Some 4.6 billion people, or more than half the world’s population, still lacked access to a basic package of essential health services in 2023, a new World Health Organization-World Bank report notes. And around 2.1 billion people faced financial hardship in getting vital health services. 

And at current rates, the world will fall far short of goals to achieve Universal Health Coverage (UHC) by the year 2030, in line with the Sustainable Development Goals, according to the 2025 UHC Global Monitoring Report, released on Saturday. 

Although the picture is more complex, the goal is tracked in terms of two basic SDG indicators – a UHC service coverage index and financial hardship in accessing services. 

The release coincided with a Japan-hosted Conference UHC High Level Forum, which brings together WHO member states to review progress and discuss the challenges faced. 

While access to health services rose sharply, and financial hardship in getting healthcare declined during the era of the Millenium Development Goals between 2000-2015, progress slowed in the SDG era – with the COVID pandemic also creating setbacks. 

At current rates, the “global service coverage index (SCI)” – which measures key indicators of access to a package of health services, will only reach 74 points out of 100 in 2030 – as compared to xxx today. And close to 1 in 4 people globally will still face “financial hardship” in accessing health services – about the same as today. 

Financial hardship is a revised indicator, now defined as outlays of 40% or more of disposable household income on medicines, treatment and diagnostics. 

The Service Coverage Index (SCI)  combines 14 tracer indicators of service coverage into a single summary measure. 

“The SCI is not a direct measure of what percentage of people have (or lack) access to essential health services,” noted Gabriella Saint-Germain, WHO team leader of financial protection, in an email to Health Policy Watch.  “Instead, it is a combined score that reflects how well a health system provides access to key services overall. However, like the service coverage index, between 2022 and 2023 there is little change in the number of people without access to essential health services. Population growth … is also a factor.”

Bright sides exist 

Amidst the gloomy forecast, some bright sides exist: 

Since 2000, roughly 53% of countries reporting data have achieved progress, measured in terms of improvements in services and access and reduced financial hardship. But since 2015, only 38% have done so.

And low-income countries saw the biggest improvements since 2015 but still face the largest gaps on both pillars measuring UHC progress – access and hardship indicators. 

All WHO regions have increased service coverage since 2015. And the African, South-East Asia, and the Western Pacific regions also reduced the share of the population facing financial hardship.

Public health expenditure increased slightly – except in low income countries

On a related note, domestic public health spending, per capita, exceeded pre-pandemic levels in all income groups except low-income countries in 2023. It also showed slight increases over 2022 levels. 

This according to the latest WHO global expenditure data, which was presented at a webinar last week.

However, in the lowest income countries, public health capita spending in 2023 was in fact  below pre-pandemic levels, while donor aid, per capita, reached an unprecedented high of  32% of total spending. 

In 46 low- and middle-income countries, aid amounted to more than half of domestic public spending, the WHO found, in an analysis of the latest data from the WHO global expenditures data base, presented at a webinar last week. And in nearly 70% of low-income countries, donor aid exceeded domestic public spending on health outright.  

2025 global health crisis could make things worse 

A fundamental cause of the stalled progress in UHC is the stagnation in public health outlays by national governments, noted Monique Vledder, head of the World Bank’s Global Health, Nutrition and Population Department, at the Tokyo press briefing.  

Ïn the lowest-income countries, public health outlays are only about $17 per capita, whereas government needs to spend around $60 to provide a package of basic health services, said  citing findings from a 2024 World Bank report. 

“If the trend continues we expect that to decrease to about $15 per capita, because of donor reductions,” said Vledder, speaking at a press briefing in Tokyo just ahead of the report’s release.  

‘Country compacts’ backed by new commitments from Gates, Gavi, UK and Japan

At the same time, around one-third of low income countries do have space in their budget to increase financing for health, Vledder contended.  “And so it’s something we focus on in the work we are doing with countries.”  

Just 18 months ago, the World Bank Group announced a plan to help countries to reach 1.5 billion more people with quality, affordable health services by 2030. 

Since the initiative was launched, “375 million people have already gained access due to country-led reforms,” Vledder said. “And work is on the way in over 45 countries to further scale proven primary care approaches that strengthen health outcomes while generating employment across the health workforce, local supply chains and supporting private industries.”

In October, the World Bank also launched a Health Works Leaders Coalition, co-chaired by the Government of Japan, and bringing together business leaders, heads of global health organizations, foundations and civil society to coordinate investment and share innovations. 

At Saturday’s UHC conference some 15 low-income countries are announcing new “national health compacts,” that aim to boost progress, and which are endorsed at the highest level of government, including health and finance ministries. 

New financial commitments to UHC are also being made by the Coalition’s members. 

This includes two new memorandum of understanding between the World Bank and GAVI and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. 

Each agreement aims to mobilize $2 billion in additional funding for health care systems and services – along with their targeted vaccines and disease portfolios. 

“Our partnership with Gavi is a vital step toward achieving our goal of delivering quality health services to 1.5 billion people by 2030,” said World Bank Group President Ajay Banga, in a press statement. “Strengthening health systems isn’t just about better care—it’s about investing in people, building skills, and expanding local manufacturing. These efforts will create jobs, boost economic growth, and build long-term resilience across the health sector.” 

Philanthropies are also involved in implementation of the country compacts, mobilizing $410 million in grant funding to the Children’s Investment Fund Foundation (CIFF) and the Gates Foundation, among others. Key donors such as the United Kingdom and Japan will also provide financing for technical assistance. 

“The compacts are key for progress at the country level,” said Vledder. 

Five proven solutions – including digital transformation and regional manufacturing  

Vledder said that the “compact” countries would be prioritizing “five proven solutions” that come together in digitally enabled Primary Health Care systems – supported by more local manufacturing of vital medicines and diagnostics. This includes:  

• Nationwide digital connection of health facilities. “For example, The Philippines is digitally connecting health facilities nationwide. Uzbekistan is digitizing processes to reduce workloads by 30%,” she said. 
• Expanding primary care delivery to virtual delivery modes. “also to make sure that those people that live remote and are most in need are receiving care”.
• Digitally enabled workforce. “For example, Ethiopia will equip at least 40% of primary health care centers with digital tools to support clinical care and workforce management. St Lucia is investing in a skilled, digitally enabled workforce and modernizing regulation and education to regional cooperation.”
• Health insurance schemes to remove financial barriers. “Morocco, for example, will extend mandatory health insurance to an additional 22 million people, and Kenya will double public health spending over five years to reach 5% of GDP and expand social health insurance coverage from 26 to 85%.”
• Boost regional manufacturing of health products and technologies. “Nigeria, for example, will train 10,000 pharmaceutical and biotech professionals, create centers of excellence and offer tax incentives to expand local production of vaccines, medicines, diagnostics and health technologies.

Said Vledder: “So all those solutions come together in what we call a fully digitally-enabled Primary Health Care platform.” 

Image Credits: UNICEF 2024 , WHO-World Bank , WHO-World Bank , WHO, Global Expenditures database, WHO Global Expenditure database, WHO Global Expenditures Database.