Intended for healthcare professionals


Universal health coverage: ensuring that nobody is left behind

BMJ 2023; 382 doi: (Published 25 September 2023) Cite this as: BMJ 2023;382:p2205
  1. Vinayak Bhardwaj, senior health economist1,
  2. Mit Philips, lead2
  1. 1University of Witwatersrand, South Africa
  2. 2Health politics team, MSF, Brussels

An urgent repurposing of the UHC agenda is needed to identify and remedy the gaps in access to healthcare for those who need it most, argue Vinayak Bhardwaj and Mit Philips

Delegates met last week at the United Nations high level meeting on universal health coverage (UHC) at a perilous time for global health. There is a gulf between the 2030 sustainable development goals to achieve quality, affordable care for everyone everywhere, and the reality that millions of people in the world face. An urgent repurposing of current universal health coverage targets is required to tackle the reality of diminishing funds for health, closure of vital health programmes for vulnerable people, and the development of universal health coverage country plans that are adapted to crises and to the needs of people on the move.

External support for health through donor aid and multi-lateral funding is decreasing, with major donor countries—including the UK and Sweden—announcing repeated cuts and reauthorisation of the President's Emergency Plan for AIDS Relief (PEPFAR) in the United States under increasing threat.12 Domestic health funding, especially in low-income countries, is already insufficient, but is being further reduced in many countries due to the current economic crisis.3

The covid-19 pandemic has further hindered progress towards UHC meaning that at the current pace there is no chance to reach the target by 2030. There is little indication of revised strategies or fundamental change in the roadmaps. A renewed focus on the health needs that are most acutely felt, in crises and among vulnerable populations, with clear objectives to overcome the barriers to access is urgently required.

Free healthcare initiatives that target and prioritise children, pregnant women, and other vulnerable people in countries including Mali, Burundi, Sierra Leone, South Sudan, and Afghanistan have been significantly cut or are seriously undermined.4 Women’s health is in dire straits as facilities across many low-income countries have cut back services unless women can pay. In some instances, those who cannot pay are being detained until medical bills are paid.45 This is effectively punishing women with low incomes and further deterring them from giving birth in healthcare facilities. Lack of access to free healthcare is a missed opportunity to improve agency and decision making for women.

Fees for healthcare that are paid out of pocket are often imposed on extremely vulnerable populations, such as victims of sexual and gender-based violence or people who use drugs.4 Many patients with infectious diseases in low income countries cannot afford the co-payments needed to obtain subsidised medicines. Even where HIV or tuberculosis treatment itself is provided free of care, additional costs are obstructing timely and consistent treatment. For example, an estimated 40-80% of households containing patients with drug-sensitive or resistant tuberculosis face catastrophic health expenses of over 20% of household spending.6

Public health facilities mostly fail to provide drugs and services free of charge for non-communicable diseases which is detrimental to patients as it further increases out of pocket payments and can interrupt treatment. In Kenya primary care should be free of charge, but healthcare for non communicable diseases is not included in the package, forcing patients to pay out of pocket in hospitals, including for insulin.4

In crisis settings, it is imperative to improve access to essential care. In epidemic outbreaks patient fees cause delays and deficiencies in detection and response.7 The current UHC 2030 agenda is largely silent on ensuring access to healthcare during crisis, even in countries facing recurring outbreaks and conflict.

Globally, one in eight people today is a migrant or is forcibly displaced.8 But there is insufficient guidance, at country and global level, to adapt models of coverage to people on the move.9 Even in some high income countries coherent mechanisms to link people to care are lacking, with legal, bureaucratic, and financial barriers leaving patients unable to access even the most essential services without paying large sums of money themselves. In our work we have seen distressing cases of migrants being unable to afford healthcare fees and care being denied to those without proper documents, leading to death and complications.

An urgent repurposing of the UHC agenda is needed to both identify and remedy the gaps in access to healthcare for those who need it most. To progress towards universal healthcare for all we recommend urgent mobilisation of resources targeted to free healthcare to mitigate financial barriers leading to people foregoing care, proactive provision and systematic monitoring of migrant-sensitive healthcare, and specific, funded plans to provide for the health needs of people during emergencies. Introducing these would be a basic requirement for any plan that genuinely intends to “leave no one behind.”


  • Competing interests: Vinayak Bhardwaj is formerly regional migration referent for Médecins Sans Frontières (MSF) Southern Africa. Mit Philips is a medical doctor with extensive field experience within Médecins Sans Frontières (MSF).

  • Provenance: not commissioned, not externally peer reviewed