The World Health Organization (WHO) and the World Bank have published the 2023 Universal Health Coverage (UHC) Global Monitoring Report, which revealed some alarming statistics concerning out-of-pocket (OOP) health expenditure and the global health service coverage rate. The report showed that only 42 out of 138 countries have achieved progress in expanding UHC service coverage since 2000 while also reducing OOP spending for the population. Alternatively, 108 countries reported worsening to no significant changes in health coverage since 2015, the year when Sustainable Development Goals (SDGs) were adopted. All 108 countries that experienced slow progress in UHC service coverage are low-income countries (LICs) and lower-middle-income countries (LMICs). Despite that, the overall global UHC Service Coverage Index (SCI) score increased from 45 to 68 out of 100 between 2000 and 2021, but no change was reported in the global SCI score between 2019 and 2021. Notably, a significant variation in country-level SCI scores has persisted since 2021, ranging from 28 to 91, with a strong association between SCI and countries’ income levels.
Despite the percentage of the global population not covered by essential health services decreasing by nearly 15% between 2000 and 2021, 4.5 billion people—more than half of the world population—were not fully covered by essential health services as of 2021.
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The report also shows that more than one billion people incurred “catastrophic” OOP health spending in 2019, while two billion people experienced catastrophic spending, impoverishing health spending at the relative poverty line, or both in the same year. Moreover, the global percentage of people living in households spending more than 10% of the household budget on OOP health expenses has continuously risen to reach 13.5% in 2019. In a comparison between 138 countries, the report found that impoverishing OOP health spending at the extreme poverty line is primarily concentrated in LICs and LMICs, which have higher poverty rates. However, there is no strong relationship between impoverishing OOP health spending at the relative poverty line and a country’s income level.
Additionally, the WHO and World Bank estimate that the slow progress towards UHC stated in the report is associated with the emergence of Covid-19, as the SCI score significantly stagnated or worsened between 2019 and 2021. During the pandemic, severe disruptions in delivering health services, logistics, and financial burden on health systems played major factors in slowing UHC progress. However, it is notable that for the majority of LMICs and LICs, the slowing rate of UHC coverage was already palpable after 2015, five years before the emergence of the pandemic.
These staggering findings could be attributed to the unrealistic expectations from the SDGs that were signed that year by the majority of world countries, including LICs and LMICs, where a large portion of them have systemic failures in their national health systems, a “brain drain” of medical personnel, a lack of health infrastructure, and severe underfunding. Therefore, the Covid-19 pandemic emerged and promptly exposed the vulnerability of healthcare systems in most of these countries. Even in 2023, with the reduction in Covid-19 cases worldwide and a partial recovery of health systems, several African health systems (as a prominent example) are still suffering from the pandemic’s detrimental impact on health workforce availability, as major resources and funding were directed to tackle Covid-19, further burdening limited national health sector budgets. This has affected the salaries of medical staff in public hospitals in several African countries, including Egypt, Nigeria, and Ghana.
Sadly, it is not expected that the current stagnation of the UHC service coverage rate will be reversed in the short term in LMICs and LICs compared to higher-income countries due to the current macro-economic challenges in sub-Saharan African countries, Latin America, and some low-income Asian countries. These factors continue to hinder the full UHC service rollout due to a lack of adequate resources. It also means bad news for the pharmaceutical industry in these countries, as delays in the implementation of UHC suppress demand for medicines and may also be a reason for poor adherence to treatment due to affordability issues.
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