Health is a fundamental human right, and Universal Health Coverage (UHC) is widely recognized to be critical for achieving that right. UHC represents the aspiration that everyone should receive good quality health services, when and where needed, without incurring financial hardship. Beyond health and wellbeing, UHC also contributes to social inclusion, equality, ending poverty, economic growth, and human dignity. The goal of UHC is expressed in the United Nations 2030 agenda as part of Sustainable Development Goals (SDGs) in Goal 3 which focuses on health (target 3.8).
Tracking Universal Health Coverage
Progress towards SDG 3.8 is tracked jointly by the World Health Organization and by the World Bank through Global Monitoring Reports which are published every two years. The target measures: (1) coverage of essential health services (SDG indicator 3.8.1) and (2) financial protection (SDG indicator 3.8.2).
The ability of people in a country to access essential health services is measured by the Service Coverage Index (SDG indicator 3.8.1). The Service Coverage Index (SCI) is calculated as the geometric mean of sixteen equally weighted indicators, focused on four healthcare areas: (a) reproductive, maternal, newborn child health; (b) infectious diseases, such as tuberculosis or malaria; (c) non-communicable diseases, including hypertension or diabetes; (d) service capacity and access, for example the number of hospital beds or health professionals per capita.
Financial protection (SDG indicator 3.8.2) is measured as the share of the population living in households where out-of-pocket (OOP) health spending exceeds 10% or 25% of the household budget. This is considered catastrophic health spending. (WDI indicators “Proportion of population spending more than 10% of household consumption or income on out-of-pocket health care expenditure” and “Proportion of population spending more than 25% of household consumption or income on out-of-pocket health care expenditure”)
The Global Monitoring Reports offer additional information on financial hardship among the poor, including measures of impoverishing health spending. Medical impoverishment is measured as the share of the population who live in households that are pushed by OOP health spending below or further below into poverty, specifically in extreme poverty or under the international poverty line of living on less than $1.90 per day (in Purchasing Power Parities) or under and $3.20 (PPP) per person per day (WDI indicators “Proportion of population pushed below the $1.90 ($ 2011 PPP) poverty line by out-of-pocket health care expenditure” and “Proportion of population pushed below the $3.20 ($ 2011 PPP) poverty line by out-of-pocket health care expenditure”).
Note: Following the update of the global poverty lines in 2022 the UHC financial protection indicators will be updated in 2023.
Progress towards UHC prior to the COVID-19 pandemic
Inequalities in health service coverage remain despite global progress and convergence
Among 193 countries with available data, SCI scores are very high (80 and above) in 31 countries, high (60-79) in 93 countries, medium (40-59) in 54 countries, and low (20-39) in 16 countries. No country has very low service coverage (SCI below 20). The data is as of 2019.
Overall, there is a strong positive correlation between country income levels and SCI scores. However, variation in SCI achievement within and across income groups highlights the importance of good policy irrespective of finances. While SCI scores remained low or medium level in most of low-income countries (27 countries or 96%), they varied widely among middle income countries. About 64% of lower- and upper-middle income countries had high or very high SCIs, 33% had medium SCIs, and 3% had low SCIs in 2019.
Before the pandemic large inequalities between countries in access to essential services persisted. However, the global SCI score improved from 45 (medium coverage) to 67 (high coverage) between 2000 and 2019. In addition, country scores had begun to converge over time. Countries which started with lower SCI scores in 2000 on average improved more compared to countries which started with higher SCI scores.
The poorest countries made the most progress in service coverage over the past two decades, as 69% of the low-income and 63% of the lower-middle income countries experienced improvements of 20 SCI points or more. By comparison, only 33% of upper-middle economies and 19% of high-income countries experienced such improvements.
It is important to note that the increases in the global Service Coverage Index in many countries over the past twenty years have been driven primarily by improvements in coverage of health services for infectious disease and, to a lesser degree, by improvements in newborn health coverage. However, service capacity and access (health infrastructure and personnel) and coverage of services for non-communicable diseases have stagnated. Improvements in the latter two domains are becoming ever more crucial considering the expansion of aging populations and an increasing non-communicable diseases burden in all regions of the world.
Financial protection for health was improving before the pandemic, but many people continue to be vulnerable to catastrophic health spending
When looking at pre-pandemic trends in levels of financial hardship caused by health expenditure (data are available up to 2017) a mixed picture emerges.
Fueled by the global increases in incomes over the past two decades, the number of people pushed (or further pushed) to living under the $1.90 or the $3.20 per day thresholds by out-of-pocket health payments (OOP) continued to decrease.
Despite these improvements, medical impoverishment remained at high levels. Although the total numbers have decreased, as of 2017, worldwide 1.4 billion people (18% of the global population) had been pushed into or pushed further into poverty (below $3.20 per day) and half a billion people (7% of the global population) into extreme poverty ($1.90 per day) by their medical expenses. More than half of those pushed or further pushed into extreme poverty live in Sub-Saharan Africa.
Moreover, the shares of people who incur catastrophic health spending, meaning they spend more than 10% or 25% of their income on health needs, have continuously gotten worse, increasing since 2000 (when the first global estimates of financial protection became available). The latest available data shows that in 2017 one billion people spent more than 10 percent of their income on health-related expenses and approximately 300 million people spent more than 25 percent.
Financial hardship due to health spending looks different across world regions. In 2017 a large share of the people who had to spend more than 10% of their income on health (catastrophic spending) lived in East Asia and Pacific (41%) and in South Asia (30%), relative to their shares in the global population (31% and 24%).
In contrast, a disproportionately low share (9%) of people with catastrophic health spending resided in Sub-Saharan Africa in 2017, although the region accounted for 14% of the global population that year. However, because of its low-income levels, Sub-Saharan Africa is still home to more than half of the 500 million people pushed or further pushed into extreme poverty.
A complete view of a country’s health financial protection requires simultaneous consideration of both service coverage and measurements of financial hardship. Otherwise, it would be unclear if, for example, low levels of catastrophic/impoverishing health spending in a country are due to high levels of financial protection or because the financial barriers to accessing care are so high that many people simply forgo health services altogether.
This figure shows global and regional trends for both dimensions of UHC. Joint progress in the two dimensions is indicated by moves towards the lower right corner of the graph where SCI scores are higher, and rates of catastrophic spending are lower.
Globally, improvements in service coverage go along with an increase in financial hardship. This global trend is largely driven by out-of-pocket spending on medication in East Asia & Pacific and in South Asia. The same pattern of increasing SCI scores and increasing catastrophic spending is found in the Middle East & North Africa. Financial hardship caused by health spending had been recently decreasing in the Latin America & the Caribbean region but in 2017 it still remained above its 2000 level. Europe & Central Asia and Sub-Saharan Africa were the only regions that achieved improvements in service coverage without substantive increases in catastrophic spending over the last twenty years. As countries transition from lower to middle-income status, people in these countries typically face higher out-of-pocket health payments and increased financial risk. This can happen because, while demand for health care is increasing, external support may be decreasing at the same time. Another potential reason is that in these countries social insurance systems are sometimes not sufficiently developed to cover the increased demand for health care, which is instead matched by increased out-of-pocket payments.
UHC during the COVID-19 pandemic
The income, fiscal, and health system shocks almost all countries experienced in 2020 and 2021 likely led to a decline in health service coverage and an increase in financial hardship. However, due to the disruptions in household survey data collection worldwide and because of the lag between data collection from household survey and the time when the information becomes available for analysis, very little evidence on the impacts of COVID-19 on UHC is available at present.
Peru, which continued its national household survey by switching from face-to-face to telephone interviews, offers a rare window into how the pandemic affected UHC indicators. As the pandemic was unfolding and strict public health measures were imposed in the second quarter of 2020, visits to healthcare provider by Peruvians with illness symptoms plummeted by 60%. Healthcare use partially recovered in the third quarter of 2020 but continued to be 25% below pre-pandemic levels at the end of 2021, indicating substantive and prolonged disruptions in service coverage.
Meanwhile, financial hardship from health spending saw a dramatic and protracted increase even though 80% of the population is enrolled in healthcare coverage schemes and despite the higher rates of forgone care during the pandemic. Between 2019 and 2020, the population share in Peru with catastrophic out-of-pocket health spending (at the 10% of income threshold) rose by 20 percent. By 2021 it had climbed to 12.9%, an almost 60 percent increase over pre-pandemic levels, and at a rate last seen a decade ago when only 40% of Peruvians had some form of health coverage. With the stark decrease in household income and increased out-of-pocket spending, the rates of medical impoverishment also skyrocketed. The share of population pushed below or further below the international upper-middle income poverty line of $5.50 per capita per day (PPP) increased by 45% between 2019 and 2020 and remained 40% above its 2019 value in 2021.
The progress made towards universal health coverage over the past twenty years, particularly when it comes to service coverage, is encouraging and shows that even poorer countries can achieve high levels of coverage with the right policies. At the same time, the evidence shows that it is challenging to improve access to services while reducing or even keeping stable levels of catastrophic spending. Moreover, initial findings from the pandemic era indicate that the previous progress towards UHC is now at stake. It is crucial that despite heightened fiscal pressure, governments continue to support universal health coverage through targeted social and health policy interventions.