Universal Health Coverage: The Emperor has no clothes

In the 1837 fairy tale, “The Emperor’s New Clothes,” everyone refuses to state an obvious truth — that the Emperor is naked. This is an important parable for the 2025 Universal Health Coverage (UHC) Global Monitoring Report released recently by the World Health Organization and the World Bank.

The headline in the press release accompanying the report says, “Most countries make progress towards Universal Health Coverage, but major challenges remain…” While this may be technically true, as I explain below, it doesn’t reflect the true picture.

Since 2015, this report has been released every two years and said the same thing: only about half the world has access to UHC, and we need to do better. No one has stated the obvious: hey, you have said the same thing every two years for the last 10 years — what gives?

So does this year’s report say the same thing? Yes, and that is the most accurate interpretation, but it’s well buried in the report. The most intuitive number in the report is how many people in the world lack access to essential health services. In the 2023 report that number was 4.5 billion and now it’s 4.6 billion. Here is the key chart from this year’s report

What’s not in this report is a time trend on this number. Luckily, we can find one in the report from two years ago. If we added the 57% data point to this chart, it would show no progress.

What is in the report is a time trend on something called the Service Coverage Index, which is not a very intuitive number. What does it mean for this to go up 10 points? And by the way this is increasing while the number of people without access is flat!

UHC is not only access to essential health services but access without financial hardship. The financial hardship indicator is presented separately. It’s also getting better. But what does that actually mean when the overall number of people without access to services is flat?

The sanguine trends on these two indicators — service coverage and financial hardship — are what justify the headline in the press release. But as we can see, if we get more thoughtful about what is really going on, the headline is misleading.

This monitoring report says these service coverage and financial hardship numbers cannot be combined. But in fact they have been combined in the previous report and as shown below. The number of people with UHC is increasing, slowly, at about the same rate as population growth. This is probably the most intuitive way to represent UHC progress. And the purple line (actuals and forecasts) can be compared with other forecasts such as if every country reached the same rate as the country with the best progress (dark blue and orange lines).

Source: https://www.who.int/publications/m/item/who-results-framework--delivering-a-measurable-impact-in-countries-feb-19-2024

OK but those are global numbers and the most important results are in countries. What does the report tell us about the country level? Here is a very helpful chart from this year’s report which shows that just over 1 in 3 countries have improved on both access to essential services and financial protection since 2015 (right panel, dark green box). Which ones are in this group (and which ones are not)? The report doesn’t say.

So the Emperor has no clothes in the sense that there has been virtually no progress on UHC since 2015. But the more important sense in which the Emperor has no clothes is what to do about it – the ‘we have to do better’ bit.

This year’s report has a number of sensible recommendations for governments, like making sure essential health care is free, strengthening primary health care, and adopting a multi sectoral approach. There are also more specific recommendations like strengthening publicly funded prepaid coverage, addressing the high costs of medicines, and expanding non-communicable disease services. Above all, the report proclaims that ‘strong political commitment is required.’ But there is nothing new in these recommendations. They are similar to the recommendations made every two years for the past decade or more. You would think someone would point out they ain’t working and call for a different approach.

Let me be the person to do that. The failure here is fundamentally one of accountability. Could we expect one or more of the 34 members of WHO’s Executive Board to say at their February meeting, ‘hey, we see no progress – it’s time to really rethink our approach!’ Not likely. In a recent conversation I had with Katri Bertram on leadership in global health (and UHC), she described that as ‘peeing in the pool.’

In our conversation, Katri identified three key issues in UHC accountability:

1️⃣ many leaders speak in “aspirational goals,” but in practice are tracking and (held) accountable for very “narrow” and “shifting goalposts.”
2️⃣ advocates fail to track and call for real results, and instead celebrate that a term is even listed on an agenda, or mentioned in a paper or speech.
3️⃣ catchy soundbites such as “health is a political choice” quickly become meaningless, and shift agency and accountability to “the other.”

In an earlier, undiplomatic blog, I advocated to “Get Shit Done (GSD) on UHC.” By that I meant a new approach which centred on results-based governance, delivery for impact, and scaling innovation. I asked, ‘Is there a group of countries (governments) that are sufficiently committed to results to demand better accountability from themselves and from international organizations like WHO?’

At the launch of the report in Tokyo on December 6th, my friend Senait Fisseha from the Susan Thompson Buffett Foundation emphasized the critical role of country-level, just-in-time data. Building on this, Nigerian Health Minister Muhammad Pate emphasized accountability at the country level, saying ‘ without it we cannot hold ourselves accountable and we cannot hold others accountable.’

When it comes to UHC, the Emperor’s robes are sewn from accountability for results.