share perspectives on what is needed to drive action to accelerate UHC and help reshape systems in a more inclusive way. Examples of positives actions already underway included governments investing in health infrastructure, creating universal health insurance and providing for those who cannot afford it, including refuges from neighbouring countries, as well as expanding coverage for services such as mental health and prevention (including vaccines).
Following the pandemic and the irrefutable evidence of the importance of a resilient health system its reassuring to see countries once again recommitting to steer their health systems toward more prevention and health promotion, resilience and equity, with UHC at the heart of their policies. However, while this political commitment is important, and the ‘renewal of vows’ can be an essential reminder of the importance of UHC and an impetus for change, affirmative action is essential if the world is to improve health outcomes. Indeed, achieving UHC by 2030 is crucial for fulfilling the promise of the 2030 Agenda for Sustainable Development and realising the fundamental human right to health. What is clear, however, is that this will require substantial public and private sector investment and accelerated action by governments and development partners. The most pressing action and a good starting point for all, is the radical reorientation of health systems towards a PHC approach, advancing equity in healthcare access and financial protection, and investing in robust health information systems.