Universal Health Coverage UN HLM 2019 Logo
Image courtesy of the UN, via the World Bank.

At the end of this posting, which is mostly about universal health coverage, please see the update on actions that, if you are in the United States, you can take to create some measure of accountability for those responsible for the genocide of the Rohingya people in Burma and to end U.S. involvement in the war in Yemen. Thank you.

Last week, world leaders agreed to a political declaration at the UN High-Level Meeting for Universal Health Coverage (UHC), recommitting themselves to health care for all. Yet the more significant news on UHC may have come the day before the gathering, when WHO released a report on UHC progress, with these stark figures in its news release:

  • Up to 5 billion people will be unable to access health care in 2030 under current trends.
  • An additional $200 billion per year is needed to scale up primary health care in low- and middle-income countries. This could save 60 million lives and increase average life expectancy by 3.7 years by 2030.

Look inside the report, and we can gain further critical insights on the path towards UHC – the funding required, how quickly scaling up health care coverage and access must happen, uncertainties in measurement (a perhaps technical sounding yet vital issue), and WHO’s own messaging. We begin with the last of these.

Note to WHO: Aim for UHC, nothing less: WHO must message for universal health coverage. If it is not a full-throated advocate, who will be? Yet, oddly, the funding requirement that WHO included in its news release is only about half of what is required to achieve UHC by 2030. As the report explains, while an additional $200 billion per year is required for primary health care, to achieve universal health coverage in low- and middle-income countries, total investments in health must be about $371 billion per year (p. 95) (covering 95% of people in low- and middle-income country, so perhaps closer to $390 billion overall). This would save nearly 100 million lives (p. 5).

WHO topline messaging going forward should be what is required for UHC, nothing less.

Uncertainty in numbers, uncertainty in reality? How many people have access to essential health services today? Only a minority of the world’s population, WHO reports: 33%-49% (in 2017), or about 2.5-3.7 billion people, meaning that 3.8-5.0 billion people lack coverage (p. 19). Come 2030, under current trends, 39%-63% will still lack access to essential health services. That’s 3.1-5.2 billion people (p. 20).

The range of uncertainty is significant. If the number of people with access to essential health services even today is so uncertain, with 1.2 billion people having, or not having, access to essential health services depending on whether the upper-end or lower-end estimate is accurate, come 2030, how will we actually know whether universal health coverage has been achieved? Perhaps more significantly, at country level, how will governments and the public know whether everyone has access to essential health services? How contested might claims of universal access be? And how can governments be sure that everyone has access if there is such uncertainty? Investment in data collection and use – including disaggregated data – is critical

Very full speed ahead: WHO has a goal of increasing coverage by 1 billion people by 2023, which would require about doubling the current pace of increase (p. 20). That increase would mean 400-600 million people with universal health coverage beyond current trends. This would still leave the world terribly far from the acceleration of assess required to cover the 3.1-5.2 billion people who would lack coverage under current trends. From 2023 on, during the second half of the Sustainable Development Goals era (2016-2030), the world will need to do far better at extending health services than during the first half.

Perhaps such acceleration would be possible; extending health infrastructure to remote rural areas and training more health workers, for example, could take time, leading to accelerating gains as the infrastructure is developed and the workers are trained. Yet reaching the most marginalized people – who live far from any health facility, or whose experiences of discrimination have led to deep distrust, or whose poverty means they cannot afford transportation or a day away from work, for instance – may be hardest, leading to slowing, not accelerating, gains as the world nears universal health coverage.

Whatever the case, one thing is clear – given the number of people who will need to receive coverage immense even if the pace of coverage gains doubles over the next several years, all that is possible must be done right away to extend access as soon as possible.

Funding UHC in low-income countries: Of the 3.1-5.2 billion people who will not have access to essential health services under current trends, 500-600 million are in low-income countries (p. 21), very large majorities of their populations. These countries’ total GDP in 2018 was below $600 billion. Following the WHO recommendation that countries spend an additional 1% or more of their GDP on health, which world leaders in their boldness noted in their political declaration (no commitment there), this would mean an additional – at least – approximately $10 per person not on track to be covered in low-income countries. (That is, increased health spending of at least about $6 billion, spread across 500-600 million people.) Yet WHO notes that on average, achieving UHC will require an additional $58 per person (p. 96). Costs are lower in low-income countries, but it would appear that between domestic government funding and external assistance, far more than 1% of GDP will be required. Low-income country governments will need to very significantly increase their health spending, and considerable external assistance will be required.


One last thing. I’ve written before about the genocide against the Rohingya and crimes against humanity and war crimes against the people of Yemen. We are at a critical moment of action. The National Defense Authorization Act for the coming fiscal year is now being finalized by a joint House-Senate committee. The version of the bill that the House of Representatives passed earlier this year includes sanctions against Burmese military officials who have perpetrated severe human rights abuses (along with sanctions on their economic holdings), and prohibits U.S. support for the Saudi-led  military campaign in Yemen. The Senate version does not include these provisions.

If your Representative or Senator is part of the House-Senate committee charged with reconciling the House and Senate versions of the bill, email or call their office, and offer your strongest possible support for including the sanctions against the Burmese military and the prohibitions on U.S. support for the military campaign in Yemen in the final version of the legislation.