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Universal Health Coverage Should Be Universal: An Analysis of a World Health Organization/World Bank Proposal

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Universal health coverage (UHC). It is an ambitious, historic goal. At least in its strongest form, it entails enabling all people to receive the health services they need. Not long ago, it seemed that UHC would be included in the Sustainable Development Goals (SDGs), which will replace the Millennium Development Goals after 2015. While no longer the clear frontrunner for the health-specific goal in the SDGs, it will likely be an important pathway towards achieving the health SDG(s). Independent of the SDG process, UHC has become a centerpiece of many countries’ health agendas.

There is wide recognition that the SDGs must focus much more directly on equity. Universal health coverage must having equity as a focus from the start, rather than as an afterthought, with the rest that the people traditionally with the least access to health services will be the last to benefit. Accordingly, when WHO and the World Bank recently proposed a set of targets for UHC in the post-2015 sustainable development agenda, they assumed a clear equity focus. One, aimed at ensuring a focus from the start on the poorer segments of the population, was that by 2030, the health services available through universal health coverage initiatives would be available to 80% of the poorest 40% of the population.

The intentions evidenced by this 80/40 target are commendable, with a direct focus on ensuring health services for the poor, an elevated concern for disadvantaged and often excluded parts of the population. Stated as a top-line target, this proposal goes beyond simply having indicators measuring coverage for different segments of the population, including different wealth quintiles. Achieving the target would be a major advance in health, and health equity.

Yet such a target is not ambitious enough. It could enable significant inequities to persist, even in countries that meet this target.

The target of universal health coverage should be just that – health coverage (meaningful coverage, at that, meaning true access, not simply some level of insurance coverage, for example) should be universal. The year 2030, the expected target date for the SDGs, will be a full three decades after the 1978 Declaration of Alma-Ata promise of “health for all” was to be achieved (by the year 2000), and 82 years after the Universal Declaration of Human Rights and the WHO Constitution enshrined the right to health (article 25; preamble). Enough with putting the day of the right to health for all still further into the future.

Achieving 100% coverage by 2030 will be a difficult challenge in some countries. Yet we should not aim for anything else. We should scale up our collective efforts to meet our ambitions, rather than scaling back our ambitions to meet our diminished efforts.

This is not to dismiss the idea of focusing on the poorest segments of the population. This will reduce the risk of countries focusing last on the poorest even within the 15-year period. It will reduce the risk that if countries believe that despite their best efforts (along with international partners, as needed) 100% coverage is not possible, they would accept less than maximal efforts to reach the poorest — the often the hardest to reach and those with the least political power. Therefore, a target could remain focused on the poorest segments of the population, on the assumption that if the poorest 40% are fully covered, those in wealthier quintiles will be too. So how about this 100/40 target?

Or perhaps dual targets of 100/20 and 100/100. Even people in the middle of the wealth bracket in some countries may still be quite marginalized or otherwise at risk of being left out. They may themselves be impoverished. For example, according to the World Bank, 46% of people in Nigeria live below the poverty line, with other statistics (from Nigeria’s own government) suggesting that in fact 61% of Nigerians live in absolute povertypoor may be with few more means than those who are officially poor. number of even middle class Americans without health insurance (though to repeat, universal health coverage cannot stop at insurance).

Dual targets of 100/20 (100% coverage for the poorest 20% of the population) and 100/100 (100% coverage for the entire population) may be appropriate, even if technically redundant. They would simultaneously highlight the need to reach everyone, and make the firm statement that the world will be keeping an extra eye on the poorest segment of the population, those most likely to be left behind.

Moreover, a target that accepts 20% of people not being covered raises the question of who is not covered. This is 8% of the total population, a significant minority. It leaves considerable scope to exclude a significant number of poorer members of society from health coverage. And in further defiance of the right to health, disfavored, discriminated against minorities — indigenous populations, or the very poorest members of society, for example — could be left out entirely even in countries achieving this target.

Consider, for example, the Rohingya, the furiously discriminated against Muslim minority in Burma, who often are not even allowed to receive government health services. They comprise only a very small fraction of the population (1.3 million of 60 million). The government of Burma could achieve an 80/40 target – and indeed even a more ambitious – though not universal – target without changing its policies towards the Rohingya.

The converse is another risk of an 80/40 target. While there is considerable overlap between poverty, marginalization, and obstacles to health care — which would therefore be well-captured in a target  focused on the poorest parts of the population — some marginalized populations face particular obstacles to accessing health care that are not necessarily congruent with simply not having enough money. For example, people with physical and mental disabilities – while severely disproportionately represented among the poor – include people who are above the two lowest income quintiles. Yet they may still face issues of physical accessibility and obstacles such as discrimination or misunderstandings of health workers about their needs. Similarly women and members of the LGBTI community who are frequently subject to discrimination and other mistreatment might avoid health services even if they are not poor. Refugees or other linguistic minority might face linguistic and culture barriers.

Even joint 100/100 and 100/20 targets would not solve this. There is no incentive in these targets to ensure that the pathway towards 100% addresses barriers not directly linked to income, even as these would ultimately need to be removed to achieve universal coverage. To avoid a low priority to removing these barriers, sub-targets (yes, targets of 100%, technically redundant but helping focus mind and policies alike) for certain sub-populations whose marginalization is not primarily derived from poverty could be in order. An approach of combining global and nationally-determined sub-targets could work. Globally mandated sub-targets could exist for frequently marginalized populations, such as people with disabilities and indigenous populations (recognizing the latter might not be universally applicable), alongside country-determined sub-targets based on the particularly situation of marginalized populations in their country. 

Sensitivity would be needed. For example, LGBTI would be a highly appropriate, universal category for such sub-targets, but given the legal and policy environment and extreme levels of homophobia (or even lower levels of homophobia or other factors) that require many LGBTI people to keep their status private, trying to measure their health coverage would be quite difficult at this time. For other populations, such as people with disabilities, while statistics might not presently exist, including targets that recognize their particular needs would force countries to develop better health information systems, which could lead to data that in turn leads to better policy interventions and greater political salience.

Another shortcoming of the 80/40 target is fluidity. The poorest 40% today will not be the poorest 40% tomorrow, and certainly not next year. People will have gotten and lost jobs and other sources of wealth. This fluidity will be greatest in this lower wealth brackets, where informal sector work is common, people move in and out of jobs frequently, and they have a small (if any) stable base of wealth. Therefore, to the extent governments incorporate the 80/40 target into their policies with an express focus on the 40%, they seem destined to miss people, or to have programs with significant administrative costs required to continually determine and re-determine eligibility. This is money that would be better spent on the health services themselves.

The administrative costs of policies targeted at the poorest 40% are likely small, however, compared to the political costs of such policies that a 80/40 or a target of its kin could spur some countries to adopt. This comes from the political reality of a target focused on a country’s poorer residents on the one hand and universal coverage, with an unambiguous universal goal encompassing the richest to the poorest, on the other. As we know well from experiences in the United States, with the political sensitivity of the universal social welfare programs of Social Security and Medicare compared to programs targeting lower-income Americans, universal programs have far greater political support and staying power. If UHC becomes about reaching the poor as opposed to meeting the needs of everyone, will UHC – much less a version that comprehensively meets people’s needs – be sustained?

Finally, there is the bigger question of what universal health coverage means. Will universal health coverage be provided through systems that are designed to achieve the same comprehensive level of health services for all members of the population – universal health systems – or will health systems be segmented such that some members of the population (such as those who make financial contributions through employment-based health insurance schemes) are guaranteed more health services than others in the population? Countries should structure UHC from the beginning to achieve the first type of health systems.

Yet an 80/40 target could push countries towards the latter, a segmented system, sufficient to ensure that the poorer part of the population receives sufficient coverage to qualify as being covered, but without the unitary health system that treats health as a right, equally for rich, poor, and everyone in between, the intent of systems (if still with major shortcomings) in such countries as Brazil and (following a Constitutional Court ruling) Colombia.

The message of the 80/40 target could be construed as intended, a message of inclusion, the need for special efforts to ensure that those most likely to be left behind. But the message of 80/40 could also be misconstrued as one of differentiation. When it comes to issues of people rich and poor, with more and less political power, this could well mean exclusion, and be manifested in a system that provides coverage for the poorer members of the population but is distinct from the system for other members of the population. This might mean a health insurance scheme for the poor that is less expensive and offers fewer benefits than other people in the country are ensured.

The right to health is worded, in full: “right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” The right of everyone. To the highest attainable standard of health. The same standard for rich and poor; no differentiation here. This needs to be the aim of universal health coverage. We need targets — and laws, strategies, policies, budgeting — for UHC that will drive the development of health systems that meet this aim — this human right, this legal obligation — while still being true to the great distances we  have yet to travel, particularly for all those people who are poor or otherwise disadvantaged and excluded.

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  • Claudio Schuftan says:

    Some of the points well taken.
    The blog would have benefited from a summary para towards the end to bring together the multiple options explored and suggesting the direction the author favors for the future.
    A caveat:
    Equity is a justice term; equality is the correct human rights term that is meant in this blog.

  • Hala Abou-Taleb says:

    Points are very well taken. It would have been very useful to reflect and suggest different policies and approaches in low resource, conflict and post conflict settings where right to health principles, values and elements are challenged and compromised in those settings. Need to acknowledge that prioritization in those settings should not be at the expense of promoting and protecting right to health and suggest practical approaches and policies and indicators to monitor them.

  • Jon Jay says:

    Keep an eye on the UHC event at the WB-IMF spring meeting on Apr 11–they’ll be sharing the revised monitoring framework, or at least some key updates. I hear the 100/100 suggestion has been very popular in civil society and could show up in the new round of edits.

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