New evaluation of universal health coverage, world will likely fall short of WHO goal

A new study projects that 3.1 billion people will still lack effective health service coverage in 2023, with 968 million of those residing in South Asia. This falls short of the World Health Organization (WHO) goal of 1 billion more people benefiting from universal health coverage (UHC) between 2019 and 2023.

Universal health coverage is defined as all people receiving quality health services without incurring financial hardship. The paper, part of the Global Burden of Disease study, was published today in the international medical journal The Lancet. Researchers focused only on measuring service coverage, developing a new framework to capture how well countries align health services with the needs of the population and how well or poorly those services contribute to people's health.

"Universal health coverage is more than just access to health care," said Dr. Rafael Lozano, the senior author of the study and Director of Health Systems at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington School of Medicine. "Measuring access is necessary but not sufficient to capture health outcomes. By striving to capture potential health gains, we hope to better diagnose and address challenges that impede the ultimate objective of UHC: improving health for all people and leaving no one behind."

Using 23 indicators, the researchers assessed effective coverage by country on a scale of 1-100 and measured progress between 1990 and 2019. Globally, UHC effective coverage performance improved by nearly 15 points over that time period, but large variations remained across countries and regions, ranging from over 96 to below 25. Japan had the highest effective coverage score (96.4) in 2019, followed by Iceland, Norway, Switzerland, and San Marino. The Central African Republic, Somalia, Chad, Guinea, and Vanuatu had the lowest performance on UHC effective coverage.

Sub-Saharan Africa had accelerated gains since 2010 compared to other regions, nearly doubling average annual improvement between 2010 and 2019 compared to 1990-2010. Zimbabwe, eSwatini, the Democratic Republic of the Congo, Guinea-Bissau, and South Africa had the fastest growth in effective coverage performance.

The researchers also found that many countries lagged on performance for non-communicable diseases, compared to communicable diseases and reproductive, maternal, and child health. Globally, non-communicable diseases accounted for a greater proportion of potential health gains in 2019.

However, in some countries, like Kenya, Namibia, and Rwanda, causes beyond non-communicable diseases still have a high level of disease burden (e.g., HIV) and are an important area for policymakers and practitioners to prioritize. The different scenarios highlight the value of measuring effective service coverage, which can help inform UHC priorities that align with a country's health needs and evolve with those needs over time, rather than a one-size-fits-all approach to service coverage.

The study did not measure the financial risk protection component of UHC, but the researchers did look at per capita health spending by country. While they found that increased spending could be important for many countries to improve UHC effective coverage performance, efficiencies in health systems are also an important component.

Health spending and its relationship to universal health effective coverage is also explored in IHME's recently published report on global health financing. Countries with high performance relative to spending levels included Peru, Rwanda, South Korea, Cyprus, and Costa Rica. The United States, Central African Republic, Turkmenistan, and Saudi Arabia were among those countries with low performance relative to spending levels.

"We are seeing countries with varied performance at the same level of spend—an indicator that money spent on health is not being translated as efficiently as it could into gains in UHC effective coverage," said Dr. Christopher Murray, IHME Director and a senior author on the study. "For most countries, increased health spending alone is unlikely to deliver on ambitious UHC targets. Improving alignment of health systems with population health needs and bolstering efficiencies, along with more money, will likely result in faster and more sustained gains."

The study was completed prior to the COVID-19 pandemic but provides an important benchmark for measuring the impact of the pandemic and progress on UHC in years to come. It also highlights the value of effective data systems.

"Whether it's a rapidly spreading virus or persistent gaps in health service delivery, establishing and maintaining strong data systems are crucial to identifying health needs and effectively responding to them so that all people, within a country and around the world, have the opportunity to live full, healthy lives," said Nancy Fullman, a Ph.D. student in global health at the University of Washington and one of the study's lead authors.