NEW YORK CITY – There has been little progress in expanding universal health service coverage (UHC) since the last UN High Level Meeting (HLM) meeting on the issue in 2019, and trends in financial protection are even worsening, with catastrophic out-of-pocket spending increasing when compared to 2015. 

The final draft of the political declaration for next week’s UN HLM on Universal Health Coverage on 21 September provides a painful autopsy of UHC’s massive failures to date – with detailed data going beyond the usual political rhetoric.  

It also charts an ambitious course for reducing current trends with a number of clear, albeit aspirational, commitments. 

These include a commitment to ensure that an additional 523 million people get access to quality, essential health services by 2025 to belatedly reach the 2019 goal of reaching one billion more people with UHC, a goal that was supposed to have been met by the end of this year. 

The declaration also commits to “reverse the trend of rising catastrophic out-of-pocket health expenditure” by 2030. 

It also pledges to “accelerate action to address the global shortfall of health workers” along with addressing the causes of health worker migration and dropout, which are increasingly serious problems in poor as well as more affluent health systems. 

While such commitments are clearly aspirational, they are still more concrete than any language of the companion declaration on Pandemic Prevention, Preparedness and Response, which is due to be approved at a UNGA HLM on Wednesday, 20 September.

A third declaration on tuberculosis (TB) will be considered at a HLM on Friday, 22 September – all contributing to an unprecedented focus on health at this year’s General Assembly. 

Building resilient health systems and coverage is a prerequisite for pandemic preparedness, said Bruce Aylward, WHO Assistant Director General for UHC, at a WHO press briefing on Thursday. 

“What they’re really putting the emphasis on is the fundamental need for universal health coverage to make us more resilient – as communities and societies, as countries – to threats such as pandemics going forward but as well as others,” Aylward said. “And they’ve really been focusing on three key things to achieve that,” he added. 

“Radically reorienting their health systems toward a primary health care approach, which really focuses on equity, getting everyone …right interventions in the right order, and in an efficient manner that includes the communities themselves. … that everyone has access to the basic package. 

“The second big emphasis is to fund the systems and also to protect people from catastrophic financial expenditures. 

“And the third thing [is] looking at how do we tackle this whole issue of ensuring we have the people on the ground that can do this work,” he said, referring to the health workforce.

Shortcomings in achieving WHO ‘triple billion’ targets

In its unforgiving litany, the draft text bluntly describes the missed goals and targets of the last UN Political Declaration on UHC adopted in 2019.  Echoing WHO’s own “triple billion” targets laid out pre-pandemic, global leaders in 2019 had pledged to extend UHC to one billion more people between 2018 and 2023, as well as protecting one billion more people from health emergencies and ensuring that one billion people enjoy healthier lives and lifestyles.

All three goals are off course, and the world is less than midway towards the target for expanding UHC coverage, the text states: “There is a global shortfall of 523 million people in achieving the commitment made in the political declaration of 2019 to progressively provide one billion additional people by 2023 with quality essential health services and quality, safe, effective, affordable and essential medicines, vaccines, diagnostics and health technologies.” 

Limited service coverage – particularly for NCDs

Service coverage for many of the world’s leading causes of death and disease continues to be limited, the draft text notes, citing over a dozen key risk factors from alcohol and drug abuse to environmental risks.

Many of these risk factors are linked to the large burden of deaths from noncommunicable diseases (NCDs) including cancer, cardiovascular and lung diseases and diabetes- responsible for some 74% of deaths worldwide. Some 86% of premature NCD deaths (before the age of 70) occur in low- and middle-income countries.

In comparison to the last 2019 HLM declaration on UHC, this year’s text makes an unprecedented leap towards broader recognition of the multiple dimensions of NCD risk and disease that must be addressed to really achieve UHC.

There are multiple references, for instance, to the health inequities experienced by people living with disabilities. With “many likely to die 20 years earlier than those without disabilities, and experience higher health costs and gaps in service availability, including for primary care, long-term care, assistive technologies and specialized services.”

Mental health disorders, which affect more than a billion people worldwide, get more than 20 references in the text, alongside more classic references to alcohol and substance abuse (three million deaths a year)  and tobacco use, responsible for 8.7 million deaths a year.

Article 19 of the declaration talks about the “2.2 billion people living with vision impairments, half with 90% of those with unaddressed vision impairment or blindness living in low-income countries”

Comprehensive approaches and integrated service delivery 

Meanwhile, Article 55, of the Declaration commits countries to more “comprehensive approaches and integrated service delivery” – which global health policy advocates have long stated is critical to more effective response. 

Such delivery can be more inclusive of diagnosis and treatment of a broader range of communicable and NCD conditions, including “cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, mental health conditions and psychosocial disabilities, and neurological conditions, including dementia.”

The text also calls for more action on “eye health conditions, hearing loss, musculoskeletal conditions, oral health, and rare diseases” as well as road traffic injuries and drowning deaths.”

“I’m excited to see that NCDs are more comprehensively reflected in the political declaration of UHC,” Dr Bente Mikkelson, director of the WHO NCD department, told Health Policy Watch. “It is a sign that member states are finally recognizing that NCDs are an integral part of universal health coverage.

“But we need follow-through on firm commitments and investments,” she warned. 

Communicable disease threats: progress still far off track 

The declaration also warns that progress remains far “off track” on the big communicable disease risks of HIV, TB and malaria, which dominated health policy goals and discussions in the first two decades of the millennium. 

“That includes an estimated 1.5 million new HIV infections in 2021; an estimated 1.6 million deaths from TB and a rise in the TB incidence rate by 3.6 per cent between 2020 and 2021; 247 million malaria cases globally, 1.65 billion people still requiring treatment and care for neglected tropical diseases; and 3 million new hepatitis infections and over 1.1 million deaths from hepatitis-related illnesses every year.” according to the declaration.

“Progress in reducing maternal mortality has also stalled, with almost 800 women and girls dying every day from preventable causes related to pregnancy and childbirth. 

“Five million children, almost half of which were newborns, died before reaching their fifth birthday in 2021, mostly due to preventable or treatable causes, with around 45 per cent linked to undernutrition.

 “Twenty-five million children under the age of 5 years missed out on routine immunization in 2021, a 5 per cent decline from 2019 and the largest sustained decline in childhood immunizations in approximately 30 years.”

Environment, antimicrobial resistance, occupational diseases and rehabilitation 

Environmental factors contribute to around 13 million deaths, with ambient and indoor air pollution causing at least seven million preventable deaths.

There are also nearly two billion people a year dying from occupational diseases and injuries; 1.27 million deaths from antimicrobial resistance. 

Finally, an estimated 2.4 billion people live with a health condition that may benefit from rehabilitation. And “rehabilitation needs are largely unmet globally and that in many countries more than 50 per cent of people do not receive the rehabilitation services they require,” the text recalls, another reference to a long-neglected issue common to both NCD and communicable disease recovery.

Gaps strike the old, young, poor and refugees 

With NCDs soaring, there’s a growing gap between life expectancy and healthy life expectancy for older people, the declaration states. 

But over 1.5 million adolescents and young adults aged 10-24 died in 2021 from injuries, drowning, interpersonal violence and self-harm, among other factors.  Meanwhile, women and girls of reproductive age continue to have inadequate access to quality reproductive health services. 

People with disabilities experience health inequities so severe that many are likely to die 20 years earlier than those without disabilities.   

Migrants, refugees and internally displaced people face high cost, language and legal barriers in accessing essential healthcare services, as do indigenous peoples and those who are poor. 

The “high prices of some health products, and inequitable access to such products within and among countries, as well as financial hardships associated with high prices of health products, continue to impede progress towards achieving universal health coverage,” the declaration notes.

Pandemic disruptions 

The COVID-19 pandemic severely affected the provision of essential health services in countries, with 92 % of countries reporting disruptions during the height of the pandemic resulting in millions of excess deaths globally and creating “new obstacles to the realization of all the 2030 Agenda for Sustainable Development.”

The pandemic also revealed sharp disparities in national, regional and global levels of preparedness and response with African countries, in particular, unable to obtain safe, effective and affordable vaccines and treatments for COVID-19. 

A study published in July in the BMJ highlights how most countries with higher levels of pandemic preparedness, as defined by ratings in a Global Health Security (GHS) index, also had comparatively lower COVID death rates – when adjusted for differences in the average age of countries’ populations. 

The GHS quantifies countries’ abilities to prevent, detect and report on emerging risks, with references to 37 indicators such as access to, and use of diagnostic tests. 

Water, sanitation, hygiene and electricity access in health services  

The GHS report raises red flags about issues that have long been neglected, such as the lack of electricity access in health services which can impede access to many modern health technologies and treatments. 

Some “22% of health care facilities lack basic water services, half lack basic hand hygiene facilities at point of care and at toilets, and 10 per cent have no sanitation service, one in four facilities do not practice waste segregation, 

“Close to one billion people in low- and lower-middle income countries are served by health care facilities with unreliable or no electricity supply,” states the declaration, citing a milestone June 2023 joint report by WHO and UNICEF  on these critical but long-ignored aspects of health infrastructure. 

Financing and healthcare workforce 

The dismal state of health care financing is not overlooked either. “On average, in low- and middle-income countries more than one third of national health expenditure is covered by out-of-pocket expenses, leading to high levels of financial hardship, and government spending accounts for less than 40% of funding for primary health care,” the declaration notes. 

Donor funding accounts for an outsized 30% of national health spending in low-income countries even though it comprises just 0.2 % of global health expenditure. 

Waste and corruption are other factors that deplete the scarce, available resources. 

And the finance shortages are felt most acutely in the healthcare workforce itself, with a global shortfall of more than 10 million health workers projected for 2030 – primarily in low- and middle-income countries.

Migration of health workers to more high-income countries or wealthier regions accelerated during the COVID-19 pandemic, with approximately 15 % of health and care workers now working outside of their country of origin. Meanwhile, women health workers are generally paid 24% less than men.  

Call to action – political leadership first of all 

Along with the big aspirational commitments to more investments, a greater focus on primary health care, and the health workforce, the text reaffirms commitments to goals and targets for dozens of diseases and risk factors.  

More access to diagnostics, vaccines and medicines as well as stronger data systems and better inclusion of women, children, older people and vulnerable groups such as migrants, minorities and people in extreme poverty all get a nod.  

But what’s included in the declaration remains far less important than the framing moment it can offer at a UN General Assembly where health will have an unprecedented focus. Will the UHC declaration and the companion declarations on TB and PPPR, really kickstart more action by countries in the final years leading up to 2030? 

“There are super important deliberations coming up,” said Aylward. “But the most important thing to achieve in universal health coverage, frankly, is the political decision [to make it happen]. It’s a big political decision because of the big financial commitment and the big commitment in terms of human resources.

“And that’s why the solution will not be what happens next week at the UNGA, but it will be a critical piece of getting started on an accelerated path to solving the problem of ensuring everyone everywhere can have access to the services they need for their physical and mental health and social well being.”

Image Credits: International Rescue Committee, Roche, WHO , Medtronics, USAID, Southern Africa/Flickr, Balasaheb Pokharkar, Adam Howarth/Flickr, Flickr – Trinity Care Foundation, (Fabio Fadeli), ©EC/ECHO/Anouk Delafortrie.