On Universal Health Coverage Day, time to think about new financing solutions for health

Financing shortfalls and COVID-19 highlight need to rethink the path to UHC

As the COVID-19 pandemic has ravaged the world, it has all too often exposed pre-existing shortcomings in our health systems. As HFI has noted, these shortcomings include inadequate care for many chronic conditions, including mental health disorders, diabetes, cardiovascular disease, and many other common noncommunicable diseases (NCDs). But today, on Universal Health Coverage (UHC) Day, the global health community will be highlighting how the pandemic has increased the urgency of the work yet to be done to ensure every person has access to affordable and effective healthcare services.

The United Nations (UN) has listed achievement of “universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” as Sustainable Development Goal (SDG) 3.8. To meet this target by 2030, the World Health Organization estimates that 3 billion people still need to gain access to essential health services. The WHO’s General Programme of Work for 2019–2023 reaffirmed the timeline for this goal, and further added the goal of “one billion more people [benefitting] from universal health coverage” by 2023. According to research recently published in the Lancet and drawn from 2019’s Global Burden of Disease (GBD) study, this goal is far off as current trajectories will offer UHC to just 390 million new people by 2023.

This slow movement toward UHC has occurred even with the UN and WHO making the issue a top priority for years. The issue isn’t a lack of attention — global health leaders have emphasized the need for UHC in no uncertain terms — it’s a lack of funding. It’s difficult to make a reasonable estimate of the total cost of UHC, and in fact the WHO itself has stated that this approach can be problematic, instead recommending “focus[ing] on the policy choices needed to accelerate progress toward UHC.” But for context, the WHO’s annual budget in 2018 and 2019 was about $2.75 billion. Keeping in mind the target of extending health coverage to 3 billion more people, this means the organization could spend less than $1 per person per year even if it directed its entire budget toward UHC efforts. The UN’s 2020 budget was slightly higher, at about $3 billion. If the two organizations pooled their resources to focus solely on UHC, together they could spend nearly $2 per person per year on the effort. The total cost of UHC may be tricky to work out, but it seems safe to assume it will cost more than $2 per person to offer essential health services with financial risk protection to billions of people around the world.

That’s why it’s time the global health community reaches for new tools that might be able to meet this massive need, like blended finance mechanisms that can amplify the impact of governments’ and multilateral organizations’ health spending by catalyzing private investments. Those WHO dollars may not be sufficient on their own, but if they bring in support from private-sector partners aimed at improving health outcomes, they could be exponentially more powerful. The pandemic has highlighted what’s at stake should we fail to meet the challenge: people’s lives.

COVID-19 has underscored the urgency of expanding UHC, as countries that are closest to offering UHC to all their citizens have tended to be able to minimize cases and fatalities from the virus. The Lancet-GBD study included the construction of an “effective coverage index,” which allows for cross-country comparisons of UHC performance (in other words, how well countries are doing at providing UHC to their residents). The index includes 23 coverage indicators, measured across age groups and weighted according to associated improvements in health outcomes. The resulting rankings show Japan, Iceland, Norway, Switzerland, and Singapore to be the top five countries for UHC performance (excluding San Marino, an anomalous microstate). These countries have also displayed the ability to keep their COVID-19 mortality rates lower relative to the world at large. The ratio of confirmed cases to deaths from the virus is much lower than the global average in each of these countries (per data drawn from the Johns Hopkins Database).

Factors other than UHC influence over how countries have performed in their pandemic response, of course. Italy and South Korea rank almost identically on UHC performance, yet Italy’s case-fatality ratio is more than twice that of South Korea — perhaps in part because of South Korea’s recent experience with a similar respiratory pandemic, MERS. The fact that the top five countries for UHC are all relatively high-income countries certainly plays a role in their ability to respond. Yet the pandemic has illustrated the undeniable public good inherent in offering affordable access to the health services.

This is true not just for highly infectious diseases such as COVID-19 but for NCDs, too. Early diagnosis and intervention for patients with chronic diseases not only lead to better outcomes for the individual, but massive savings in healthcare spending and productivity in society at large. Better still is prevention of NCDs in the first place. Researchers have estimated that investments in cardiovascular disease prevention, for example, could result in returns of anywhere from 5 to 10 times the initial investment.

It is clear that UHC is certainly a worthy goal, and one on which the global health community should be laser focused. But it’s equally clear that we need a new approach, given that the world is already falling behind the WHO and UN established targets. That means spending smarter, both in the ways we fund UHC efforts and the aspects of UHC we target. According to the researchers who constructed the effective coverage index, accelerated progress on UHC is “increasingly unlikely unless concerted action on NCDs occurs and countries can better translate health spending into improved performance.” Blended finance investments in NCD care are one promising option for making this crucial step happen. Blended finance instruments can be tied to real health outcomes, ensuring every dollar spent is going toward improving health system performance, and the catalytic nature of blended finance allows stakeholders to harness larger investments from public and private sector players toward making a dent in the massive burden of NCDs. On this year’s UHC day, it’s time to move beyond simply reaffirming the value of UHC to taking concrete steps to achieve it.

By Thomas Roades, Andrea Feigl, Erin Gregor, and Jenna Patterson