Image courtesy of WHO/World Bank.
Image courtesy of WHO/World Bank.

Not long ago, WHO and the World Bank came out of with a report that led to headlines like this one in the New York Times: “400 Million Lack Basic Health Services, Report Finds.” And no wonder these were the type of headlines that emerged. The World Bank’s own press release led with the same 400 million number, announcing “400 million people do not have access to essential health services.”
In a world of more than 1 billion people living in extreme poverty (less than $1.25 per day) and 2.2 billion living on less than $2 per day (2011 data), that more people do not lack access to essential health services may seem like a remarkable achievement, making health an area where at least many of the world’s poorest, most marginalized people are included in society, able to get the health services to which they have a right. And it would seem that even as the world prepares to establish universal health coverage as one of the targets in the health goal of the Sustainable Development Goals (target 3.8), that 400 million of now more than 7.2 billion people in the world lack access to essential health services would means that about 94% of the world’s population do have access to essential health services.
It turns out, however, that would be a highly over-optimistic misread of what WHO and the World Bank found. By more reasonable understandings of how many people lack access to essential health services, untold hundreds of millions more than 400 million people lack access to essential health services. The road ahead to universal health coverage is considerably longer than the headline figure implies.

As a preliminary matter, it should be noted that the essential health services selected are all for health care, not addressing such underlying determinants of health and public health measures as access to clean water and sanitation and comprehensive tobacco control measures. In 2012, nearly 750 million people lacked access to improved drinking water sources, while far more still, 2.5 billion people, did not have access to improved sanitation facilities.
The WHO/World Bank report, Tracking Universal Health Coverage: First Global Monitoring Report, states: “at least 400 million people currently lacking access to one of seven essential services for Millennium Development Goal (MDG) priority areas” (p. 2). The health services monitored are not all essential health services, nor do they span a wide range of illness and injury. Rather, they are these: “The total estimate of 400 million includes all women whose demand for family planning is not met, pregnant women who did not make at least 4 antenatal visits…, infants who did not receive 3 doses of DTP-containing vaccine, HIV-positive adults and children not receiving HIV treatment, adults with new cases of TB not receiving TB treatment and children 1–14 years not sleeping under an insecticide-treated bed net (ITN))” (p. 21).
These health services are, indeed, all essential, all quite worthy of inclusion. Yet surely health services for non-communicable diseases, including mental health care, and injuries are “essential” too. One frequently proposed measure regarding non-communicable diseases is access to medicine to control hypertension. The report itself suggests that hypertension treatment coverage could be good tracer indicator for universal health coverage, yet “no global or regional estimates of hypertension treatment coverage exist” (p. 26). If they did, and if WHO and the World Bank included these estimates in the number of people lacking access to essential health services, that number would surely shoot up. Based on country surveys in select non-OECD countries, only 7-61% of people identified in household surveys as having high blood pressure had been diagnosed and were on medication, and even fewer receiving effective treatment, with their blood pressure under control.
Beyond these, what of more expensive but still vitally important health care – effective cancer and Hepatitis C treatments, for example – that universal health coverage based on the universal right to health would include?
Even taking the 7 MDG-related essential health services that the report uses in its measurement, far more than 400 million people lack access by (what would seem to me) more common understandings of who lacks access. The figure comes from estimating the number of people who need the health services in a given year. The point-in-time nature of the measurement – in particular, only of people who needed the specified service in 2013 – pushes the total figure downward. So the 38 million women who delivered a child in 2013 without a skilled birth attendant and the 50 million women who did not have four antenatal visits that yea are included in the 400 million figure. But the women who were pregnant in 2014 (or 2012, and so forth) and similarly lack access to skilled birth attendants or antenatal care are not counted. Similarly, the 22 million people without access to HIV/AIDS treatment in 2013 were included, but not anyone who might become infected, even if they, too, lack access to treatment.
Notably, the health services that the report counts towards the 400 million figure are not health services that everyone uses equally. The large majority of those included as lacking access are women aged 15-49 and infants and children aged 0-14.  In a world where women are disproportionately denied their rights and still subjected to immense discrimination, it is nice for purposes of this statistic that women are far more likely to count. Still, if you are a male at least 15 years old or a woman 50 years or older – as about 3.5 billion people in the world are – then unless you have HIV/AIDS or TB, you have no chance of being reflected in this measure of access to essential health services.
If you do are not HIV+ but would not access treatment if you were, or if you are a woman who is not now pregnant but would not access a skilled birth attendant if you became pregnant, wouldn’t you count yourself among the world’s people who lack access to essential health services?
I believe that WHO and the World Bank made a thoughtful effort to measure access to health services. It is difficult to measure. Is access to health services a matter of whether people have a health center within 5 or 10 kilometers of their home? What if they are near a health center but that health center has too few health workers – or empty medicine shelves? Is that access to health care? Is it whether people are formally covered by health insurance, regardless of the level of coverage or whether the health system is in place to actually enable them to get the health services they need (making this a particularly weak measure of access)?
Basing a measure of access on how many people receive the health services they need is a sound approach, a reminder that ultimately, that is the question – are people able to get quality (one dimension not captured here) health services whenever they need them? Though this approach would have to be combined with health services that one needs all the time, access to underlying determinants of health (as above, like clean water and sanitation) and the existence of effective public health measures (again, like tobacco control).
The report itself – beneath the headlines – covers many of the concerns I have raised here. It addresses health issues beyond the MDGs. It raises the issue of quality and the difficulty measuring it (p. 11). The report makes quite clear that while a number such as how many people lack access to essential health services makes a ready headline, the reality is far more complex.
Why does all this matter? First, because we must not think we have made more progress than we have in fact made – which could give the false impression that it is okay to move on to other matters. We still have a very long way to go. Second, this raises the difficult questions of what access entails. Going forward, as the global community monitors progress on universal health coverage and the Sustainable Development Goals, if access to essential health services is the metric, we must be sure that official monitoring – important since what is monitored may well affect what governments prioritize, and the health services people actually receive – encompasses the full range of illness and injury. And third, if the headline-making figure is access, other aspects of people’s right to health – including the quality of health services and their acceptability (e.g., culturally respectful, respecting the dignity of all patients) – that fall under the headlines risk also falling under the radar. “Access” must mean access to quality, respectful care.
WHO and the World Bank have taken a thoughtful approach to measure access in considering actual coverage of needed health services, but in their next report, they would do well to be far more comprehensive in the services they consider. That will be more complicated, but will paint a far truer picture.