Universal health coverage is a matter of equity, rights, and justice

Authors: Gabriela Cuevas Barron, Justin Koonin, Svetlana Akselrod, Helga Fogstad, Corine Karema, Lucica Ditiu, Katie Dain, Neena Joshi

This article was first published in The Lancet Global Health.

We know that the world is not well prepared for the next pandemic, or for threats posed by climate change, zoonosis, and increased conflicts. We also know that vulnerable and marginalised populations are hardest hit when an emergency strikes: women; children and adolescents; LGTBQI+; indigenous people; incarcerated people; people living with non-communicable diseases, mental health conditions, and comorbidities; refugees and internally displaced migrants; people living in remote rural areas; and millions of people living in low-income and middle-income countries with fewer socioeconomic safety nets.¹ Inequity is one of the greatest challenges of our times.² When entire population groups cannot access essential health services, including prevention and response services in times of crisis, we are not protecting and delivering on the right to health.

As countries meet in July for the High-level Political Forum (HLPF) to discuss recovery from COVID-19 and implementation of the Sustainable Development Goals,³ we call on all countries to urgently prioritise strengthening resilient and equitable health systems to achieve universal health coverage. Univeral health coverage is a matter of health, rights, and justice, and also a key enabler of human security.⁴

Despite governments having made ambitious universal health coverage commitments, including commitments to leave no-one behind, many population groups lacked access to and did not have financial protection for health care even before the COVID-19 pandemic.⁵ The pandemic highlighted and increased gaps in population coverage and inequalities. Countries in which population groups were already stigmatised, criminalised, or discriminated against before the pandemic faced exacerbated access challenges, as some countries used the pandemic to curtail human rights, creating further barriers to access for certain population groups.⁶

On the other hand, countries in which populations were reached through trusted sources and networks had higher uptake of public health, including vaccination, and lower rates of excess mortality.⁷ Countries with integrated, people-centred primary health-care systems, providing nearly 90% of essential health services,⁸ reached most people.

Universal health coverage is sometimes misunderstood as a goal to provide all available health services and products free to every person through national health insurance schemes.⁹ In reality, universal health coverage means that all people can access the health services they need without suffering financial hardship. As the health needs across income groups, ages, and health status vary, it is the government's responsibility to determine how people access essential health services at affordable cost. For progress on population coverage, and to determine who can access the health services they need, governments must make political choices, and support these by prioritised funding (domestic and external).

When large numbers of people and population groups are covered with health promotion and prevention services, an emergency response is more effective and responsive to individual and community needs. Strong population coverage ensures people and health systems are better prepared to prevent debilitating effects, including millions of deaths. Connecting universal health coverage and health security is key to sustainably and effectively strengthening health systems, emergency preparedness, and response capacity.

Governments have the primary responsibility to protect and ensure people's health, but governments alone cannot achieve universal health coverage. They might not have the strongest relationships with all populations nor be able to reach them, and might themselves undermine human rights and gender equity.⁶ Civil society organisations and community-based health care play an important role in filling these gaps. These institutions also hold governments to account for their commitments.

At the HLPF in July and the three UN High-level meetings on health, upcoming in September, 2023, all countries must recognise that progress in providing tuberculosis care, strengthening pandemic preparedness, and delivering the human right to health through universal health coverage are interrelated goals, requiring a concerted focus on the most vulnerable and marginalised populations.

We call on all countries to make actionable commitments, using the Action Agenda from the UHC Movement,¹⁰ and propose three focus areas to ensure that people are not only covered and can access services, but these services are also of quality, consist of their specific requirements, and are accessible when they need them.

First, integrating health services at the primary care level ensures that people's diverse health needs are addressed across the life course. A woman visiting a health centre might need contraception, antenatal care, malaria treatment, non-communicable diseases prevention and control, vaccinations against COVID-19, or all of these. Integrated health services, with sufficient trained health workers, are the most effective way to reach all people.

Second, people need to be informed about the drivers of health and wellbeing and be empowered to co-design services to suit their needs. Health service coverage schemes alone do not determine who is covered. Women and men often have different health needs. Discriminatory laws, policies, and programmes, as well as disempowerment and lack of agency, can leave large population groups excluded.

Third, governments' fiscal space, political and budgetary priorities, as well as external development assistance, are key in determining population coverage at the national level. During the COVID-19 pandemic the slogan “no one is safe until everyone is safe” was used to denote that covering every person nationally and globally was the business of everyone.⁵

Resilient and equitable health and community systems with strong population coverage make us all better prepared for health emergencies. Expanding and making population coverage more equitable is key to protecting all people, and is the cornerstone to delivering equity, the right to health, and justice.

We declare no competing interests. We thank Katri Bertram for her support in drafting and editing this Comment.

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