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  • Universal health coverage (UHC) is about ensuring that people have access to the health care they need without suffering financial hardship. It is key to achieving the World Bank Group’s (WBG) twin goals of ending extreme poverty and increasing equity and shared prosperity, and as such it is the driving force behind all of the WBG’s health and nutrition investments. 

    UHC allows countries to make the most of their strongest asset: human capital. Supporting health represents a foundational investment in human capital and in economic growth—without good health, children are unable to go to school and adults are unable to go to work. It is one of the global economy’s largest sectors and provides 50 million jobs, with the majority held by women. 

    Global movement towards UHC

    Health is also an essential part of the Sustainable Development Goals (SDGs). For example, the SDG 3.8 target aims to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” In addition, SDG 1, which calls to “end poverty in all its forms everywhere” could be in peril without UHC, as almost 90 million people are impoverished by health expenses every year.

    Access to affordable, quality primary healthcare is the cornerstone of UHC, but many people around the world still struggle to fulfil their basic healthcare needs. Mental health, often overlooked, is also an important element of UHC, as it is critical to people’s ability to lead a productive life.

    In recent years, the UHC movement has gained global momentum, with the first-ever UN High-Level Meeting on UHC held in September 2019. A Political Declaration was unanimously adopted by member states, affirming their high-level political commitment to UHC and outlining a number of necessary actions. Twelve co-signatories including the WBG also launched the Global Action Plan for Healthy Lives and Well-being for All (GAP) to jointly support countries in delivering on the SDG3 targets. In January 2020, the second UHC Forum was held in Bangkok, aiming to enhance political momentum on UHC in international fora.

    Providing Affordable, Quality Primary Healthcare

    Providing affordable, quality health services to the community, in particular to women, children, adolescents and people affected by mental health issues, represents a long-term investment in human capital. 

    Primary health services are a fundamental element of UHC, yet research warns that, if current trends continue, up to 5 billion people will still be unable to access health care in 2030. Maternal and child mortality remain high in several parts of the world. More than a fourth of girls and women in Sub-Saharan Africa cannot access family planning services, fueling unplanned pregnancies and maternal, infant and child mortality and morbidity. In 2015, the WBG and partners set up the Global Financing Facility (GFF), a multi-stakeholder initiative that focuses on helping countries improve maternal, child and adolescent health services.

    Many countries that are experiencing rapid population growth have young populations that could drive economic growth and reduce poverty. But to unleash the benefits of the demographic dividend, countries must invest in the health and well-being of their people to build human capital and boost inclusive growth.

    Improving reproductive, maternal, newborn, child and adolescent Health (RMNCAH) and addressing mental health disorders is crucial to achieving UHC. Major challenges subsist, among them:  

    ·       Maternal mortality: Most of the world’s maternal deaths occur in developing regions: in least developed countries, the lifetime risk of maternal death for women is on average one in 56 compared to one in 7,800 in high-income countries like Australia or New Zealand. In Sub-Saharan Africa, which alone accounts for two in three maternal deaths (66%), the risk is one in 37. A further 20% of maternal deaths occur in South Asia. Most of these fatalities are preventable if pregnant women have timely access to the healthcare they need.

    ·       Child mortality: Mortality rates among children under five have more than halved from 12.5 million to 5.2 million between 1990 and 2018, according to a joint 2020 report published by the WBG, WHO and UNICEF. Yet a child’s chance of survival is still dependent on where they are born: worldwide, 15,000 children under five still die every day. In Sub-Saharan Africa, one child in 13 dies before his or her fifth birthday—compared to one in 199 in high-income countries. The WBG, WHO and UNICEF also collaborated on another 2020 publication that highlighted stillbirth, an issue that remains largely overlooked. Every year, 2 million babies are stillborn around the world and progress on reducing these numbers has not kept up with the decline in under-five mortality. In 2000, the ratio of stillbirths to under-five deaths was 0.30; by 2019, it had risen to 0.38 worldwide. In Sub-Saharan Africa, stillbirths increased from 0.77 million in 2000 to 0.82 million in 2019.

    ·       High fertility: Globally, women are giving birth to fewer children today than three decades ago. However, there are still a handful of countries with persistently high fertility such as Niger (7.0), Mali (6.0) or Democratic Republic of Congo (6.0). In other countries with lower fertility such as Ethiopia, fertility varies within different regions. It ranges from 1.7 in Addis Ababa, the capital city, to 6.4 in Somali, a regional state. Countries with persistently high fertility often face a high burden of maternal, infant and child mortality.

    ·       Adolescent fertility: More adolescent girls are giving birth in countries with high fertility rates. In Sub-Saharan Africa, the adolescent fertility rate is 102 births per 1,000 girls. Underage mothers are more likely to experience complications due to pregnancy such as obstructed labor and eclampsia, increasing their risk of death. Children born to adolescents are also more likely to have a low birth weight, ill-health, stunting and other poor nutritional outcomes.

    ·       Mental, neurological and substance use disorders (MNS):  These common, highly disabling disorders are associated with significant premature mortality and they impose a human, social and economic toll. Every 40 seconds, a person commits suicide somewhere in the world.

    To fully realize the goal of universal health coverage and improve human capital outcomes across the world, mental health programs must be integrated with service delivery at the community level and covered under financial protection arrangements. Estimates suggest that nearly 1 billion people live with a mental disorder. In low-income countries, more than 75% of people with the disorder do not receive treatment. Approximately half of all mental health disorders emerge by the age of 14 and some 20% of children and adolescents worldwide suffer from some type of mental disorder. In countries affected by fragility, conflict and violence, more than one in five people (22.1%) suffer from mental ill-health. Women and children who have experienced violence, soldiers returning from war, migrants and refugees displaced by conflict, the poor, and other vulnerable groups in society are disproportionately affected. The  Covid-19 pandemic has caused a global increase in mental health disorders due to various factors including anxiety, lockdowns, job losses, while also disrupting, or even halting, critical mental health services in 93% of countries worldwide.

    Since MSN have an early age of onset—often in childhood or early adolescence—and are highly prevalent in the working-age population, they contribute economic output losses estimated between $2.5-8.5 trillion globally, projected to nearly double by 2030.

    Mobilizing Resources for UHC

    In June 2019, the first-ever G20 Finance and Health Ministers joint session was hosted by the Presidency of Japan. The discussion aimed to galvanize G20 countries towards the common goal of financing UHC in developing countries. It was informed by a World Bank report showing that people in developing countries spend half a trillion dollars annually — over $80 per person — out of their own pockets to access health services. Such expenses hit the poor the hardest and threaten decades-long progress on health.

    World Bank/World Health Organization (WHO) research from 2019 shows that countries must increase spending on primary health care by at least 1% of their gross domestic product (GDP) if the world is to close glaring coverage gaps and meet the health targets agreed under the SDGs. A lack of universal access to quality, affordable health services endangers countries’ long-term economic prospects and makes them more vulnerable to pandemic risks.

    Without urgent action, developing countries faced with aging populations and growing burdens of non-communicable diseases will find themselves increasingly challenged to close the gap between the demand for health spending and available public resources, and will prolong the reliance on out-of-pocket spending by patients and their families.

    Last Updated: May 19, 2021

  • Today, most low- and middle-income countries are designing and implementing strategies that are accelerating progress toward UHC. At the first-ever UN High-Level Meeting on UHC in September 2019, member states reaffirmed their commitment to achieving UHC by 2030 and asserted the right of people to enjoy the highest attainable standard of physical and mental health as an integral part of the SDGs.

    Supporting Country Progress

    While the path to UHC is specific to each country, the WBG’s aim is to support countries to build healthier, more equitable societies, as well as to improve their fiscal performance and country competitiveness. The WBG does this through global, regional, and country-level research and knowledge generation, financial investments and technical assistance, and global convenings.

    To deliver good outcomes, the WBG focuses on four priority areas.

    First, it is important to ramp up investments in affordable, quality primary healthcare. Health systems based on a foundation of strong primary health care are more efficient and equitable, producing higher value and better health outcomes: More resources to detect and treat conditions early, before they become more serious, will not only save lives but also reduce health costs.

    Second, it is key to redouble our efforts to engage the private sector and unlock new models for health financing and delivery. The unmet coverage and financing needs are too vast for the public sector to close the gap alone.

    Third, the WBG is going beyond health to improve health outcomes and supporting communities by improving education, broadening social services, and creating jobs. The Human Capital Project aims to support countries in taking an integrated, whole-of-government approach to improving human development outcomes.

    Fourth, the way health is financed needs to change so countries get better outcomes for the money they are spending. The WBG and other international partners are helping them catalyze domestic resources to build sustainable national health systems.

    Joining forces is key, and the WBG works with several partners to accelerate progress towards UHC. It is a co-convener with the WHO of UHC2030, the global movement to build stronger health systems for UHC. This multi-stakeholder platform also advocates for increased political commitment to UHC and facilitates accountability and knowledge sharing. As one of 12 co-signatories of the Global Action Plan for Healthy Lives and Well-being for All, the WBG is committed to aligning its ways of working with partners to reduce inefficiencies and support country efforts to deliver on their international commitments on health.

    Boosting RMNCAH and Mental Health Services

    Ensuring that every woman and child has access to health care, and mental health disorders are recognized and addressed, is pivotal to bolster human capital outcomes and core to the World Bank Group’s agenda to build prosperous economies and end poverty. It is also fundamental to achieving Universal Health Coverage.

    To propel the reproductive, maternal, newborn, child and adolescent health (RMNCAH) agenda and harmonize fragmented approaches, the WBG and partners launched the Global Financing Facility (GFF) in 2015, a multi-stakeholder partnership that supports country-led efforts to improve the health and well-being of women, children and adolescents.

    Another key effort is the Sahel Women’s Empowerment and Demographic Dividend (SWEDD) project. Active across the region, SWEDD is empowering women and adolescent girls and increasing their access to quality education and reproductive, child and maternal health services in Benin, Burkina Faso, Chad, Côte d’Ivoire, Mali, Mauritania, and Niger. The project mobilizes all of society to harness the tremendous economic potential of women—from religious leaders, legislators and health workers to mothers and husbands—benefiting their families, communities and countries as a whole.

    To highlight the scale of mental health issues and the gains that can be achieved when addressing them, the World Bank Group, in partnership with WHO and other national and international organizations, is supporting efforts to put mental health at the center of global health and development agendas. Global events such as Moving the Needle: Mental Health Stories from Around the World have increased awareness about mental health as a development challenge and the associated economic and social costs of inaction.

    World Health Organization (WHO) data show that, although mental ill-health is often underestimated and ignored, it accounts for 30 percent of the non-fatal disease burden and 10 percent of the overall disease burden worldwide, including death and disability. 

    Countries’ lack of health service capacity is one key factor hindering progress in addressing mental illness. In low- and middle-income countries, more than three quarters of people with a severe mental disorder do not receive treatment for their illness. Yet, financing mental health services provides long-term dividends: according to WHO, every $1 invested in mental health yields a $4 return on investment

    A World Bank working paper on Harnessing Technology to Address the Global Mental Health Crisis explores how  technologies such as virtual therapies and online learning can help in responding to mental health challenges in some communities and contexts. 

    Monitoring Progress Toward UHC

    Ongoing WBG research is helping to evaluate UHC progress globally, including the quality of primary care, health coverage expansion initiatives, and inequalities in health outcomes. The WBG and World Health Organization (WHO) jointly released the latest Global Monitoring Report on Financial Protection in Health 2019, which found that financial hardship due to out-of-pocket health spending increased continuously between 2000 and 2015. In 2015 alone, close to 90 million people were pushed into extreme poverty because they had to pay for health expenses out of their own pockets. In 2015 and 2017, WBG/WHO published similar reports measuring health service coverage and financial protection to assess countries’ progress towards UHC. They also jointly developed a monitoring framework to help countries track their progress and results in UHC.

    Countries are increasingly adopting health systems reforms that benefit poor households with the goal of ensuring UHC, according to ongoing World Bank research. Originally released in 2015, the report, Going Universal: How 24 Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up, describes how different countries are pursuing UHC, based on systematic data collection, in order to provide practical insights to policymakers. In 2018 and 2019, studies on an additional 17 countries were released.

    Last Updated: May 19, 2021

  • IDA, the World Bank’s fund for the poorest countries, is one of the most important tools to finance healthcare in lower income countries. IDA’s support ranges from building stronger health systems and service delivery capacity, to working with governments to prepare for pandemics and other health emergencies. Over the last decade, IDA has provided US$13.5 billion to fund essential health interventions for 770 million people, and immunizations for 330 million children.  The share of IDA funding for health and nutrition has increased by 60% over the last decade, reflecting rising demand from countries. 

    Achieving strong country outcomes

    Through IDA, the World Bank is for instance supporting Saint Lucia in improving its public healthcare system. The Health System Strengthening project aims to ensure that at least 100,000 people on the island of 178,000 inhabitants are registered to the National Health Scheme by the end of the project, and that at least 60 percent of diabetic and hypertensive patients over 18 years old are treated according to national protocols in public primary health care facilities. In addition, primary health care centers will be equipped to serve as the first point of detection for selected infectious diseases.

    In Yemen, IDA has helped save lives through the Emergency Health and Nutrition Project, which has reached more than 14.6 million people across the country, and through the Emergency Cash Transfer Program, which aims to ensure vulnerable Yemenis have money to buy food and basic necessities. Under the latter Program, cash transfers have so far been provided to about 9 million people across Yemen’s 333 districts.

    The multi-stakeholder Global Financing Facility (GFF), founded in 2015 by the WBG and partners to support maternal, child and adolescent healthcare is already having an impact. Early country results show that GFF support leads to better targeting of the poorest and most vulnerable groups, increased access to services and more domestic financing for malnutrition, maternal mortality and adolescent girls’ health. 

    Other initiatives to support women and reproductive, maternal and child healthcare also show promising results on the ground. The  Sahel Women’s Empowerment and Demographic Dividend (SWEDD) project has helped train over 6,600 midwives, create 3,420 safe spaces to give a second chance to 102,600 vulnerable out-of-school girls, and reach more than 4 million people through awareness raising campaigns on issues such as reproductive, maternal and child health and violence against women. In addition, 100,000 girls from poor backgrounds in Niger received school kits, scholarships, housing and academic support.

    Mental health disorders, often neglected in the past, are receiving more attention around the world. In the Khyber Pakhtunkhwa province of Pakistan, for example, over 100 small business entrepreneurs received five weeks of Cognitive Behavioral Therapy training. The intervention helped significantly reduce the intensity and prevalence of depression and anxiety symptoms among participants and contributed to higher levels of well-being, compared with a group of entrepreneurs that did not receive training.

    In Afghanistan, more than 2.2 million people received mental health services in 2018 across the country, compared to around half a million people in 2009. In Yemen, the World Bank’s emergency health programs offered mental health services and trauma care throughout the country. And in the Horn of Africa, the World Bank supported counseling for Somali women and children impacted by gender-based and sexual violence as part of a primary care package for those living in refugee camps in Kenya and Ethiopia.

    With support from the World Bank Group’s $6 billion COVID-19 Global Health Emergency Response Program, several countries such as Bosnia and Herzegovina, Cambodia, Ecuador, India, Lesotho, Liberia, Morocco, Marshall Islands, Mongolia, Nigeria, Sri Lanka and Turkey have launched psychological support programs to address the negative impact of the COVID-19 pandemic on mental well-being. Investing in mental health services contributes to an inclusive, resilient recovery.

    Partnering to accelerate country progress

    One of the most important challenges to achieving UHC globally is the availability and sustainability of financing. That is why the WBG, along with partners, also convenes the Annual Health Financing Forum at its Spring Meetings in Washington, DC. The Forum brings together countries and partners to explore the frontiers of resource mobilization for health and provides a platform to advance knowledge and its application in UHC financing. By bringing the finance and health sectors together, and by bridging policy with evidence, the Forum creates one of the only global spaces where key actors can help catalyze progress in countries towards sustainable financing of UHC.

    In addition, the WBG is also a partner in the Joint Learning Network for UHC, a network of policymakers and practitioners from low- and middle-income countries who learn from one another, jointly problem solve, and collectively produce and use new knowledge, tools, and innovative approaches to accelerate country progress toward UHC.

    WBG research has for example highlighted the case of Bangladesh as a country that has rapidly improved its health outcomes at low cost. It shows how the country benefited from a combination of factors, including public funding for highly cost-effective interventions, alignment of government and development partner financing, extensive use of female community health workers and innovative civil society organizations, and contributions from a large and unusually competitive private sector.

    Last Updated: May 19, 2021

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