Universal health coverage

EXECUTIVE BOARD

EB154/6

154th session

19 December 2023

Provisional agenda item 6

Universal health coverage

Report by the Director-General

1. At the half-way point to the 2030 Sustainable Development Goal of universal health coverage

(UHC), more than half the people in the world are still not fully covered by essential health services

with a quarter of the world’s population facing financial hardship due to out-of-pocket health spending.

Progress towards UHC has stalled alarmingly in many countries and financial protection has been

progressively worsening for two decades.

2. This situation and progress towards Sustainable Development Goal 3 (Ensure healthy lives and

promote well-being for all at all ages) were addressed at the United Nations General Assembly’s

high-level meeting on universal health coverage on 21 September 2023, with the subsequent adoption

on 5 October 2023 by the General Assembly at its seventy-eighth session of a new political declaration

on universal health coverage: “expanding our ambition for health and well-being in a post-COVID

world”.

World leaders committed themselves to redoubling efforts to achieve UHC by reorienting

health systems and investments through a primary health care approach. Despite the growing

complexities of delivering health for all and ensuring the right to health at a time of challenging

demographic, environmental and macroeconomic trends, many countries showed in their statements

ways in which progress towards UHC can be achieved through investing in a primary health care

approach with strong political commitment. Urgent action and investments are needed. In the political

declaration, Member States reaffirmed their resolve to provide health coverage for one billion additional

people by 2025 and to provide measures to ensure financial risk protection and eliminate

impoverishment due to health-related expenses by 2030. They decided to convene a high-level meeting

on universal health coverage in 2027 to review the implementation of these commitments.

PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE

3. WHO’s global monitoring report for 2023 on tracking universal health coverage,

launched on

18 September 2023 by WHO and the World Bank, shows that the world is off track in making significant

progress towards achieving UHC by 2030 (Sustainable Development Goal target 3.8). In total,

4.5 billion people were not fully covered by essential health services in 2021, and 2 billion people

experienced catastrophic health spending

or impoverishing health spending (namely, any form of

financial hardship) due to out-of-pocket spending on health in 2019, the most recent year for which data

are available.

Resolution A/RES/78/4 (https://www.undocs.org/Home/Mobile?FinalSymbol=A%2FRES%2F78%2F4&Language

=E&DeviceType=Desktop&LangRequested=False, accessed 27 November 2023).

Tracking universal health coverage: 2023 global monitoring report. Geneva: World Health Organization; 2023 and

Washington DC: World Bank; 2023 (https://www.who.int/publications/i/item/9789240080379, accessed 24 November 2023).

Defined as exceeding 10% of a household budget.

EB154/6

4. Although the global UHC Service Coverage Index increased from 45 to 68 (out of a possible 100)

between 2000 and 2021, progress slowed after 2015 as most countries saw stagnation or deterioration

in service coverage. Overall, country-level estimates of that index have become more equal since 2000,

as countries with lower scores have made progress towards catching up to their peers with higher scores.

However, there was an abrupt reversal in this trend after 2015 in all regions except in the African and

South-East Asia regions where inequality continued to be reduced. Moreover, within-country

inequalities persist, with rural and poorer populations experiencing lower service coverage than national

averages.

5. Catastrophic out-of-pocket health spending reduces households’ ability to obtain other essential

goods and services. Since 2000, the size of the global population with out-of-pocket health spending

exceeding 10% of the household budget has continuously increased to surpass one billion people

in 2019.

6. For people living in poverty or in near poverty, any amount of out-of-pocket health spending can

be a source of financial hardship, even if it represents less than 10% of their household budget, as they

have a lower capacity to pay for health care. In 2019, 1.3 billion people incurred impoverishing health

spending at the relative poverty line, and 344 million people faced impoverishing out-of-pocket health

spending at the extreme poverty line of US$ 2.15 a day in 2017 purchasing power parity.

7. Within countries, financial hardship was concentrated among the poorest (people living in the

least well-off households) mostly owing to the higher rates of impoverishing out-of-pocket health

spending. Catastrophic health spending was more prevalent among households with older members

(aged 60 years or over). People living in rural areas and the poorest are the least likely to be fully covered

by essential health services and they also face higher rates of financial hardship.

8. The lack of dual progress on service coverage and financial protection is consistent across all

geographical regions and country income groups. There have been some important gains in the global

coverage of essential health services since 2000, notably substantial improvements in service coverage

for infectious diseases, particularly in low-income and lower-middle-income countries. Progress in

service coverage for noncommunicable diseases and maternal and child health, however, was minimal;

service coverage improved between 2000 and 2015 in low-income and lower-middle-income countries,

but at the same time these countries experienced the largest increases in catastrophic out-of-pocket

health spending. Since 2015, all regions have experienced the same pattern of stagnating service

coverage and worsening financial hardship.

9. Despite improvements until 2015, progress in coverage of essential health services (Sustainable

Development Goal indicator 3.8.1) decelerated and stagnated between 2019 and 2021, while

catastrophic health spending (indicator 3.8.2) worsened continuously between 2000 and 2019.

10. Despite the alarming overall global trend of stagnation in extending UHC, 30% of countries (42 of

the 138 countries with available data for both indicators since 2000) expanded service coverage, while

reducing their respective share of the population incurring catastrophic out-of-pocket health spending.

Extending quality service coverage together with progress on financial protection is crucial to achieving

UHC. Although this has not occurred in most countries, experiences from countries at every income

level have demonstrated the feasibility of implementing strategies that are effective in tackling financial

hardship, particularly for the poorest and most vulnerable, while expanding service coverage.

EB154/6

11. Available data from a relatively small subset of 23 countries show a worsening in catastrophic

and impoverishing out-of-pocket health spending and an increase in forgone care owing to financial

barriers in 2020‒2021 during the pandemic of coronavirus disease (COVID-19) (when fewer household

surveys were completed).

12. The combined macroeconomic, fiscal and health impacts of the COVID-19 pandemic and

emerging evidence of rising poverty led to the weakening of financial protection globally and the

worsening of service coverage. The disruptions resulted from a mix of demand and supply factors and

the diversion of significant health system resources to COVID-19-related services. Globally, there was

a stagnation of the UHC Service Coverage Index from 2019 to 2021 during the COVID-19 pandemic.

13. Urgent political action is needed to address the alarming stagnation of progress towards UHC.

Significantly improving the service coverage dimension of UHC by 2030 will require accelerating the

expansion of all essential health services, especially those for which minimal progress is being seen,

such as coverage for NCDs and maternal health. Any reduction in coverage levels could lead to rapid

increases in disease burden, potentially exacerbated by multiple crises, such as the expansion of the

habitats of the vectors of vector-borne diseases due to global climate change.

14. To reduce financial hardship, the heavy reliance on out-of-pocket health spending to fund health

services, especially in low-income and lower-middle-income countries, must be addressed by public

financing. Out-of-pocket health spending for people living close to the poverty line should be

minimized, and those living in poverty should be exempted from such payments. Removing financial

barriers to care would also improve service coverage, financial protection and health outcomes by

reducing the amount of care forgone.

15. Proactive policies, including increasing and aligning public and other health funding streams,

ensuring the efficient and equitable use of funding, expanding and strengthening the health and care

workforce, as well as expanding primary health care services and the orientation of the health systems

towards a primary health care approach across the life course, are crucial for advancing towards UHC

by 2030 amid ongoing economic, geopolitical and climate challenges.

UNITED NATIONS GENERAL ASSSEMBLY: HIGH-LEVEL MEETING AND

POLITICAL DECLARATION ON UNIVERSAL HEALTH COVERAGE

16. In adopting the political declaration on universal health coverage through the General Assembly

(see paragraph 2 above), Member States committed themselves to taking key national actions and

redoubling efforts to accelerate progress towards UHC by 2030. The political declaration reaffirms that

health is a precondition for and an outcome and indicator of the social, economic and environmental

dimensions of sustainable development and the implementation of the 2030 Agenda for Sustainable

Development. It also calls for greater priority for health in governments’ budgets and parliamentary

action along with smarter investments geared towards health promotion and disease prevention. Leaders

agreed that a primary health care approach is the best path to universal health coverage and resilience,

and that reorienting health systems in this manner is the most effective, efficient and equitable way to

deliver the promise of UHC.

17. Member States underlined their commitment to a comprehensive range of issues, including

boosting public financing for universal health coverage and primary health care and scaling up

investments in the education and training, employment and decent work, protection and retention of the

health and care workforce.

EB154/6

18. Member States also reiterated their commitment to ensure that no one is left behind on the path

to UHC and to reaching the furthest behind first. This goal involves equity approaches and setting

policies that influence health and well-being through the way people live, eat and work. It also requires

inclusive governance for health with social participation that supports the active engagement of people,

communities and civil society in decision-making processes, including the design, delivery and review

of health policies, programmes and plans to ensure better responses to individual and community health

needs, while fostering trust as part of a whole-of-society approach.

19. Member States also emphasized that clear vision and political commitment are crucial to advance

reorientation of health system towards UHC through a primary health care approach that includes

legislation, policy decisions and the financing of action, as well as stewardship, social participation and

accountability grounded in the principles of equity, human rights and social justice.

20. The political declaration further mandated the submission of progress reports to the United

Nations General Assembly at its seventy-ninth session (in September 2024) and eighty-first session

(September 2026) in order to inform a high-level meeting on UHC to be convened in 2027.

21. To take forward the recommendations of the political declaration on UHC, the Government of

Kazakhstan, WHO and UNICEF co-hosted an international conference (Astana, 23 October 2023) on

primary health care policy and practice in order to commemorate, respectively, the forty-fifth and fifth

anniversaries of the Declaration of Alma-Ata and the Declaration of Astana. The conference highlighted

the urgent need for collective action on primary health care and was an important opportunity for the

world to review and take stock of country evidence and experience. An advance copy of a global report,

entitled “Implementing the PHC approach: A primer”, was released; it includes 50 country experiences

highlighting the policy changes that support pathways for reorienting health systems towards primary

health care as well as lessons learned.

CONCLUSIONS AND NEXT STEPS

22. The Secretariat will continue to provide support to Member States in reorienting health systems

towards a primary health care approach as the most equitable, effective, inclusive and efficient path to

UHC. This work spans action to advance the three core components of primary health care,

with an

emphasis on primary care and public health functions; multisectoral policy and action; and empowered

people and communities, expediting implementation of the joint operational framework for primary

health care of WHO and UNICEF.

23. Though the UHC Partnership, WHO’s largest platform for international cooperation on UHC and

primary health care, the Secretariat is providing flexible and tailored strategic and technical support to

reorient health systems towards a primary health care approach in more than 120 Member States, with

more than 150 policy advisers on UHC deployed in WHO country and regional offices. In practice, their

support covers a wide range of activities aimed at reorienting health systems towards primary health

care in order to accelerate progress towards both UHC and health security.

WHO, UNICEF. A vision for primary health care in the 21st century: towards universal health coverage and the

Sustainable Development Goals. Geneva: World Health Organization; 2018 (https://iris.who.int/handle/10665/328065,

accessed 5 December 2023).

WHO, UNICEF. Operational framework for primary health care: transforming vision into action. Geneva: World

Health Organization and United Nations Children’s Fund; 2020 (https://www.who.int/publications/i/item/9789240017832,

accessed 25 November 2023).

EB154/6

24. The Secretariat will continue to collaborate with Member States and partners to tackle all health

system bottlenecks that hinder progress towards UHC, including challenges related to the health and

care workforce. This collaboration will involve prioritizing strategic investments in the protection,

education, employment and retention of the health and care workforce, particularly in countries facing

critical shortages and those with unique challenges like small island developing States. Through its

Working for Health programme

and the Working for Health Multi-Partner Trust Fund

(established in

2018), the Secretariat has provided direct supported to 23 Member States and two regional economic

groups in the African Region (the Southern African Development Community and the West African

Economic and Monetary Union) for developing, monitoring and guiding investment strategies in

workforce planning and financing, education and employment, protection and performance.

Additionally, the Secretariat will continue to collaborate with Member States on enhancing governance

and institutional capacity for workforce planning and management, including strengthening

multisectoral policy dialogue to deliver the intersectoral actions required to strengthen health and care

workforce education and employment. With data from 189 countries in 2020 demonstrating that 67%

of the health and care workforce are women, the Secretariat will also continue to facilitate the

identification of policy interventions that can address the systemic inequalities that have detrimental

impacts on the health and care workforce and health and care systems.

25. Another major health system bottleneck is inadequate health financing. At a time of fiscal and

macroeconomic constraints globally, the Secretariat will work closely with Member States in protecting

or increasing their health and other social expenditures and in spending more efficiently in order to

achieve higher service coverage and improved financial protection particularly for the poor, the

vulnerable and the marginalized. The Secretariat will also provide support to Member States as they

update and implement health financing strategies that are prioritized toward a primary health care

approach that is multisectoral in addressing the determinants of health and enables equitable access. The

Organization will continue to monitor and report the UHC indicators on service coverage and financial

protection, as well as out of pocket expenditures and its main drivers, to guide action.

26. The Secretariat is actively engaging Member States, international financing institutions,

development banks, philanthropic partners and civil society through multistakeholder platforms and

partnerships to drive progress towards UHC through a primary health care approach. Mechanisms

include the Health Impact Investment Platform launched on 23 June 2023 by WHO and multilateral

development banks to strengthen primary health care; the UHC2030 platform managed in collaboration

with OECD and the World Bank to advance political commitment and collective action for UHC; and

the primary health care accelerator in the Global Action Plan for Healthy Lives and Well-Being for All.

WHO’s Working for Health 2022–2030 action plan was adopted by the Health Assembly in 2022 in resolution

WHA75.17 (2022). The resolution also called on Member States to utilize, where relevant, the Global health and care worker

compact as guidance to inform national review, action and implementation on how to protect and support health and care

workers

For more information, see website of Working for Health Multi-Partner Trust Fund: expanding and transforming the

global health workforce (https://mptf.undp.org/fund/whl00, accessed 27 November 2023).

EB154/6

ACTION BY THE EXECUTIVE BOARD

27. The Board is invited to note the report and to identify opportunities to reorient health systems to

primary health care and advance implementation of the political declaration on universal health coverage

to accelerate progress. The following questions are proposed as a guide for discussion.

• How can Member States with the support of the Secretariat accelerate progress towards UHC

in ways that reach the furthest behind first in:

– enhancing financing for health sufficiently, equitably, efficiently and sustainably to expand

coverage of quality health services through a primary health care approach while ensuring

financial protection?

– optimizing and increasing national investments in the education, employment and retention

of the health and care workforce? Are there particular needs for groups of countries, for

example, small island developing States, countries with high inward/outward migration of

health and care workers, and countries with complex emergencies?

= = =