Introduction to Universal Health Coverage (UHC)
Universal Health Coverage (UHC) first emerged when the World Health Organization (WHO) published its 2010 Global Report on Health Financing titled “The Road to Universal Health Coverage.” This document presented a technical concept in development that proposed integrating three related aspects: the population, service provision, and costs assumed by the health system. Simultaneously, this idea aimed to serve as a mobilizing notion across diverse contexts by embodying values such as equity and the right to health.
First Contradiction: Separate Indicators for an Integral Goal
The ODS Target 3.8 is divided into two indicators:
- Indicator 3.8.1 measures coverage of essential services through a composite index of selected interventions (vaccination, childbirth care, chronic disease management, etc.)
- Indicator 3.8.2 measures protection against catastrophic health expenditure, i.e., the proportion of the population incurring healthcare costs exceeding 25% of their household income.
While both are crucial, separating them as independent indicators fractures the very concept of universal coverage, which by definition should integrate access, quality, and financial protection. These indicators cannot be directly summed or cross-referenced, failing to produce a composite value. Consequently, a country can report progress on indicator 3.8 of the ODS while experiencing contradictory advances or declines in access and financial protection.
In Mexico, this paradox is evident. According to the 2022 National Household Income and Expenditure Survey (ENIGH) by Mexico’s National Institute of Statistics and Geography (INEGI), average household health expenditure increased by 30.9% between 2018 and 2022, leading to a rise in the percentage of Mexican households facing catastrophic health expenditure from 2.5% to 3.3%. Simultaneously, the 2022 National Health and Nutrition Continuous Survey (ENSANUT) reports a slight increase in public medical service access compared to previous years, but private service usage remains high, particularly among the uninsured population. These figures illustrate how fragmented measurement of UHC can conceal contradictions in its implementation.
Second Contradiction: Confusing Contact with Outcome
Nominal coverage (the performance of a medical act) is mistaken for health assurance, although it does not measure clinical outcomes or effective protection. This is evident in chronic disease management, such as diabetes and hypertension treatment. Many countries report high nominal coverage percentages for these conditions, but when examining how many patients are genuinely controlled (with appropriate glucose or blood pressure levels), the numbers plummet. Here, nominal coverage existed on paper, but health did not improve.
In Mexico, the second contradiction of UHC is perceived by observing that medical service access does not guarantee effective clinical outcomes. According to the 2022 ENSANUT, 18.3% of adults live with type 2 diabetes, but only 4.3% maintain adequate glucose control (hemoglobin A1c <7%). For hypertension, 47.8% of adults suffer from it, with 13% having controlled blood pressure. These data express that, despite reporting high treatment rates for diabetes (73%) and hypertension (82.3%), effective control remains limited, indicating a significant gap between provided medical care and expected health outcomes.
This example demonstrates that nominal coverage is inadequate as a health gain evaluation tool. Simply having contact with patients is insufficient; that contact must be beneficial and resolution-oriented.
Third Contradiction: Declaring What’s Not Measured, Measuring What’s Not Regulated
Effective coverage—access to services genuinely addressing health issues—is a concept promoted by WHO but not officially measured. WHO has mentioned it since 2003 in technical documents, yet it hasn’t incorporated it as an ODS 3.8 indicator. Instead, the Institute for Health Metrics and Evaluation (IHME) has developed effective coverage indices adjusted by need. Measuring coverage based on the population requiring attention rather than those seeking it makes a significant difference. The third inconsistency arises from the outcome: WHO declares the goal but doesn’t measure it, while IHME measures the goal but cannot regulate it.
This contradiction is evident in the discrepancy between official indicators and independent assessments. According to WHO, Mexico achieved a 2021 essential health services coverage index (indicator 3.8.1) of 75, suggesting moderate access to essential services (fifth decile). However, IHME’s effective coverage measurements, considering both access and health gain in each intervention, revealed that Mexico’s effective UHC index was 61 (third decile among countries with the least coverage) in 2019. Despite high nominal coverage, health outcomes do not always show significant improvements, especially in chronic disease control like diabetes (second decile) or Chronic Kidney Disease and Acute Lymphoblastic Leukemia (first decile) with low coverage indices.
This case highlights that nominal coverage is an insufficient instrument for evaluating health gain. It’s not enough to merely count the services provided; those services must be beneficial and resolution-oriented.
Fourth Contradiction: Modern Language in Arcane Structures
This disconnect between promises and evaluations allows for a revealing metaphor: “UHC is like storing cheap young wine (promise) in an old bottle (arbitrary structures).” The promise is modern, ambitious language centered on the right to health and equity, but served in outdated bottles: fragmented institutional frameworks, information systems designed for accountability, and political structures reluctant to expose true disparities. We continue measuring the easy, not the important.
UHC was envisioned as an integrating ideal, but it’s operated as a mosaic of separate goals, partial measurements, and diluted results. This risks transforming UHC into a simulated modernity operating in unproductive structures.
Measuring effective coverage goes beyond technical refinement. It involves transitioning from counting services delivered to counting protected lives, resolved issues, and closed gaps. Until this shift occurs, universal rights declarations will continue with fragmented indicators, and medical care offerings will satisfy statistical targets but not necessarily patients.
Recommendation
- Reformulate monitoring systems, incorporating effective coverage measurements reflecting genuine health outcomes rather than merely institutional contacts.
- Unify official indicators into a synthetic, integrated reading that allows simultaneous evaluation of access, quality, and financial protection.
- Review regulatory consistency between declared goals and budgetary and organizational practices to prevent universal health rights translating into fragmented provisions and diffused responsibilities.
UHC is not achieved by expanding the number of affiliated individuals or reporting medical acts; it’s realized when people access useful, timely services without affecting their family’s finances. This should be the benchmark for measuring what truly matters.
*The author is a Tenured Professor in the Department of Public Health, Faculty of Medicine, UNAM and Emeritus Professor in the Department of Health Measurement Sciences, University of Washington.
The opinions expressed in this article do not represent the position of the institutions where the author works.
[email protected]; [email protected]; @DrRafaelLozano
