The World Health Organization’s (WHO) executive board discussed ways to deliver Universal Health Coverage (UHC) on Wednesday, and while most member states expressed support for UHC, they highlighted bottlenecks of lack of finance and  trained healthcare workers for being off track with its implementation.

In its report to the board, the WHO estimated that over half of the world’s population is not covered by essential health services, and a quarter face financial hardship due to out-of-pocket health spending.

In the past two decades, due to a combination of conflicts and the impact of the COVID-19 pandemic, financial availability for health has worsened, the discussions revealed.

Small island nations, developing countries, countries with high levels of migration of health workers as well as those with ongoing conflicts, voiced a range of challenges that they face, and need support to address.

“In 2019, 1.3 billion people incurred impoverishing health spending at the relative poverty line, and 344 million people faced impoverishing out-of-pocket health spending at the extreme poverty line of $2.15 a day in 2017 purchasing power parity,” the WHO report noted.

For UHC to be implemented, there needs to be an increase in health funding, it needs to be used efficiently and equitably, the health and care workforce needs to be strengthened, and primary healthcare (PHC) needs to be expanded, according to WHO.

“Investment in health is actually on the decline now, and many governments are shifting towards other sectors,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “It is the continued investment in health that can help us in preventing the next pandemic. And it’s the continued investment in health and in UHC that will help us to respond,” he said.

Tedros reiterated that both low-income and high-income countries need to focus on strengthening PHC.

High debt burden is stunting progress 

WHO has found that the current expenditure on health is not adequate. “Emerging evidence shows increased financial hardship, especially among the poorest, with an uneven recovery post-2020/2021. A notable concern is the higher public spending on national debt over health in developing countries,” the report said.

Rwanda, speaking on behalf of the 47 countries in the WHO African region, drew attention to the burden of debt repayments on poor countries.

“The African neighbour states also note with great concern that, as noted by the UN Secretary-General, many countries are forced to spend more on servicing debt than on health and education. In this regard, the IMF has reported that the average debt ratio in Sub-Saharan Africa has doubled in the decades from 30% of GDP at the end of 2013 to almost 60% of GDP by the end of 2022,” he said.

Meanwhile, Yemen’s representative said that 70% of health expenses in his country are borne by individuals and they face tremendous financial hardship as a result.

Pressure placed by conflicts

Palestine, which is currently facing intense and deadly aggression from Israel, said that it has no functional public health system left. “We are facing several challenges and obstacles to maintain the primary healthcare and minimum services using the available resources,” the representative of Palestine said, adding that any discussion on UHC can only be had after their destroyed health system is rebuilt.

Yemen, which has seen several years of conflict, spoke of the additional pressure placed by people displaced by war: “There are a great many displaced persons in our country…internally displaced, in particular, approximately three million of them. We are also facing an influx of refugees and migrants, which is of course a tremendous burden for our health system and makes it more difficult for us to achieve UHC.”

Afghanistan also spoke of the resource crunch and the lack of female healthcare workers. The representative bravely asked member countries for help in advocating for women’s rights and access to education, which has been severely restricted under Taliban rule in the country.

Conflict-ridden Syria said it was aware of the challenges its citizens were facing in accessing healthcare but expressed an inability to do more.

“Because of the conflict that has been raging in our country for more than 12 years now, the work of our health ministry has been made much more difficult. And we now have to give top priority to emergency response rather than UHC because of the war,” the country’s representative said, while asking for support from the global community.

Lessons from countries with UHC

On the other hand, countries that have achieved UHC fell into two buckets: those who are looking to build on the progress and those struggling to keep the level of progress up.

The expansion of UHC was a key issue for the elections of the new Regional Directors taking place in three new regions last year, as the new appointees needed to have enough knowledge on how to help countries expand access to healthcare, and the different models that can be employed to reach there.

The new Regional Director of the Western Pacific region Dr Saia Ma’u Piukala also said that expanding UHC access would be one of his key priority areas, as Health Policy Watch reported earlier.

Malaysia that achieved UHC in the 1980s said it planned to further, “expand coverage to quality health services through primary healthcare [by] increasing funding, improving the distributions of primary healthcare facilities, ensuring adequately trained human resources for health and facilitating Public Private Partnership moving forward”.

Small-island nations who are at the forefront of climate change are struggling with the rising extreme weather events that have increased pressure on health systems, while simultaneously also damaging the economy.

Maldives spoke of the challenges of continuing the high level of investment on healthcare as climate change and global conflicts hit its two main sources of income – tourism and fishing.

“Therefore Maldives is taking a two-pronged approach. One is to further strengthen PHC with low-cost intervention, including multi-tasking multi-discipline health workforce, early detection for NCDs and timely reference. The other is investing more in health promotion, including digital health literacy and promoting a healthy lifestyle in healthcare settings,” the country’s representative said.

Shortage and safety of healthcare workers

A key challenge for many countries in the developing world, and those at the forefront of facing climate impacts, is the shortage of healthcare workers, as well as threats to their safety.

“Barbados continues to grapple with a shortage of nursing personnel and allied professionals. The country currently makes up for this by recruiting nurses from Ghana and Cuba, but a long-term solution is required to ensure sustainability,” the representative from the island nation said.

In addition, retaining the workforce in rural areas is a challenge. “The most willing to leave the health system is the medical staff in primary care, especially in rural areas. Being a difficult speciality, family medicine became almost completely feminized,” said the representative from Moldova.

Increases in resources and infrastructure improvement could help with some of these challenges, with Ethiopia stressing that it is crucial to ensure the safety and security of health and care workers.

The Philippines too said that out migration of healthcare workers has hit its ability to deliver UHC hard and that destination countries needed to play a role in supporting the source country’s health systems through investments.

Tedros acknowledged this in his remarks by pointing out that while migration cannot be stopped as it is human to want to migrate, more health professionals can be trained to handle this shortage.

Denmark, speaking on behalf of the European Union, expressed concerns over the lack of consensus on several issues, and Germany reiterated that comprehensive sexual and reproductive health and rights are an essential part of UHC.

“While many of the member states have highlighted the bleak situation globally in terms of half the world’s population not having access [to essential health services] and another quarter suffering financial hardship, I think we should remember as well [that] 30% of the countries for which we have data, have been able to make progress on both of those indicators,” said Dr Bruce Aylward, WHO’s Assistant Director-General of UHC, as the report was noted by the executive board.

Image Credits: WHO, WHO, Mercy Corps, Photo by Carlos Magno on Unsplash.