Intended for healthcare professionals


Putting health equity at heart of universal coverage—the need for national programmes of action

BMJ 2019; 367 doi: (Published 25 October 2019) Cite this as: BMJ 2019;367:l5901
  1. Eric A Friedman, global health justice scholar1,
  2. Lawrence O Gostin, faculty director1,
  3. Matthew M Kavanagh, director, global health policy and governance initiative1,
  4. Mirta Roses Periago, member2,
  5. Michael Marmot, director3,
  6. Anna Coates, chief4,
  7. Agnes Binagwaho, vice chancellor5,
  8. Joia Mukherjee, chief medical officer6,
  9. Mushtaque Chowdhury, vice chair7,
  10. Tracy Robinson, senior lecturer8,
  11. Valdiléa G Veloso, director9,
  12. Chenguang Wang, professor of law10,
  13. Miriam Were, member11
  1. 1O’Neill Institute for National and Global Health Law, Washington, DC, USA
  2. 2National Academy of Science of Buenos Aires, Argentina
  3. 3UCL Institute of Health Equity, University College London, London, UK
  4. 4Office for Equity Gender, and Cultural Diversity, Pan American Health Organization, Washington, DC, USA
  5. 5University of Global Health Equity, Kigali, Rwanda
  6. 6Partners In Health, Boston, MA, USA
  7. 7BRAC, Dhaka, Bangladesh
  8. 8University of the West Indies, Mona, Kingston, Jamaica
  9. 9Evandro Chagas National Institute of Infectious Diseases, Rio de Janeiro, Brazil
  10. 10Tsinghua University, Beijing, China
  11. 11Champions for AIDS-Free Generation, Nairobi, Kenya
  1. Correspondence to: L O Gostin gostin{at}

Better data on health disparities and commitment to interventions focused on the determinants of inequality are essential, argue Eric Friedman and colleagues

Income inequality is growing,1 fuelling both right wing populism2 and demands for progressive, inclusive policies. Global disquiet over inequality prompted the United Nations to pledge in the sustainable development goals (SDGs) that “no one will be left behind.”3 Health inequities present a defining challenge of our time,4 and governments need to adopt and rigorously implement national programmes of action to respond across multiple dimensions so that economic and social status no longer determine human health and wellbeing.

Most of the data collected on health has been at national and global levels. Such aggregated data may mask deep unfairness in the distribution of good health, much as a growing gross domestic product can mask highly unequal distribution of wealth. For example, a baby born in a largely white, wealthy suburb of St Louis in the US can expect to live 35 more years than one born in a mostly black, lower income suburb a few miles away; the average life expectancy in Saint Louis County is close to 79 years, but ranges from 56 to 91across neighbourhoods.56 Globally, life expectancy is 72 years but people in the United Kingdom live an average of 81 years while those in Sierra Leone average only 54.7

There have been few actionable, inclusive national initiatives expressly designed to achieve health equity—a missed opportunity as countries create national development strategies and develop health plans that include precise national health targets. Despite some important work on health equity, international institutions have not brought equity to the centre through concrete, actionable strategies. The political declaration on universal health coverage agreed at the 2019 UN high level meeting on universal …

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