As the world struggles to recover from the relentless coronavirus pandemic, the goal of Universal Health Coverage (UHC) has become more relevant than ever. UHC means that people have access to community services that promote healthy habits, disease prevention and early detection, quality medical treatment and rehabilitation services without suffering financial hardship.

COVID-19 has underscored just how elusive UHC is. Over the past 20 months more than 5.2 million people have died from COVID-19 and many more have seen their access to regular or urgent care restricted. More than 114 million people have lost their jobs and the health coverage that comes with it, and an unprecedented 97 million people have been pushed into poverty and are now more vulnerable to catastrophic spending. The pandemic has also reduced tax revenues and diverted existing resources to other needs just when fresh health funds are most urgent. Will we fail in our quest for UHC? It is too early to say, but there is reason for optimism.

Mixed progress on UHC

December 12th marks both the 10^th anniversary of the endorsement by all countries of the United Nations resolution to accelerate progress toward UHC, and 5 years since the UN officially designated the 12^th of December as International Universal Health Coverage Day. We are fast approaching 2030, the established deadline to meet the sustainable development agenda, including the overarching health goal of UHC. This is a good time to pause and reflect on progress made so far, what has worked well and what could have been done differently and on how to gear back, refocus, remove access barriers, and accelerate progress.

Even before the pandemic hit, UHC implementation was mixed, and we were not on track to reach UHC. Significant reductions in mortality—mostly related to transmissible disease and maternal, newborn, and child health—had been observed in most non conflict-affected countries for several decades. But the incidence of catastrophic health expenditure (defined as large out-of-pocket spending in relation to household consumption or income), increased continuously from 2000 to 2015, especially in the poorest regions of the world.  

There are many reasons for this. Most importantly, the pledges to accelerate progress have not translated into the necessary budget commitments. On average, overall health spending in low- and middle-income countries (LMIC) has increased minimally, from 5 percent to 5.4 percent of GDP from 2010 to 2018. Moreover, rich donor countries have decided to scale back on development assistance for health at critical times—most notably in three essential areas of health care: 1) HIV, TB, malaria, and other infectious diseases, 2) maternal, newborn. and child health, and 3) family planning. Finally, and no less important, population growth, aging, and the introduction of new health technologies, for instance COVID vaccines and treatments, keep expanding the scope and needs for essential interventions, turning UHC into a moving target.

Time to double down

The pandemic will leave behind important lessons. As health systems are stressed, they reveal their intrinsic strengths and weaknesses in both rich and poor settings. One emerging consensus is that strong health systems help protect the economy. Countries that responded early and decisively to the pandemic also managed to shelter their economies from excessive disruptions by keeping their labor force protected and properly communicating what works best to keep populations safe. Where highly fragmented health care systems are the norm, it also revealed the difficulties of an effective and coherent national response—whether in preventive measures or access to scarce hospitalization services.

Supply chains and procurement systems for essential services and commodities, such as oxygen, face masks, or vaccines, proved more fragile and less responsive than planned and the capacities of health systems to produce and properly communicate basic health activity and mortality statistics in a timely, reliable, and actionable way became a major concern. 

Getting back on track will be challenging but achievable. Political commitments should now translate into more actionable recommendations and mobilizing more resources for health is the obvious place to start. Lost global economic output is estimated at almost 3 trillion USD for 2020 alone. If the economic value of lives lost is included the figure is 3 times larger. This is only a fraction of what is required to deliver UHC for essential services to all countries across the world. 

The leading takeaway from the pandemic is that investing in health system strengthening for UHC not only saves lives but also delivers high rates of economic returns. New and existing resources will not be enough, and smarter choices need to be made on who should get coverage and what should be offered. Preventing and controlling disease through primary care has been emphasized as the most cost-effective way  to tackle transmissible and fast emerging non-communicable diseases.

There is a high probability that the poorest regions of the world will be left behind and external help will be needed in a more coherent and systematic way; targeted and sustained development assistance for health should be the third line of action. 

And finally, financial protection will require comprehensive reform in the financial arrangements to effectively pool national resources, giving priority to those interventions that close the access gaps across populations.

Universal Health Coverage will remain first and foremost a political movement that needs to creatively and effectively find its way into national and local policy priorities. There is still time to turn the UHC into a success story. We should not let a health crisis of this magnitude go to waste. The pandemic has been a stark reminder of the human and economic costs of not having made larger and smarter investments in health.