Comment

The universal health coverage ambition faces a critical test

Universal health coverage (UHC) has been a focus of cure or prevent. Although the mortality-to-incidence Published Online
August 27, 2020
the global development conversation over the past approach is conceptually sound, its validity is contin­ https://doi.org/10.1016/
decade and, increasingly, of national policy making gent on the quality of data on mortality and disease S0140-6736(20)31795-5

in countries across a wide range of income levels. prevalence, which is known to be weak in many low- See Online/Articles
https://doi.org/10.1016/
The political salience of UHC is rooted in its attractive income countries. For example, in India, one in three S0140-6736(20)30750-9
value proposition: to provide good quality health-care deaths is not registered in the vital statistics system
services to all citizens who need them without causing and a medically certified cause of death was recorded in
financial hardship. just 17% of registered deaths.3 The GBD 2019 Universal
However, comparing progress towards UHC across Health Coverage Collaborators deal with this limitation
countries is exceedingly challenging given the wide by modelling missing national values using systematic
variations in national resources, health systems, epi­ triangulation and imputation techniques. There is much
demiological and policy priorities, and availability to admire about the ambition, scope, and innovative
(or unavailability) of reliable, recent data among analytical methods of the paper. Yet the paper also raises
countries. In The Lancet, the Global Burden of Diseases, some fundamental questions about the relevance of this
Injuries, and Risk Factors Study (GBD) 2019 Universal approach to measuring UHC progress at this moment in
Health Coverage Collaborators tackle this challenge by time.
constructing a weighted mean of the effective coverage First, the concept of UHC and thus its measurement
of 23 health services in 204 countries.1 This is an do not encompass the resilience of health systems to
improvement over past measures of service coverage crisis. Epidemics and disease outbreaks are not counted
(eg, contact with the health system) because coming explicitly in any UHC measure—they are relegated to
to the clinic does not always improve a person’s health a separate silo of “preparedness”. Yet, as we have seen
when the care is of low quality or available services do in the COVID-19 pandemic, ensuring that all people
not match the patient’s needs. Effective coverage, by have access to testing, treatment, rehabilitation and,
contrast, captures the proportion of possible health when available, prevention through vaccination, are
gains people receive from interacting with the health universally viewed as core functions of a successful
system.2 health system. Any index of UHC that is fit for purpose
The GBD 2019 Universal Health Coverage Col­ thus must encompass the fuller goals of a health sys­
laborators found overall improvements in effective tem, including its ability to avert deaths from outbreaks
coverage between 1990 and 2019 but also persistent,
large divides, with a number of rich countries achieving
95 or higher on the 0–100 scale and several low-income,
fragile states scoring closer to 25. The authors estimated
US$1398 per capita as the threshold for achieving a UHC
effective coverage score of 80. Although financing was
not a focus of the analysis, both the amount and means
of financing via primarily public insurance schemes
rather than out-of-pocket spending are notable findings
that will challenge current spending envelopes and
financing modalities for health care in many countries.
Because of a dearth of data on effective coverage in
many countries, the authors used service coverage for
four of the 23 indicators and mortality-to-incidence
Sanjit Das/Panos Pictures

or mortality-to-prevalence ratios for the remainder.

Mortality-to-prevalence ratios capture deaths from
conditions that health systems ought to be able to

www.thelancet.com Published online August 27, 2020 https://doi.org/10.1016/S0140-6736(20)31795-5 1

 Comment

while maintaining high-quality health services for other to their population, UHC may become an empty signifier:
conditions.4 a non-threatening tool for enhancing a country’s global
Second, bundled national metrics do not tell us about status rather than maintaining and improving health for
who benefits from UHC in the country. It is possible all its citizens.
to achieve a decent score on the effective coverage MEK reports personal fees from Rabin Martin and Merck and Company, outside
the area of work commented on here. JEA and PA declare no competing interests.
index by averting amenable mortality for part of the
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access
population while neglecting the needs of the rest. article under the CC BY-NC-ND 4.0 license.
Without national disaggregation, such metrics can
*Margaret E Kruk, John E Ataguba, Patricia Akweongo
obscure large inequities and introduce false equivalence [email protected]
in inter-country comparisons.5,6 Department of Global Health and Population, Harvard T H Chan School of Public
Finally, as the world grapples with the adverse Health, Boston, MA 02115, USA (MEK); Health Economics Unit, School of Public
Health and Family Medicine, Health Sciences Faculty, University of Cape Town,
consequences of globalisation, diminishing trust in Cape Town, South Africa (JEA); and Department of Health Policy and Planning,
experts and data, and growing awareness of structural School of Public Health, University of Ghana Legon, Accra, Ghana (PA)

racism, sexism, and imbalances in global power, it is time 1 GBD 2019 Universal Health Coverage Collaborators. Measuring universal
health coverage based on an index of effective coverage of health services
to ask: for whom is this measure? As with other global in 204 countries and territories, 1990–2019: a systematic analysis for the
Global Burden of Disease Study 2019. Lancet 2020; published online
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meaningful measures and governments’ accountability

2 www.thelancet.com Published online August 27, 2020 https://doi.org/10.1016/S0140-6736(20)31795-5