What are the paths to universal health coverage? Some countries offer clues

Universal health coverage (UHC) is seen as central to achieving a vast range of Sustainable Development Goals related to health and wellbeing. But it's also viewed as critical to eradicating poverty, ensuring quality education, achieving gender equality, and building just, peaceful, and inclusive societies, among other goals.

The global Health for All movement first took hold in the late 1970s. The goal was to ensure that everyone has access to the full range of safe, effective, and affordable health services, whenever and wherever they need them, without suffering financial hardship or discrimination. By 2010, the publication of the World Health Organization’s (WHO) World Health Report marked a shift of focus from which health services countries should provide to how to finance strong health systems and ensure everyone could afford to use them.

Nine years later, world leaders re-affirmed their commitment to achieving UHC and, at the United Nations General Assembly (UNGA) in September 2023, they made the first high-level political declaration to achieve UHC worldwide by 2030.

This year's International Universal Health Coverage Day on December 12 serves as a stark reminder that the world faces interrelated crises that all impact global health – from climate change to conflict to pandemics – driving escalating calls from health experts and leaders for urgent action on UHC.

Overall, health service coverage has improved around the world over the past two decades. According to the service coverage index (SCI) built by the WHO and the World Bank, based on the population-weighted score of an index of selected essential services, the global SCI score rose from 45 to 68 out of 100 between 2000 and 2021, with lower-income and lower- and middle-income countries (LMICs) seeing the most significant progress. Still, the WHO says today more than half the world’s population – 4.5 billion people – is not covered by essential health services.

At the same time, about two billion people continue to experience financial hardship due to out-of-pocket (OOP) spending on health. Catastrophic spending, a term for when OOP exceeds a certain threshold of household budget (the WHO uses a 10% threshold) has worsened or seen little change in most countries since 2000. Overall, the estimated number of people who spend a distressingly large proportion of their income on health climbed from 588 million people in 2000 to more than one billion in 2019, leaving them with less to spend on other essential goods and services such as food, shelter, clothing, or education. This, in turn, increases the health burden on families and health systems around the world.

Countries that are further ahead on the path to UHC can provide clues to where governments should focus their efforts and funding. One of the key factors in achieving UHC is a strong primary health care system, many health leaders agree. The government of Thailand understood that when it established universal health care in 2002, introducing affordable health care for its entire population of 66 million at the time. The move triggered a rapid rise in demand for health services and the government responded by heavily investing in its public health workforce. Between 2002 and 2018, the Thai government more than doubled the number of qualified nurses and midwives in the country and almost tripled the number of qualified medical doctors. “Ultimately, universal health coverage is a choice – a political choice,” said WHO Director-General Dr. Tedros Adhanom Ghebreyesus at this year's UNGA. “But the choice is not just made on paper … Most of all, it’s made by investing in primary health care, which is the most inclusive, equitable, and efficient path to universal health coverage.”

Expanding primary health care effectively means keeping equity top of mind in the decision-making process. For example, part of the driving force behind Ethiopia's rapid progress toward UHC is the recognition that women have specific health care needs, such as access to family planning and prenatal care, and that the health system must meet these needs to be inclusive and equitable. The Ethiopian government launched its flagship Health Extension Program in 2003 with a focus on boosting access to women's health. By 2019, fertility in the country had decreased from 5.5 to 4.4 births per women, reflecting the fact that the percentage of married women using a modern method of contraception had shot up to 40.5% compared to 6.3% two decades earlier. The number of women giving birth in facilities, with access to skilled birth attendants and potentially life-saving emergency obstetric care, instead of at home, also increased. In 2019, more than three-quarters of women who had received at least four antenatal care visits delivered in a hospital or other health facility, up from about a quarter in 2000.

Lowering OOP expenditure is also crucial to achieving universal health coverage. When Ghana committed to moving toward UHC, it was already a public health care leader in Sub-Saharan Africa, thanks in large part to its National Health Insurance Scheme (NHIS). The scheme, which began full operations in 2005, ensures treatment is provided free at the point of delivery and is heavily subsidized by a national health insurance levy and various taxes. A number of studies show that since the NHIS launched, OOP health payments have broadly decreased among insured people in Ghana – one found that the insured were 7% less likely to face catastrophic OOP expenditures than the uninsured.

Despite the improvements, deep inequalities still exist in Ghana. Less than 70% of the country's population is covered by the NHIS and enrollment is lower among the poorest households, who are also hit disproportionately hard by catastrophic OOP, especially when non-medical-related health care costs are taken into account, such as transportation costs, lost income, and non-routine tests.

To accelerate their progress toward achieving UHC and reach the global goal of Health For All, countries need to ensure they reach women, the poorest, and others who are often neglected in health policy decision making, such as people living with disabilities and the elderly. That means focusing funding on expanding primary health care systems – with family planning and prenatal care as key elements – and developing targeted policies to address the specific issues that make poorer households more vulnerable to catastrophic OOP