The universal health coverage ambition faces a critical test
Authors: Margaret E Kruk, John E Ataguba, Patricia Akweongo
Journal: The Lancet (2020)

Universal health coverage (UHC) has been a focus of the global development conversation over the past decade and, increasingly, of national policy making in countries across a wide range of income levels. The political salience of UHC is rooted in its attractive value proposition: to provide good quality health-care services to all citizens who need them without causing financial hardship. However, comparing progress towards UHC across countries is exceedingly challenging given the wide variations in national resources, health systems, epidemiological and policy priorities, and availability (or unavailability) of reliable, recent data among countries. In The Lancet, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 Universal Health Coverage Collaborators tackle this challenge by constructing a weighted mean of the effective coverage of 23 health services in 204 countries.1GBD 2019 Universal Health Coverage CollaboratorsMeasuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; (published online Aug 27.)https://doi.org/10.1016/S0140-6736(20)30750-9Google Scholar This is an improvement over past measures of service coverage (eg, contact with the health system) because coming to the clinic does not always improve a person's health when the care is of low quality or available services do not match the patient's needs. Effective coverage, by contrast, captures the proportion of possible health gains people receive from interacting with the health system.2Leslie HH Malata A Ndiaye Y Kruk ME Effective coverage of primary care services in eight high-mortality countries.BMJ Glob Health. 2017; 2e000424Crossref PubMed Scopus (47) Google Scholar The GBD 2019 Universal Health Coverage Collaborators found overall improvements in effective coverage between 1990 and 2019 but also persistent, large divides, with a number of rich countries achieving 95 or higher on the 0–100 scale and several low-income, fragile states scoring closer to 25. The authors estimated US$1398 per capita as the threshold for achieving a UHC effective coverage score of 80. Although financing was not a focus of the analysis, both the amount and means of financing via primarily public insurance schemes rather than out-of-pocket spending are notable findings that will challenge current spending envelopes and financing modalities for health care in many countries. Because of a dearth of data on effective coverage in many countries, the authors used service coverage for four of the 23 indicators and mortality-to-incidence or mortality-to-prevalence ratios for the remainder. Mortality-to-prevalence ratios capture deaths from conditions that health systems ought to be able to cure or prevent. Although the mortality-to-incidence approach is conceptually sound, its validity is contingent on the quality of data on mortality and disease prevalence, which is known to be weak in many low-income countries. For example, in India, one in three deaths is not registered in the vital statistics system and a medically certified cause of death was recorded in just 17% of registered deaths.3Gupta M Rao C Lakshmi PV Prinja S Kumar R Estimating mortality using data from civil registration: a cross-sectional study in India.Bull World Health Organ. 2016; 94: 10-21Crossref PubMed Scopus (22) Google Scholar The GBD 2019 Universal Health Coverage Collaborators deal with this limitation by modelling missing national values using systematic triangulation and imputation techniques. There is much to admire about the ambition, scope, and innovative analytical methods of the paper. Yet the paper also raises some fundamental questions about the relevance of this approach to measuring UHC progress at this moment in time. First, the concept of UHC and thus its measurement do not encompass the resilience of health systems to crisis. Epidemics and disease outbreaks are not counted explicitly in any UHC measure—they are relegated to a separate silo of "preparedness". Yet, as we have seen in the COVID-19 pandemic, ensuring that all people have access to testing, treatment, rehabilitation and, when available, prevention through vaccination, are universally viewed as core functions of a successful health system. Any index of UHC that is fit for purpose thus must encompass the fuller goals of a health system, including its ability to avert deaths from outbreaks while maintaining high-quality health services for other conditions.4Kruk ME Myers M Varpilah ST Dahn BT What is a resilient health system? Lessons from Ebola.Lancet. 2015; 385: 1910-1912Summary Full Text Full Text PDF PubMed Scopus (294) Google Scholar Second, bundled national metrics do not tell us about who benefits from UHC in the country. It is possible to achieve a decent score on the effective coverage index by averting amenable mortality for part of the population while neglecting the needs of the rest. Without national disaggregation, such metrics can obscure large inequities and introduce false equivalence in inter-country comparisons.5Victora CG Barros AJD França GVA da Silva ICM Carvajal-Velez L Amouzou A The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries.Lancet Glob Health. 2017; 5: e402-e407Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 6Ataguba JE Ingabire MG Universal health coverage: assessing service coverage and financial protection for all.Am J Public Health. 2016; 106: 1780-1781Crossref PubMed Scopus (14) Google Scholar Finally, as the world grapples with the adverse consequences of globalisation, diminishing trust in experts and data, and growing awareness of structural racism, sexism, and imbalances in global power, it is time to ask: for whom is this measure? As with other global metrics, the UHC index is maximally tailored to promote accountability to global bodies, such as the UN, and to be debated in global journals and conferences.7Shiffman J Knowledge, moral claims and the exercise of power in global health.Int J Health Policy Manag. 2014; 3: 297-299Crossref PubMed Scopus (113) Google Scholar How would the index look if the direction of accountability shifted to people in countries: the users (and non-users) of health care? This would require political courage to face health-system flaws, investment in national health measurement, and commitment to using data to improve health systems.8Kavanagh MM Katz IT Holmes CB Reckoning with mortality: global health, HIV, and the politics of data.Lancet. 2020; 396: 288-290Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Although domestic funding is the necessary base, global actors should be prepared to shift resources towards helping countries produce national data that are most useful to local actors working to build high-quality health systems. Without nationally meaningful measures and governments' accountability to their population, UHC may become an empty signifier: a non-threatening tool for enhancing a country's global status rather than maintaining and improving health for all its citizens. MEK reports personal fees from Rabin Martin and Merck and Company, outside the area of work commented on here. JEA and PA declare no competing interests. Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Full-Text PDF Open Access