Universal health coverage: a global problem with local solutions

With health for all leaving no one behind as its stated aim, the concept of universal health coverage (UHC) is at the forefront of planning and implementation of global health policies and programmes. In 2005, the World Health Assembly called governments around the world to promote health systems and services that would facilitate the delivery of UHC to all population groups.

On 12 December 2012, the United Nations General Assembly endorsed a resolution on global health and foreign policy urging all countries to accelerate progress on UHC. As, on 12 December this year, we observe International Universal Health Coverage Day, we must ensure everyone has access to quality healthcare services as needed, without facing financial hardships. A large proportion of the global population continues to be deprived of healthcare services, emphasizing the continuing relevance of UHC and its significance in achieving SDG 3.

Progress on achieving UHC has been a mixed bag since 2012, with some positive results and with many unmet needs. According to WHO data, about 2 billion people in 2019 were facing financial hardship as a result of healthcare expenditure, including 1 billion who experienced catastrophic out-of-pocket expenses, and 344 million people who went deeper into extreme poverty due to incurring them. On a positive note, the UHC service coverage index (SCI) increased from 45 to 68 between 2000 and 2021, but the pace of progress on SCI has been stagnated since 2015. In 2021, about 4.5 billion worldwide were not fully covered by essential health services.

In September 2019, a High-Level Meeting (HLM) on UHC was organized by the UN to understand the gaps, to create a roadmap for future action, and to reaffirm political commitments. Understandably, progress has been much more challenging in low-income countries (LICs) and lower-middle-income countries (LMICs). For example, impoverishing health spending at the extreme poverty line is primarily concentrated in these countries, which have higher poverty rates. The COVID pandemic further stagnated progress. Rural and isolated areas in LICs and LMICs show greater vulnerabilities, with the most affected groups being older people and women and girls of all ages.

Additionally, population ageing, with growing numbers of older people who require greater healthcare, will present complex challenges for UHC delivery in future. Inequality also remains a major challenge for UHC; in many cases, overall national data may show progress, but this may mask specific concerns and vulnerabilities within a given country.

A wide range of challenges present barriers to progress on UHC. On a broader national level, these include lack of coordination within and between health departments and other agencies, inadequate human resources for services delivery, and insufficient financial allocations. At the ground level within the local communities, key gaps include lack of awareness and lower levels of health education, meagre participation of local communities in planning and implementation of initiatives, limited human resources required for service delivery, and a significant lack of partnerships addressing different aspects of UHC.

While achieving UHC is a complex task that requires strong political will, adequate financial support and national-level policies and programmes, the efforts made at ground level by community-based organizations (CBOs) and civil society organizations (CSOs) continue to be of paramount importance. This support may range from community mobilization, awareness generation, training and capacity-building to delivery of primary care and health education services and enhancing the spread of health insurance coverage.

GRAVIS, a CSO, takes a holistic and community-led approach towards progressing on delivery of UHC in remotely located rural areas of India. It strongly emphasizes the importance of forming and nurturing local CBOs, including intergenerational learning groups (ILGs), self-help groups (SHGs) and village health committees, and engaging in capacity-building to facilitate local ownership of health programmes; Gravis also believes in demonstrating the outreach medical services model and in facilitating partnerships that address health education, health insurance coverage and delivery of primary care within communities at risk. As such, an important focus has also been on training of caregivers and health worker cadres. A population of about 2.5 million, vulnerable to health-related financial hardships and poverty, benefit from GRAVIS’s integrated approach.

It is essential that UHC is looked at with a global vision that has a localized approach and a community-centred implementation strategy. Moving forward, a stronger focus may be needed on identifying of and capacity-building of local CSOs and CBOs who can contribute actively towards community mobilization. There is also an urgent need to create and nurture multistakeholder partnerships addressing gaps related to health services delivery and in health insurance coverage. Continued focus on vulnerable groups including older people and women and girls will be extremely important in future interventions. Finally, bridging data gaps to reflect neglected and remotely located population groups will also be crucial to assess progress and determine future priorities.

On International UHC Day, it is important to raise awareness of UHC, financial protection and the unmet needs of vulnerable communities around the world. Overall progress on the health aspects of the UN’s 2030 Agenda largely depends on how effective UHC interventions are in the foreseeable future. It is time to strengthen localized, communities-led action to make UHC a reality. The pace that has been stagnant since 2015 must accelerate once again.