Universal health coverage provides the fairest and most efficient route to protecting people from ill health, and from impoverishment linked to ill health. This benefits not just individuals; it also contributes to the collective well-being of families, communities and societies. Crises raise the stakes, making political action on UHC more urgent than ever.
Purpose of the Commission for Universal Health
The Chatham House Commission for Universal Health was established in 2022, at a moment when crises and shocks were proliferating around the world. The commission’s purpose has been to explore the opportunities that these circumstances may offer for accelerated progress towards universal health coverage (UHC), recognizing the obstacles UHC faces and the importance of maintaining progress towards it.
The commission’s primary goal has been to develop and share evidence to support countries to meet their commitments to reach UHC by 2030 (as agreed in the Sustainable Development Goals and reiterated at the UN General Assembly in 2019) and build more resilient health systems to strengthen preparedness for future pandemics.
The work has been taken forward by a team of 47 commissioners (listed in the acknowledgments section at the end of this report), chaired by Helen Clark, former prime minister of New Zealand, and Jakaya Kikwete, former president of Tanzania, and supported by a technical secretariat based at Chatham House. Its messages are aimed particularly at political leaders.
Commissioners have met regularly over the last two years, including five times as a commission, to contribute insights on the key questions and shape messages. Four working groups were also established, tasked with, respectively: addressing definitions and conceptualization; the development of the literature review and conceptual framework; country case studies; and identifying opportunities for future UHC reforms. Periodic all-commissioner meetings ensured coherence across these strands.
This report presents the findings of the authors and the secretariat team at Chatham House based on their own research, and drawing on the invaluable contributions and insights of the members of the commission.
Overview
Today’s political leaders are faced with multiple crises associated with the aftermath of the COVID-19 pandemic, new and protracted conflicts, rising food and energy prices, and the climate emergency. The commission investigated whether some leaders might be looking to implement UHC reforms as part of the response to such crises. The commission therefore held discussions, both within its working groups and with external stakeholders, to assess whether any countries are already implementing UHC reforms and whether others are considering such a strategy.
Our work suggests that responses to contemporary crises do appear to be fostering interest among political leaders in launching or expanding ambitious UHC reforms. This tends to be most evident in middle-income countries that have not yet made the transition to a predominantly publicly financed UHC system. One of the primary aims of the commission has been that findings and lessons from previous post-crisis UHC reforms can inform new UHC initiatives. Our findings indicate that crises do appear to be a factor in driving UHC reforms, especially in regions that have previously made slower progress towards UHC – notably in Africa and South Asia.
Our findings suggest that responses to contemporary crises appear to be fostering interest among political leaders in launching or expanding ambitious UHC reforms.
In South Africa, for instance, the COVID-19 pandemic highlighted deep-seated inequalities in the country’s health system, and appears to have spurred President Cyril Ramaphosa into accelerating the legislative process to launch a National Health Insurance (NHI) programme. The NHI Act, which was signed into law in May 2024, will create a tax-financed single-payer health system that will provide a universal entitlement to health services in both the public and private sectors. With no party winning an overall majority in South Africa’s general election, conducted shortly afterwards, it is uncertain how and when the act will be implemented or whether it may be amended by the incoming coalition government. In Egypt, in January 2021, President Abdel Fattah El-Sisi directed the government to complete the implementation of the country’s National Health Insurance System (NHIS) by 2027 – five years earlier than previously scheduled. Egypt’s UHC reforms will prioritize achieving full population coverage by increasing pooled public financing, drawing on mandatory social health insurance contributions and tax financing to replace out-of-pocket (OOP) expenses.
In Tanzania, President Samia Hassan signed the Universal Health Insurance Bill into law in December 2023, committing the government to extending health coverage to all citizens through mandatory social insurance contributions and increased tax financing covering vulnerable households. In Kenya, President William Ruto’s government enacted four pieces of UHC legislation in November 2023 – the Social Health Insurance Act, the Primary Health Care Act, the Digital Health Act, and the Facility Improvement Financing Act – with the intention of extending public health coverage to all Kenyans and long-term residents. Kenya’s comprehensive reforms also aim to restructure healthcare financing and administration nationwide.
In South Asia, political leaders in larger middle-income countries, which have historically seen low levels of public health spending and high levels of health-related impoverishment, have latterly been showing increased interest in launching or expanding universal health reforms. In September 2023, for example, India’s health ministry launched a nationwide campaign to enrol eligible households into the country’s vast Ayushman Bharat health insurance programme. Launched by Prime Minister Narendra Modi in 2018, the scheme already covers over 500 million people, and the government is now extending access to more groups of workers: in the budget for 2024 (an election year), it was announced that over 3 million community health volunteers would be eligible for free membership. Meanwhile, state-level governments have been launching universal health reforms. In the union territory of Delhi and the state of Punjab, notably, universal access to free primary care services is provided via hundreds of mohalla clinics. This has become a flagship policy of the Aam Aadmi Party – the governing party in both of these states – in its election campaigning.
In Bangladesh, Prime Minister Sheikh Hasina has demonstrated her administration’s political commitment to expanding health coverage by co-hosting UHC events with the Chatham House Commission for Universal Health in Dhaka in May 2023 and at the United Nations General Assembly in September 2023. At these events, Hasina emphasized UHC as a constitutional obligation, pledging to provide essential healthcare for the entire population of Bangladesh through public provision by 2030. Launching her election manifesto in December 2023, she announced: ‘A Universal Health System will be established to ensure equal healthcare for all citizens’, and ‘Primary health care and medicine distribution free of cost will be continued through community clinics.’
In Pakistan in 2021, at the height of the COVID-19 pandemic, the then prime minister Imran Khan announced his intention to launch a welfare state based on a universal right to food security and access to health services. His subsequent removal from office in 2022 meant that he was unable to take these pledges forward, but the strong showing by former members of his (banned) party in the 2024 general election suggests that UHC reforms could return to the political agenda.
It might appear unaffordable and infeasible for many countries to contemplate launching ambitious UHC reforms in the current context. However, the evidence from our research would suggest the opposite: economic and political crises may actually provide a window of opportunity for bold action on universal health.
Why focus on UHC now?
UHC consists of three interrelated components: (i) quality health services according to need; (ii) financial protection from direct payment for health services when consumed; and (iii) coverage for the entire population. The right to the highest attainable standard of physical and mental health is enshrined in several international legal instruments. It is a fundamental human right, which governments have committed to fulfil under the UN Sustainable Development Goals.
But the world is failing to make significant progress towards UHC by 2030. Improvements to health services coverage have stagnated since 2015, and the proportion of the population facing catastrophic levels of OOP health spending has increased. As the World Health Organization (WHO) Council on the Economics of Health for All has highlighted, proactively addressing social and economic determinants of health is a long-term investment, not a short-term cost, because it avoids the high costs of inaction. The decline in global GDP of 3.1 per cent in 2020 – i.e. the first year of the COVID-19 pandemic – could have been significantly lower if adequate prior investments had been made in disease prevention and response systems.
UHC serves as a cornerstone for broader economic resilience, fostering progress beyond pure economic growth. WHO estimated in 2018 that investments in extending access to UHC in the period 2019–23 could yield a return of 9:1, taking account of life expectancy gains and the intrinsic value of lives saved. A one-year increase in life expectancy has been estimated to boost GDP per capita by 4 per cent. In 2000–11, improvements in health contributed to an estimated yearly growth in income of 1–2 per cent across low- and middle-income countries. UHC can also release precautionary savings that households have had to make in the absence of financial protection in relation to healthcare, as was observed in China. UHC is particularly important for the significant population working in the informal economy with no financial safety nets or job security. Globally, 61 per cent of the labour force work in the informal sector. Illness means these workers can lose their source of income, and their very survival is threatened. In India alone, 93 per cent of the workforce is informal (some 500 million people). For them, especially women, health is key to economic security and well-being.
Historically, global crises and shocks have often shifted the understanding of health as an important right and changed political incentives in relation to it. In the aftermath of the First World War, for example, the 1918–20 ‘Spanish flu’ pandemic spurred a global reappraisal of public health policies. Crises create a potential ‘window of opportunity’ to embark on a new path and overcome obstacles previously regarded as insuperable. The world is emerging from the COVID-19 pandemic into an era characterized by what is often termed ‘polycrisis’ affecting current and future generations, including multiple armed conflicts as well as social, economic, environmental and epidemiological challenges. This demands a radical reappraisal to underpin new health, social and economic policies, and a reorientation of economies worldwide around the goal of Health for All. In this context, the Commission for Universal Health has sought to work with governments to promote UHC as a legal responsibility and political priority that goes beyond health, to include intergenerational, economic, societal, environmental and political benefits.
What are the benefits of UHC?
UHC significantly enhances people’s lifelong well-being. Improved health at each life stage not only benefits individuals, but also contributes to the collective well-being of families, communities and societies. Prevention and promotion strategies efficiently reduce morbidity and mortality while curbing disease transmission, thus protecting both individuals and the broader community and healthcare system.
Health security is a key component of UHC, and is vital for disease outbreak prevention and preparedness. It can therefore confer regional and global benefits by curbing disease spread, thus supporting efforts to tackle rising levels of antimicrobial resistance. Meeting international legal obligations for risk reduction and emergency preparedness prevents health system collapse during emergencies, ensuring that essential UHC elements benefit affected populations.
By providing protection and pooling health and health financing risks across population groups, UHC additionally underpins social development across the life course (including educational development), reduces inequities, including gender-based inequalities, and can improve social cohesion and peacebuilding, contributing to resilience and avoiding or mitigating future crises.
There are a number of key mechanisms through which health coverage and health can help address poverty and support economies. These include financial protection by avoiding catastrophic expenditure and impoverishment when people access healthcare. Education is another important pathway: better health improves educational attainment, with long-term benefits in terms of jobs and pay. Better health also contributes directly to worker productivity through reduced absenteeism and better performance. There is, too, a notable effect on investment, linked to the effect of longer life expectancy and higher incomes in boosting savings. Finally, there can be a demographic mechanism, with better health contributing to changed family structures and hence growth opportunities. Moreover, healthcare is one the biggest sectors of the economy globally, already providing an estimated 65 million jobs in 2020.
Ensuring equitable access to healthcare and protection from healthcare costs has proved popular with electorates and delivered benefits for the politicians who led these reforms. Conversely, failure to provide social protection to populations can drive disillusionment with the political system, fuelling populism and undermining the political process.
Failure to provide social protection to populations can drive disillusionment with the political system, fuelling populism and undermining the political process.
A further benefit of UHC is that, while increasing access to healthcare for all, it offers the possibility of providing better healthcare more cost-effectively than alternative models. It is sometimes argued that, as many people can afford to pay for their healthcare, it would be best to let them do so through private insurance provided by employers and their own contributions while concentrating publicly financed resources on meeting the needs of the worse off. This is the type of health system that has evolved in South Africa and – following the passing of the 2010 Affordable Care Act, known as ‘Obamacare’ – the US.
In the case of the US, 14 years after the introduction of the Affordable Care Act, there are still massive problems for millions of Americans in accessing affordable healthcare. The US in 2021 spent 17.8 per cent of GDP on healthcare, almost twice the average for high-income countries. Yet, in spite of Obamacare, in 2021 8.6 per cent of the population remained without insurance. Moreover, most measures of health outcomes such as life expectancy or child and maternal mortality are significantly lower than in other high-income countries. Affordability is still a major reason why almost half of adults in the US avoid or delay accessing healthcare that they need.
The difficulties of the US system are twofold. First, the system tends to discourage access through the cost of insurance, the prevalence of the copayments required from patients by insurance companies, and restrictions on procedures or medicines that insurers are prepared to reimburse. This affects not just the poor, but also people well up the income scale. Second, on the supply side, the system encourages high-cost services not necessarily related to patient needs. Doctors are paid by fee-for-service, which prioritizes high-cost procedures over cheaper approaches. Moreover, the overheads inherent in running an insurance-based system with multiple players generates a vast quantity of transaction costs and paperwork for hospitals, clinicians and patients. It has been argued that if a single-payer UHC system replaced the current model, the same healthcare outcome could be achieved with an annual saving of over $600 billion.
The same argument applies to concerns about the affordability of publicly financed UHC in view of the healthcare issues raised by the prospect of rapidly ageing populations – a trend that will be seen in many developing countries over the coming years. It will be even more important to find cost-effective and equitable means of effectively meeting the increasing demand for health and social care this represents. Versions of publicly financed UHC, including essential public health functions, rather than voluntary insurance models, are far more likely to achieve this.
