Universal Health Coverage

Practitioners and campaigners today are increasingly strongly focused on achieving ‘Universal Health Coverage’ – based on the conviction that all people should receive the health services they need without suffering financial hardship when paying for them. For some time it has been a priority objective for World Health Organization (WHO).

Since 2015, much of this effort has taken place in the context of achieving the Sustainable Development Goals (Goal 3: Ensure healthy lives and promote wellbeing for all at all ages). See, for example, the WHO’s annual publication, ‘World Health Statistics 2019’. Below are two extracts:

SDG indicators of health service coverage and financing

Populations in low-income countries generally have less access to essential health services; values of the universal health coverage (UHC) service coverage index are lower, as are indicators such as skilled birth attendance, women who have their need for family planning satisfied with modern methods of contraception, and immunization coverage. Low-income countries also experience greater shortages of health care professionals […] and domestic government health expenditure as a proportion of total general government expenditures is lower (despite lower absolute levels of general government expenditure and greater health needs). The proportion of the population that suffer catastrophic health expenditures (>10% or >25% of total household expenditures or income) is higher in middle-income countries than in low- or high-income countries. However, at all income levels people can suffer catastrophic health expenditures, even in high-income countries and in countries where most of the out-of-pocket health spending is due to medicines.

Achieve universal health coverage

For many conditions, particularly in low-income countries, premature deaths can be averted by improving access to and use of preventive and curative health services. This may require a strengthened health workforce and increased provision of health facilities, equipment, medicines and vaccines. It will also require removing barriers to accessing services including economic barriers (as a consequence of out-of-pocket expenditures and insufficient public financing) and cultural barriers (where the workforce providing services does not have the necessary cultural sensitivity). Efforts in support of UHC must focus on reaching those whom services are not reaching, such as marginalized, stigmatized and geographically isolated people of all ages and genders. In some countries, health and social systems are strained by natural disasters or conflict, and the populations affected can account for a large proportion of unmet SDG need. Stronger and more resilient national health systems need to be backed by the regional and global alert and response mechanisms that will mitigate the impact of health emergencies.

Under the auspices of the UN, governments are currently negotiating a ‘Universal Healthcare Agreement’ which is intended to boost international and national efforts to achieve this objective. It is due to be signed at the UN General Assembly in September 2019. This will be a political declaration. A ‘zero draft’ is currently being discussed. According to the website Devex.com:

The current “zero draft” of the UHC agreement, published in May, recognizes the need for a “paradigm shift” and a boost in domestic investment to guarantee health care access for all. But it does not include specific domestic funding commitments, which will be key for full UHC implementation […]

Peter Sands, director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said in June:

The pathway to UHC is not something you reach by investing in something called UHC. You make that pathway by building parts of the health systems, addressing the health care needs of a specific population and by addressing specific conditions. It will inevitably involve a mix of focusing on specific segments of populations, specific diseases and functional components of the system. The good thing about it is that the UHC discussion is putting a lot of attention on, “How does one think about that journey towards a broad set of care services for all populations, through a system that is financially sustainable?” You are still going to come down to, “OK, so what are we going to do tomorrow and where will we put the dollars?”

In a 1 July Written Statement, Secretary of State for International Development Rory Stewart said:

The UK pioneered Universal Health Coverage through the establishment of the National Health Service and we continue to host many of the best medical scientists and practitioners in the world. Good health is a foundation for development; it enables people to go to school, go to work, and contribute to the economy. It is firmly in the UK’s national interest to work with countries to promote good health, to prevent and respond to disease outbreaks, and to contribute to the fight against antimicrobial resistance […] The UK will also support the High-Level meeting on Universal Health Coverage at the UN General Assembly in September […]

Statistics on global healthcare coverage

Target 3.8 of the Sustainable Development Goals is “Achieve universal health coverage”. SDG-Tracker, a project looking at progress towards meeting these goals created by the University of Oxford and the Global Change Data Lab, tracks this target by using the Healthcare Access and Quality (HAQ) Index. This Index uses death rates from causes of death that could be prevented through timely and effective medical care to create a numerical representation of the quality and availability of health care in particular countries or regions.

The HAQ index goes from 0 (worst) to 100 (best). The highest-scoring countries are, unsurprisingly, typically fairly wealthy; in 2015 the highest-ranked countries were Andorra (at an index level of 94.6), Iceland (93.6) and Switzerland (91.8), with the lowest being Somalia (34.2), Afghanistan (32.5) and the Central African Republic (28.6). For comparison, the UK was ranked 30th in 2015 (84.6) and the US was ranked 35th (81.3).

According to this index, access to healthcare has been increasing fairly steadily over the past 35 years, with almost all countries represented in the index seeing at least some improvement.

This chart shows that all quartiles of countries have seen some improvement. However, it also shows that there has been little change in the range of access to healthcare – that is, the countries with the worst healthcare are a long way behind those with the best, and this gap is showing little sign of closing.

Both the biggest and smallest changes in healthcare have been seen in relatively poor countries. The biggest increases in percentage terms have been seen in Ethiopia and Laos, both of which have seen improvements of around 90% between 1990 and 2015; the smallest increase was in Eswatini (1%) and the only decrease was in Lesotho (-13%). For comparison, the global average increased 32% over this period.

Further information on access to healthcare, and the financing behind it, is available in the Our World in Data article Financing Healthcare.

1.2 Aid spending on healthcare

In 2017, the most recent year for which we have data, the UK provided £926 million in bilateral aid for health.[1] This represents 10.5% of all bilateral aid; a similar proportion (11.6%) of UK multilateral aid in 2016 was spent on health.

Aid spending on health is generally higher now than in previous years, although its highest level was £946 million in 2013:

The country where the most bilateral aid was spent on health in 2017 was Nigeria, with £46.7 million, followed by the West Bank and Gaza Strip (£45.0 million).

Looking further afield, the Institute for Health Metrics and Evaluation has estimated that across the world nearly $58 billion has been provided in health aid (“development assistance for health”) between 1990 and 2017. The biggest recipient of this aid was Nigeria, with $1.8 billion; the biggest donor was the Bill and Melinda Gates Foundation, which gave a total of nearly $15 billion over the same timeframe. The largest national donor was the US, at just under $12 billion, and the second largest was the UK at $5 billion.[2]

[1] DFID, Statistics on International Development: Final UK Aid Spend 2017, 29 November 2018. Health represented by broad sector codes 121 and 122.

[2] IHME, Development Assistance for Health Database 1990-2018, 19 June 2019