The Road to 2030
Revitalizing Multi-sectoral Partnerships to Achieve Universal Health Coverage
Produced by FP Analytics, with support from IFPMA.
FP Analytics retained complete control of the direction of the research.
Universal health coverage (UHC) is central to ensuring the health and well-being of all populations, strengthening global health security and pandemic preparedness, and achieving the United Nations Sustainable Development Goals (UN SDGs). As articulated in SDG 3.8, UHC enshrines equitable access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all, without risk of financial burden. Additionally, UHC is key to achieving a range of non-health-related development goals, including the full scope of the SDGs and the improvement of economic development in low- and middle-income countries (LMICs). Despite these transformative potential impacts, progress toward implementation has been slow: only 11 percent of countries worldwide have adopted a concrete strategy to achieve UHC. Even before the onset of the COVID-19 pandemic in 2020, the world was far from on track to meet SDG 3.8 by 2030, and the pandemic has since undone some of the health care gains of recent decades. It disrupted efforts to prevent and manage non-communicable diseases (NCDs) in 136 countries, while 92 percent of the countries surveyed reported disruption to overall health services following the pandemic, including childhood vaccination programs.
As UHC takes priority at both the 2023 World Health Assembly and the United Nations General Assembly (UNGA), stakeholders who are committed to improving public health systems have a timely opportunity to catalyze action. The global health community can capitalize on the shared agendas of major international institutions to undertake collaborative, multi-stakeholder action to invest in and achieve UHC. This issue brief, produced by FP Analytics with support from the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), examines evidence on the opportunities and challenges related to UHC and explores how actors within the health care sector, including the private sector, can work together to build resilient, strong, and sustainable health systems in LMICs and around the world, by leveraging their expertise, resources, and approaches to innovation.
Progress Toward UHC is Too Slow to Meet SDG Deadline
SDG 3.8 is the achievement of universal health coverage by 2030, including financial risk protection, access to quality essential health care services, and access to effective, quality, and affordable essential medicines and vaccines for all.
Note: Indicator 3.8.1 is coverage of essential health services. The UHC Index is measured on a scale from 0 to 100, where 100 is the optimal value. The UHC Index is the geometric mean of 14 indicators measuring the coverage of essential services, defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn, and child health; infectious diseases; non-communicable diseases; and service capacity and access, among the general and the most disadvantaged population.
DATA SOURCE: Our World in Data
UHC is a mechanism to unlock wider social and economic gains
Achieving UHC globally by 2030 will require rapid, robust, and effective investments in health care, with cooperation among the public and private sector, multilateral institutions, and civil society. Prior to the outbreak of the COVID-19 pandemic, the World Health Organization (WHO) estimated that, on average, countries would need to increase their health spending by 1 percent of their total GDP to meet the fast-approaching deadline for the SDGs, with extreme variation in that percentage share between the richest and poorest countries. The widespread negative impacts of the COVID-19 pandemic on health systems make that proportion even higher today. Indeed, UHC2030 recently published an action agenda calling for LMICs to adopt a target to increase annual national health care spending to at least 5 percent of GDP by 2025.
Achieving UHC could yield transformative, long-term social and economic dividends for individuals, communities, and countries, while reducing or eliminating costs to patients that may currently prevent access to necessary care. Around 800 million people worldwide spend at least 10 percent of their household budget on health care, and almost 100 million people are pushed into extreme poverty every year due to health-related expenses. Prior to the pandemic, researchers found that poor-quality health care cost between U.S. $1.4 and $1.6 trillion per year in lost productivity in LMICs. Yet, extensive evidence shows better health throughout a person’s lifetime contributes to higher economic productivity, especially as fewer days are lost to illness and disability, and individuals are able to work for longer if they choose. For example, early cost-effective and accessible intervention to prevent and treat NCDs—already the number-one cause of death worldwide and likely to grow as populations age—is projected to yield a U.S. $7 return for every dollar invested. Addressing communicable diseases prevalent in LMICs will be likewise impactful: a 2021 economic impact assessment of 120 countries found that reducing tuberculosis mortality rates to meet the target set in the SDGs would save U.S. $13.1 trillion and avoid 23.8 million deaths.
Access to maternal and neonatal health can also reap dividends. For instance, a modeling study of Small Island Developing States found that achieving SDGs relating to maternal and neonatal health would create a return on investment of 15 to 1. Moreover, good health in infancy and early childhood grows human capital, as children are able to attend school regularly, leading to better-educated adults who are adaptable to evolving labor markets. Relatedly, childhood immunization programs are critical: modeling by Gavi, the Vaccine Alliance, projects that its vaccination program has averted more than 16.2 million deaths since 2000. Investment in high-quality life-course care, while requiring a mobilization of resources and political will, can produce compounding economic benefits that far surpass the money spent.
Global strategies and country-specific approaches to achieving UHC in LMICs
LMICs face a significant challenge in advancing progress toward UHC due to the limited financial resources available to optimize quality, accessibility, affordability, and effectiveness of health services for all segments of the population. The most vulnerable are particularly at risk, including marginalized women, children, older adults, and people with disabilities. While there is no universal target for national UHC spending, there is evidence of a strong, positive correlation between public health expenditure and UHC performance, which is measured across three dimensions: (1) service coverage; (2) population coverage; and (3) financial protection. Strengthening any one of these three dimensions can help to strengthen the others. For example, interventions to bolster financial protection—making health services affordable through subsidized low-cost or no-cost services—can improve access to quality health care by alleviating out-of-pocket costs, which may otherwise pose a major deterrent to seeking care. Yet, a recent survey of global UHC commitments in 138 countries revealed that financial protection suffers from “systematic under-prioritization and underinvestment.”
The 2019 UNGA Political Declaration of the High-Level Meeting on UHC emphasizes the importance of strong, effective national investments in and stewardship over UHC administration. The WHO estimates that an additional 5 percent of annual domestic health spending on preventative measures, such as cervical cancer screenings, in LMICs could significantly reduce the incidence of NCDs. Domestic public resources, such as tax revenue, help mitigate the risks associated with over–reliance on official development assistance (ODA), shifting some of the responsibility for financing to governments to design feasible policies, create enabling environments, and ensure resources are continually directed toward health interventions that can yield the greatest impact for the largest number of people.
Public-private collaboration can also drive progress toward UHC, including by catalyzing innovation, particularly in LMICs with limited public resources and competing development priorities. Private-sector innovation in developing vaccines and other medicines and increasing access to these products can create a ripple effect of social and economic improvements. For example, the development of a tuberculosis vaccine for adults could avert 37.2 to 76.0 million cases and 4.6 to 8.5 million deaths by 2050. Additionally, every dollar invested in developing and deploying this vaccine could generate U.S. $7 in health and economic benefits between 2025 and 2050. National governments have a pivotal role to play in stewarding and forging these types of relationships, and in creating the enabling environments to promote and support innovation in health services, technologies, and medications. Moreover, multi-stakeholder partnerships stewarded by ministries of health and finance can bring together corporations, local entrepreneurs, non-governmental organizations (NGOs), and civil society representatives. Such partnerships can further enable the mobilization of resources beyond the capacity of governments alone. When planned and implemented with intentionality, these partnerships can generate impacts beyond improving health to support increased community resilience and economic development in LMICs.
Government Spending on Health Care is Not Enough to Meet Needs
Only 17 countries are expected to meet the projected necessary government spending to meet UHC goals by 2026.
Of 135 total low- and middle-income countries:
109 countries are on track to spend at least 50% of their projected needed government per capita health spending target by 2026.
69 countries are on track to spend at least 75% of their projected needed government per capita health spending target by 2026.
Only 17 countries will meet or exceed their projected needed government per capita health spending target by 2026.
Note: Of 135 total LMICs, 109 countries are on track to spend at least 50 percent of their projected needed government per capita health spending target by 2026. Of those countries, 69 countries are on track to spend at least 75 percent of their projected needed government per capita health spending target by 2026. Of those countries, 17 countries will meet or exceed their projected needed government per capita health spending target by 2026.
DATA SOURCE: The Lancet Global Health
Public-private collaboration on high-impact interventions to boost resources for UHC
Improving primary health care services: Primary health care (PHC) is the frontline of medical intervention, and fundamental to the achievement of health care for all. According to the WHO, effective PHC can deliver up to 90 percent of the services identified as crucial to realizing UHC, and achieve 75 percent of the health gains projected from meeting the SDGs. Most individuals primarily interact with health systems through PHC—it encompasses the delivery of vaccinations, maternal and infant care, NCD detection and treatment, palliative care, and much more throughout a person’s lifespan. Reliable PHC can help communities cope better with public health emergencies and pandemics, as it is an avenue through which to monitor disease prevalence and launch community-wide vaccination and treatment programs. For example, Uganda has rolled out a COVID-19 vaccination campaign focused specifically on displaced people that deputizes community health workers and village health centers to identify recipients and administer doses.
Expanding access to high-quality PHC, while initially costly, can be a high-impact intervention with continuous returns. An analysis of 67 LMICs found that a global investment of between U.S. $200 billion and $328 billion in additional funding will be needed every year between 2020 and 2030 in order to achieve the standard of PHC recommended by the WHO. Governments can mobilize a range of partners to leverage the ingenuity, finances, technical expertise, and experience necessary to achieve this critical goal:
- Private- and public-sector business accelerators can invest in innovative new approaches to health services that are scalable, if proven effective and efficient. Investments in enterprises supporting remote or underserved communities, such as mobile health clinics, telehealth programs, and ambulatory care, can be especially impactful.
- Companies developing and selling health products can continue to identify new commodities and services to support primary health care goals, including expanding diagnostics and testing, equipment, and digital recordkeeping.
- Insurance companies can collaborate with the public sector and patient groups to reduce out-of-pocket and unexpected health care costs by offering pre-payment and co-payment plans, tiered and sliding-scale pricing models, risk-pooling mechanisms, and raising public awareness of affordable services.
- Telecom and broadband internet service providers can collaborate with governments and health care companies to extend internet and telephone coverage in order to improve remote and rural communities’ use of telehealth services.
- Civil society groups and industry associations can continue to amplify the messages and policies of ministries of health to build political will and public support for ongoing PHC expansion work.
Strengthening global supply chain: Significant gaps persist in access to existing medicines, treatments, and tests. Of the medicines identified by the WHO as “essential,” around 80 percent exist in generic form, yet their penetration in LMICs remains low. To increase uptake, barriers such as lack of training and awareness among medical personnel, and lack of reliable transport infrastructure need to be addressed. Improving access to medicines will also require strengthening the resilience of the health supply chain, which is susceptible to disruption from global events. For example, the concentration of health-related manufacturing capabilities largely in India and China means that changes in either side of the import-export trade relationship can have an outsized impact on the entire health care supply chain, creating shortages of essential medicines, including antibiotics.
A wide range of stakeholders across the public and private sectors have an opportunity to collaborate more closely to increase affordability of and access to essential medicines, and the low-cost, but highly effective, interventions and screenings identified in the WHO Best Buys:
- Research-based pharmaceutical companies can continue to deploy and expand strategies to increase access to new products in LMICs at launch. This could include extending voluntary licensing agreements for new and existing products to manufacturers operating in LMICs, to reduce the risk of supply chain disruption, and investing in regionalized and localized industry.
- Generic and biosimilar manufacturers can work to scale-up the local manufacturing capacity of both APIs and final-product medications within LMICs. These companies can also create sliding scale and preferential pricing models, in partnership with governments and public health systems, to increase financial protection.
- Innovation-focused enterprises, including pharmaceutical companies and generic manufacturers, and academic institutions can undertake adaptive research to identify and disseminate more effective and efficient medications, treatments, and tests, thereby continually improving medical care. These include context-relevant adaptations, such as specialized medications for children or the immunosuppressed, treatments for both existing and emerging diseases prevalent in specific LMICs, and products that are easier to store and transport, such as heat-stable formulations.
Case study: Improving access to HIV/AIDS testing and treatment in sub-Saharan Africa
Globally, 85% of people with HIV are aware of their positive status, the majority of whom live in LMICs. Access to effective antiretroviral (ARV) treatments has been uneven in poor communities and countries, exacerbated by the gap in diagnoses. A wide range of health industry stakeholders have come together in the past two decades to extend access to HIV testing and treatment, such as:
- In the early 2000s, pharmaceutical companies that had developed effective ARV therapies granted voluntary licenses over their patented products to enable generics manufacturers to develop, manufacture, and sell generic versions of the medications in resource-limited low-income countries. The UN-backed Medicines Patent Pool continues to facilitate these relationships and has signed voluntary licensing agreements for the patents of 14 HIV ARVs to date.
- In Africa, a multi-stakeholder public-private partnership was created in 2014 between Roche, UNAIDS, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), The Global Fund, the Clinton Health Access Initiative, and the U.S. Centers for Disease Control and Prevention (CDC) to increase access to HIV viral load testing and early infant diagnosis. In 2019, the program expanded to include tuberculosis, hepatitis, cervical cancer and most recently, COVID-19. Annually, over 8 million patients manage their HIV infection with HIV viral load testing and 11 million babies have been tested for HIV since 2014 to reduce infant mortality.
The biopharmaceutical company, ViiV Healthcare (majority-owned by GlaxoSmithKline, with Pfizer and Shionogi) has established the Positive Action program, aimed at tackling social barriers to addressing HIV. Working with community-based civil society groups and NGOs, the program focuses on the populations worst affected by HIV—including women and girls, adolescents, men who have sex with men, transgender people, sex workers, intravenous drug users, and incarcerated people—to provide health services and reduce social stigma.
- Mothers2Mothers trains and employs women living with HIV as community health care workers, to provide primary care services to women, children, and adolescents, and improve detection and education around HIV and other diseases. Since its establishment in 2001, the program has created 12,000 jobs for women with HIV and provided health services to over 15 million people in sub-Saharan Africa.
Growing the health care workforce: Increasing access to health services and medications calls for well-trained health care workers. Reaching the standard of PHC recommended by the WHO will require an average global increase in health care workers from 5.6 workers per 1,000 to 6.7 workers per 1,000. However, the WHO projects that by 2030 there will be a deficit of 10 million health care workers. This shortfall is a truly global challenge, exacerbated by poor wages and working conditions in many places, including in advanced economies. The gap will be most acute in LMICs, which experience high levels of brain drain, wherein trained health care professionals seek better, and better-paid, opportunities elsewhere. Prior to the pandemic, out-migration by physicians was estimated to cost LMICs U.S. $15.86 billion in excess mortality per year.
Meeting recommended targets for health care workforce coverage warrants conducive policies, investments in education, and the growth of vocational opportunities. Effective government stewardship will be essential to identifying need and coordinating a response, alongside certain non-governmental partners:
- Universities and tertiary education institutions can conduct active outreach to communities and groups under-represented in the local health care workforce, and, where possible, offer scholarships.
- Private health care companies can collaborate with higher education institutions to provide funding and resources for health-related training courses and degrees, including financing the training of health workers from under-served communities and marginalized groups, and donating equipment and educational materials.
- Pharmaceutical companies and developers of medical equipment can provide regular, free training and upskilling programs for health workers to learn to operate new-to-them testing and treatment equipment and stay up to date with the latest procedures.
Few LMICs Meet the Target Threshold of Health Care Workers
Health care workers include doctors, nurses, midwives, dentists, and pharmacists.
69.7% have less than the recommended 15 doctors per 10,000 population
77.3% have less than the recommended 3 dentists per 10,000 population
64.4% have less than the recommended 30 nurses per 10,000 population
72.8% have less than the recommended 3 pharmacists per 10,000 population
Note: The workforce density thresholds in the stats above come directly from the National Health Workforce Accounts Database. They represent a general target for health care workforce density but do not reflect the heterogeneity of countries’ conditions, health care needs, optimal workforce composition, or skills mix. A more detailed explanation is available at the data source.
DATA SOURCE: The National Health Workforce Accounts Database, World Health Organization; the WHO’s Global Strategy on Human Resources for Health: Workforce 2030 Report
Multi-stakeholder collaboration to enable resilient health systems and achieve UHC: In addition to the potential pathways outlined above, health care and health-adjacent companies, foundations, and NGOs can lead in several important areas:
- Investors, board members, and shareholders can integrate the principles and objectives of UHC into their business practices, organizational strategies, and overall missions. By viewing returns on investment in the long-term and defining objectives in terms of access to life-saving treatments and screenings at a low cost, large and small businesses across the health care industry can set an example to all health care actors by prioritizing patient needs.
- Philanthropic foundations can help to close gaps in public health and infrastructure investment by supplementing resources provided by multilateral development banks or governments, or through ODA. This could include identifying and championing innovative sustainable financing streams for health systems in LMICs to move them toward greater domestic ownership and financing in the future.
- Companies operating in LMICs across all sectors can collaborate with national governments and with regional and global development institutions to undertake and support high-quality data collection on relevant public health metrics.
- Companies that are relevant to the wider health ecosystem can provide vital support for health goals by extending affordable, reliable access to services, such as water and electricity, safe public transit and transport infrastructure, broadband internet, and last-mile delivery and logistics, to connect all communities to high-quality care.
Case study: Reducing maternal mortality and improving maternal health outcomes
Maternal mortality remains a serious global challenge, with LMICs accounting for 95 percent of all recorded maternal deaths in 2020. In 2012, an international coalition of government health ministries, development agencies, NGOs, and pharmaceutical companies launched Saving Mothers, Giving Life, a public-private partnership to reduce maternal mortality rates in Uganda and Zambia. Partners included Merck & Co., Inc. (known as MSD outside of the United States and Canada), USAID, the Government of Norway, and Every Mother Counts. The program targeted the labor, delivery, and early post-partum period in which an estimated two thirds of maternal deaths and 45 percent of newborn deaths occur. Over a five-year period, the project implemented five core interventions: increasing the prevalence of skilled attendance at birth; improving the safety of facilities and hospitals for delivery; supplying the resources needed for basic and emergency obstetrics; implementing systems for communication and transportation between hospitals and expectant mothers; and collecting and analyzing high-quality data. At its close, the program had reduced maternal mortality by 44 percent in the facilities targeted in Uganda, and 38 percent in facilities targeted in Zambia. Uganda has since used the structure of the program to develop a Uganda Reproductive, Maternal, and Child Health Services Improvement Project, in partnership with the World Bank, and as a model to develop its maternal, newborn, and childhood health strategy.
Looking ahead: Working together to achieve universal health
Progress toward UHC has been slow, and in recent years disrupted by acute global and regional crises that have necessitated the diversion of resources, personnel, and financing. As the 2030 deadline for completion of the SDGs approaches, these challenges will persist without concerted action. Meanwhile, others will emerge, including the complex effects of climate change on public health, to which LMICs are particularly vulnerable, and the global phenomenon of accelerated population aging. Stakeholders in improving public health across all sectors have an opportunity to work together to redouble commitments to UHC and undertake significant investments in the health of LMICs. By leveraging the expertise, resources, and networks of the variety of stakeholders within its ecosystem, the health care industry can continue to make and contribute to significant gains toward achievement of UHC.
Publication date: May 2023
By Isabel Schmidt (Senior Policy Analyst), Anjana Nair (Policy Fellow), and Dr. Mayesha Alam (Vice President of Research). Maps produced with Datawrapper.
This report was made possible by financial support from the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). It was produced by FP Analytics, the independent research division of the FP Group. FP Analytics retained complete control of the direction of the research. Foreign Policy’s editorial team was not involved in the creation of this content.