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Governments have been urged to strengthen public spending on health as COVID-19 stalls progress towards universal health coverage. John Zarocostas reports from Geneva. WHO and the World Bank are urging governments to strengthen public spending on health in the face of new evidence the COVID-19 pandemic could derail two decades of global progress towards universal health coverage. They draw on new research that reveals that in 2020 more than half a billion people were pushed into or further into extreme poverty by out-of-pocket payments for health services. “All indications show that financial protection will likely be adversely impacted by shifting health and economic dynamics resulting from COVID-19”, concluded the WHO/World Bank Global Monitoring Report on Financial Protection in Health 2021, arguing that the influence of financial barriers to seeking care and the potential for impoverishment due to out-of-pocket spending on health “will only grow”. “There is no time to spare,” said Tedros Adhanom Ghebreyesus, WHO director-general, on Dec 12, Universal Health Coverage Day. “All governments must immediately resume and accelerate efforts to ensure every one of their citizens can access health services without fear of the financial consequences. This means strengthening public spending on health and social support, and increasing their focus on primary health care systems”. He said: “WHO's top priority remains universal health coverage, built on the foundation of strong primary health care.”

an access health services without fear of the financial consequences. This means strengthening public spending on health and social support, and increasing their focus on primary health care systems”. He said: “WHO's top priority remains universal health coverage, built on the foundation of strong primary health care.” Tedros said the world “is way off track” to reach the Sustainable Development Goal (SDG) target on universal health coverage, and noted it was also falling short on the target to have an additional 1 billion people benefiting from universal health coverage by 2023. “Even before the pandemic, the world was 730 million people short of that target, now we estimate that shortfall to be between 800 and 840 million.” But the road ahead will not be easy, say global health leaders. “Within a constrained fiscal space, governments will have to make tough choices to protect and increase health budgets,” said Juan Pablo Uribe, World Bank global director for health, nutrition, and population. Similarly, Stephen MacFeely, WHO director for data and analytics, told reporters at the launch of the monitoring report. “With rising poverty and shrinking incomes, resulting from the global economic recession we see the progress that we’ve made [on universal health coverage] over the last 20 years has been halted. And it's likely to worsen financial hardship in the coming years.”

s, told reporters at the launch of the monitoring report. “With rising poverty and shrinking incomes, resulting from the global economic recession we see the progress that we’ve made [on universal health coverage] over the last 20 years has been halted. And it's likely to worsen financial hardship in the coming years.” In its report, WHO said that the pandemic stretched countries’ health systems beyond their limits in 2020, and noted that as a result, for example, immunisation coverage dropped for the first time in a decade, and deaths from tuberculosis and malaria increased. Joseph Kutzin, WHO director for Health Governance and Financing, said equity is a major concern on the path to universal coverage and outlined the need “to prioritise poor and vulnerable populations, including those with chronic needs for care and those with elderly household members through targeted public spending and policies that protect individuals from the need to pay”. Peter Sands, executive director of the Global Fund, speaking on Dec 9, was equally forceful and stated: “To tackle the inequities, we must go beyond simple notions of equal access or one-size-fits-all and deliberately create ‘compensating inequalities’ in service provision to focus resources on the most vulnerable.”

Joseph Kutzin, WHO director for Health Governance and Financing, said equity is a major concern on the path to universal coverage and outlined the need “to prioritise poor and vulnerable populations, including those with chronic needs for care and those with elderly household members through targeted public spending and policies that protect individuals from the need to pay”. Peter Sands, executive director of the Global Fund, speaking on Dec 9, was equally forceful and stated: “To tackle the inequities, we must go beyond simple notions of equal access or one-size-fits-all and deliberately create ‘compensating inequalities’ in service provision to focus resources on the most vulnerable.” Health experts say that securing the necessary funds is a daunting challenge. Feng Zhao, World Bank practice manager for health, nutrition, and population global practice, said tough choices will have to be made in health investments to safeguard essential health services. These investments will come primarily from domestic resources, but international assistance will remain highly critical, he added. Richard Kozul-Wright, director of globalisation and development strategies at the UN Conference on Trade and Development, told The Lancet that the way out of the crisis and delivering on the SDGs also require spending flexibility in government budgets and manageable levels of debt.

Health experts say that securing the necessary funds is a daunting challenge. Feng Zhao, World Bank practice manager for health, nutrition, and population global practice, said tough choices will have to be made in health investments to safeguard essential health services. These investments will come primarily from domestic resources, but international assistance will remain highly critical, he added. Richard Kozul-Wright, director of globalisation and development strategies at the UN Conference on Trade and Development, told The Lancet that the way out of the crisis and delivering on the SDGs also require spending flexibility in government budgets and manageable levels of debt. “But this was not the situation for many developing countries even before the pandemic hit, with debt servicing greater than health spending in more than 60 countries.” said Kozul-Wright. “The pandemic has seen fiscal revenues drop sharply and more than US$500 billion added to the burden of developing country debt. A premature return to a world of higher interest rates and austerity budgets will leave reliable and affordable health coverage a luxury enjoyed by the privileged few.”

s.” said Kozul-Wright. “The pandemic has seen fiscal revenues drop sharply and more than US$500 billion added to the burden of developing country debt. A premature return to a world of higher interest rates and austerity budgets will leave reliable and affordable health coverage a luxury enjoyed by the privileged few.” Robert Yates, executive director at the centre for universal health at Chatham House, believes the crisis could be an opportunity for leaders, and “we might see a sort of new wave of universal health reforms coming out of this.” The prerequisite for UHC, he said, is political commitments and public financing, and noted “history has shown that you often sort of get this political commitment and the public financing coming out of crises.” For the WHO/World Bank Global monitoring report on financial protection in health 2021 see https://www.who.int/publications/i/item/9789240040953 For the WHO/World Bank Global monitoring report on financial protection in health 2021 see https://www.who.int/publications/i/item/9789240040953