Regional Committee for the Eastern Mediterranean Sixty-fifth session Provisional agenda item 4(a)
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EM/RC65/4 October 2018
Advancing universal health coverage
Executive summary
1. Universal health coverage (UHC) means that all people and communities can use health services they need, of sufficient quality to be effective, without facing financial hardship. Multiple global and regional commitments identify UHC as a top priority, notably including the 2030 Agenda for Sustainable Development and the World Health Organization’s (WHO’s) 13th General Programme of Work 2019−2023 (GPW 13). This paper analyses the current situation regarding UHC in WHO’s Eastern Mediterranean Region and shows the potential for advancing UHC by 2023 based on the projected impact of policy interventions and WHO recommendations.
2. Current health coverage in the Region is analysed using two tools: the framework for action to advance UHC in the Eastern Mediterranean Region and the UHC service coverage index. Many challenges to UHC are identified. With some assumptions, it is estimated that 53% of people in the Region have access to basic health services – below the global (population weighted) coverage of 64%. However, projections show that a regional population weighted coverage of 60% could be achieved by 2023 if WHO recommendations are implemented. This suggests that the Region is in a good position to realize its proportional share of the global GPW 13 target of 1 billion more people benefitting from UHC by 2023.
3. Based on the analysis, some key actions are recommended to help countries advance towards UHC. In the richer countries of the Region, advancing UHC will mainly be achieved through managing noncommunicable diseases and reducing their prevalence; while in middle-income countries a combination of better provision of financial protection for the use of health services, while maintaining or expanding the essential packages of health services is the key to success in the next few years. Low- income countries should prioritize resource generation for health care and improve the availability and accessibility of health services, while tackling the key health care priorities for reproductive, maternal, newborn and child health, as well as priority communicable diseases. Nevertheless, all countries of the Region would benefit from expanding and improving primary health care services, and strengthening public health services. Defining a set of interventions as part of a UHC priority benefits package, and ensuring effective and equitable coverage of all population groups, are also crucial.
Introduction
4. In May 2018, the Seventy-first World Health Assembly approved the 13th General Programme of Work 2019−2023 (GPW 13) of the World Health Organization (WHO). GPW 13 was developed through extensive consultation, and will guide the Organization’s work for at least the next five years. It identifies three interconnected strategic priorities and ambitious goals related to the 2030 Agenda for Sustainable Development. The strategic priorities and goals encapsulate the step-change in public health that needs to be achieved globally by 2023 to keep on track with achievement of the health-related Sustainable Development Goals (SDGs).
5. This paper is one of a series intended to foster discussion at the 65th session of the WHO Regional Committee for the Eastern Mediterranean on what needs to be done in order to implement GPW 13 in the Region. It focuses on the strategic priority of achieving universal health coverage (UHC) and its related goal: to ensure that 1 billion more people benefit from UHC.
6. UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, without facing financial hardship. UHC cuts across the health-related SDGs and impacts on multiple other SDG targets. The
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essence of UHC is strong and resilient people-centred health systems. Progressively advancing towards UHC is a political choice with important social and economic benefits.
7. UHC has three dimensions: population coverage, service coverage and financial protection. Important progress has been made in developing methods to measure it, but there are still limitations. Currently, UHC measurement focuses on two SDG indicators: 3.8.11 on service coverage and 3.8.22 on financial protection (1). To monitor indicator 3.8.1, a “UHC service coverage index” has recently been developed to capture coverage by individual and population-based health services, including some health system aspects. Indicator 3.8.2 assesses the negative financial implications for individuals of direct out-of-pocket payments, a concept that has been in use in various forms since 2000. The different dimensions of UHC interact and affect each other: for example, improving access to – or quality of – health services may increase financial hardship if not explicitly covered by financial protection arrangements.
8. Multiple global and regional commitments identify UHC as a top priority (2,3,4). Member States have therefore been reorienting their national development and health policies and plans to incorporate the SDGs and UHC. SDG target 3.8 is to achieve UHC, including financial risk protection, and access to quality essential health care services, medicines and vaccines for all by 2030. In this context, a framework for action on advancing UHC in the Eastern Mediterranean Region was developed in 2014 and updated in 2016 (5).
9. This paper aims to:
• review where the Region stands with regard to the three dimensions of UHC and existing challenges, paying particular attention to health programmes;
• use statistical projections and scenario modelling to extrapolate the Region’s contribution to the GPW 13 UHC goal; and
• propose ways to enhance the Region’s contribution to the mission and strategic priorities of GPW 13.
Current situation: developments and challenges
10. The Eastern Mediterranean Region is home to over 650 million people living in 22 countries with highly diverse socioeconomic and geopolitical environments. In 2015, average gross domestic product (GDP) per capita in the Region was US$ 12 120. However, its most populous country, with around one third of the population, has a GDP per capita of around US$ 1400. The Region faces emergencies on an unprecedented scale, due to political conflict as well its propensity to epidemic- and pandemic-prone diseases. More than half the population live in countries with graded emergencies: four countries at grade 3, two at grade 2 and three at grade 1. Almost 30 million displaced persons – more than half of all displaced persons globally – originate from the Region. Currently, nine countries feature in the World Bank list of fragile situations and six are among the 15 countries identified as extremely fragile by the Organisation for Economic Co-operation and Development (OECD).
11. The diversity of the countries in the Region and the unprecedented scale of complex emergencies make it challenging to chart progress towards UHC. Accurate measurement of health service coverage and financial risk protection is based on many pieces of information. If data are weak or from indirect sources (or estimation processes) they may lack the objectivity and sensitivity required to reflect the impact of policies. While some countries have made remarkable progress in generating high-quality data, there is a lack of reliable, timely and comparable information across countries. Challenges include weak civil registration systems, limited population-based surveys, poor quality data from health facilities, lack of
1 Indicator 3.8.1 Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access among the general and the most disadvantaged population). 2 Indicator 3.8.2 Proportion of population with large household expenditures on health as a share of total household expenditure or income.
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disaggregated data, and fragmented data collection systems. Strengthening national health information systems must therefore be a key aim in the context of the SDGs.
12. This paper uses two analytical tools to examine where the 22 countries of the Region stand and how they can progress towards UHC by 2023: the framework for action to advance UHC in the Eastern Mediterranean Region and the UHC service coverage index. The framework has four strategic components with associated actions for Member States, WHO and partners. The UHC index has four main categories of indicator for service coverage. The indicators of the UHC index can be combined to give a composite health coverage score for each country. Those scores are reported later in this paper, but first the components of the framework and the index are described to identify the main challenges facing different countries.
Framework for action to advance UHC in the Eastern Mediterranean Region
13. Component 1: Developing a vision and strategy for UHC. Several Member States have developed a national vision for UHC or necessary legislation and/or strategies. The Islamic Republic of Iran, Oman and Saudi Arabia have prepared long-term visions for health system transformation towards UHC. Bahrain, Egypt and Sudan have enacted new laws with provisions for health system institutional reforms, Jordan, Pakistan, Sudan and Tunisia have developed health sector-wide strategies for UHC, and Morocco and Sudan have issued royal and presidential declarations for UHC.
14. Component 2: Improving health financing system performance and enhancing financial risk protection. Despite fiscal challenges, Member States are using public funds and developing prepayment mechanisms towards UHC. In 2012, Morocco generalized its Régime d’assistance médicale to cover 8.5 million vulnerable people. In 2014, the Islamic Republic of Iran used funds generated through VAT increases and subsidy reform to insure around 10 million people. However, the Region as a whole is a low investor in health, accounting for 1.9% of global health expenditure for 8.6% of the world’s population in 2015 (6). Insufficient public funding for health, non-existent or dysfunctional prepayment mechanisms and inefficient use of scarce financial resources continue to compromise health system performance in several countries. For the past 15 years, around 40% of health spending in the Region has come from out-of- pocket payments. As a result, around 55.5 million individuals face catastrophic health spending and 7.7 million are impoverished each year (2010) (7).
15. Component 3: Expanding the coverage of needed health services. Defining country-specific essential health service packages, and ensuring their effective delivery and high quality, is a strategic starting point for expanding UHC. Member States have pursued diverse explicit/implicit service packages. Most countries in emergencies have developed explicit minimum service packages that facilitate resource mobilization. The third edition of Disease Control Priorities (DCP3) has spurred a renewed interest in developing health service packages for UHC. Afghanistan, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco and Pakistan are actively engaged in developing country-specific UHC priority benefits packages guided by DCP3 and in collaboration with WHO.
16. Health service quality and patient safety are now prominent on health policy agendas. There is a growing understanding that improvements in access to health services without commensurate attention to quality will not lead to the desired population health outcomes. Challenges in improving quality and safety in the Region include insufficient leadership commitment, low capacities of health professionals and national regulatory authorities, and lack of community engagement and empowerment.
17. Component 4: Ensuring expansion and monitoring of population coverage. Population coverage is conceptually integral to the financial protection and service coverage dimensions of UHC. Although some vulnerable populations in the Region are still not covered by prepayment arrangements, recent years have seen improvements in this regard. In 2015, Pakistan launched the Prime Minister’s National Health Program, funded from federal and provincial sources, which aims to cover 100 million people living on less than US$ 2 per day. In 2017, Sudan expanded use of Zakat funds to subsidize coverage for an additional 2.5 million poor families. In 2017, Jordan included all individuals aged over 60 in its civil
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insurance programme. In 2017, Egypt incorporated coverage of the informal sector in its comprehensive Social Health Insurance Law. Attention has been given to covering refugees within national insurance schemes in the Islamic Republic of Iran, Jordan, Lebanon and Sudan.
UHC service coverage index
18. The UHC service coverage index is formulated as a single indicator, ranging from 0 to 100, to monitor countries’ progress on SDG indicator 3.8.1. The index is computed from 16 tracer indicators (Tables 1 and 2).3,4 Baseline data for the tracer indicators are from 2015, drawn from sources such as WHO and United Nations databases and publications (7).
19. Category 1: Reproductive, maternal, newborn and child health. The four tracer areas in this category are: family planning; pregnancy and delivery care; child immunization; and child treatment. Contraceptive prevalence and antenatal care coverage in the Region range from 11.7% to 58.6% (8) and 3.3% to 100% (9), respectively. This inequitable service coverage leads to a high regional maternal mortality ratio of 166 deaths per 100 000 live births (2015) (10). In 2016, 80% of infants received three doses of diphtheria- tetanus-pertussis vaccine (DTP3) in the Region. Of the 3.7 million infants who did not receive DTP3, 97% were in countries affected by emergencies. In 2016, more than 800 000 children aged under-5 years died in the Region. About 15% of these deaths were due to pneumonia (11,12). However, only 62% of suspected pneumonia cases sought care from an appropriate provider and only 50% received antibiotics (13).
20. Key challenges undermining access to good quality reproductive, maternal, newborn, child and adolescent health (RMNCAH) services include: verticality and fragmentation of disease prevention and control programmes; low involvement of subnational RMNCAH teams in strategic planning; weak or non-existent referral/counter-referral protocols; inadequate attention to adolescent health; lack of integrated RMNCAH service packages; shortage of relevant health workforce and absence of effective task shifting; and inadequate health information including inadequate surveillance of maternal and perinatal deaths. These challenges are compounded in remote and emergency-affected areas.
21. Category 2: Infectious diseases. The four tracer areas are: tuberculosis treatment; HIV treatment; malaria prevention; and water and sanitation. In the Region, around 31% of tuberculosis cases are estimated to be undetected, and treatment coverage for drug-resistant tuberculosis is less than 25% (14). Only 18% of people living with HIV have access to antiretroviral therapy (ART) (15), and many people are at risk of malaria. The Region has the highest number of people with hepatitis C (15 million) among all WHO regions, and there is a high and rising level of antimicrobial resistance.
22. Low political commitment to communicable disease control, including antimicrobial resistance,5 has resulted in increased burden. Other challenges include: vertical disease programmes and their weak integration at policy and service level; poor enforcement of regulations for reporting and notification by the private sector; low allocation of domestic funds; and increased reliance on donor support for priority health programmes. Decentralization of the health systems without proper capacity-building has negatively affected planning, implementation, monitoring and evaluation of health care programmes and outcomes in some countries. Dysfunctional reporting and referral systems limit capacity for early detection of outbreaks and timely response.
3 The tracer indicators were selected based on the following criteria: (1) the relevance of the indicator, reflecting epidemiological burden and the presence of cost-effective interventions; (2) its viability, with current, comparable data available for most countries; (3) its conceptual soundness with a measurable numerator and denominator, a clear target and ideally a definition that encompasses service coverage; and (4) its usability – indicators should be easy to communicate, particularly those that are already reported across countries. 4 Two tracer indicators were excluded in the calculation of the UHC index due to lack of data for many countries: cervical cancer screening and access to essential medicines. 5 Only four countries in the Region have officially endorsed national action plans on antimicrobial resistance, and eight countries have national infection prevention and control programmes.
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23. Category 3: Noncommunicable diseases. The four tracer areas are: prevention of cardiovascular disease; management of diabetes; cancer detection and treatment; and tobacco control. In the Region, more than 60% of deaths are attributable to noncommunicable diseases. WHO has developed a draft regional framework on strengthening integration and management of noncommunicable diseases in primary health care. In 2015, a framework to scale up action on mental health was endorsed by the 62nd session of the Regional Committee (16). In 2017, a framework for action on cancer prevention and control was endorsed by the 64th session of the Regional Committee (17), and regional guidance for early detection of priority cancers was published. A WHO kit for the management of common noncommunicable diseases during emergencies has been developed and deployed. The Region has the highest burden of mental, neurological and substance abuse disorders globally, primarily due to high rates of depression and anxiety disorders attributable to emergencies. Mental health has been included in the UHC benefits package in Lebanon, and Jordan and the Syrian Arab Republic are integrating mental health into primary health care.
24. Key challenges include: limited engagement with non-health actors; paucity of information on health and financial burden; and industry interference. In many low-income countries, noncommunicable diseases are detected late when patients need expensive hospital care for severe complications. Mental health disorders continue to have a low public health profile. Limited integration of noncommunicable diseases at primary health care level results in a fragmented service delivery approach. Most available benefits packages fall short of evidence-based cost-effective interventions to address noncommunicable diseases – the so-called “best buys”.
25. Category 4: Service capacity and access. The four tracer areas are: hospital access; health worker density; access to essential medicines; and health security. Mean hospital bed density in the Region is 14 beds per 10 000 population. An overall shortage of health workers is coupled with an uneven geographical distribution and mix of skills, as well as concerns regarding quality and performance. Six countries in the Region are considered to be in health workforce crisis. The unavailability of defined essential packages of services, medicines and products, as well as treatment guidelines, affects access to and quality of care.
Projected health service coverage in 2023
26. The UHC global monitoring report provides data for countries in the Region. As of mid-2017, the estimated population of the Region was about 650 million. With some assumptions, the WHO report’s findings on UHC coverage (7) can be used to conclude that around 347 million of those people have access to basic health services, representing a weighted population coverage of 53% – below the global population weighted coverage of 64%. Levels of service coverage as measured using the UHC index for countries in the Region are presented in Table 2. In 2015, values for the UHC service coverage index ranged from 22 (Somalia) to 77 (Kuwait and Qatar). Only five countries had an estimated UHC index value higher than 70, and six countries – representing about half the population of the Region – had an index value below 50 (Table 3).
27. To provide a projection of health service coverage in the Region for 2023, two additional analyses were performed. First, national trends were calculated for each of the tracer indicators for which data are available. The trends were used to project the regional and national status of the UHC index in 2023. Then, the projections were adjusted in the light of policy interventions and WHO recommendations (related to each area of work) being implemented in the Region, taking into account infrastructure improvements and national capacities for enhancing UHC. Projections for 2023 demonstrate there is a clear opportunity for the Region to expand population weighted coverage of UHC in the Region to at least 60%. This would equate to an additional 109 million people benefitting from UHC by 2023. It is projected that in 2023, values for the UHC index will range from 36 to 80 in the countries of the Region: 10 countries would have an estimated index value higher than 70, and four countries would have an estimated index value below 50 (Table 4). More importantly, progress in the UHC index is projected for all countries in the Region except three.
28. Projecting improvements in coverage of financial protection is more challenging. In most countries, SDG 3.8.2 indicators have remained stagnant for the past decade with periodic improvement or deterioration
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in response to national policies or economic fluctuations. It is therefore important to establish regional goals for reducing out-of-pocket payments to limit catastrophic expenditure, particularly as potential health care costs are increasing due to population demand and technological advances. Prudent health financing policies are crucial to sustain and expand access to essential health services.
Proposed approach
29. Moving towards UHC requires simultaneous progress across its three dimensions. Expanding access to health services should be combined with due consideration for equitable access and adequate financial coverage of populations, as well as ensuring services of acceptable quality at an affordable cost. Moving towards and sustaining UHC requires health system development approaches that consider all these aspects. The use of tracer indicators in the UHC index should support health system development in a way that facilitates and gives prime focus to the programmatic priority areas of work.
30. Projections suggest that despite emergencies the Region is in a good position to realize its proportional share – 109 million people – of the global target of 1 billion more people benefitting from UHC by 2023. Progress depends on the continued commitment of Member States to advancing UHC, supported by WHO. Although progress can be shown to be within reach, countries of the Region face diverse challenges that may require different strategies and policies for UHC advancement. The projections in this paper are also limited, as they do not quantitatively capture the potential financial impacts of health care delivery expansion on the population.
31. Priority diseases and risk factors need to be addressed using cost-effective and affordable interventions. Studies show that economic growth in the Region has been accompanied by a substantial rise in noncommunicable diseases. The projections demonstrate that higher-income countries most affected by noncommunicable diseases will find it challenging to improve their UHC index by 2023, further highlighting the importance of implementing public health policies. The increasing burden of noncommunicable diseases (including mental, neurological and substance use disorders, malnutrition, violence and injuries) calls for implementation of “best buys” and other interventions (18,19,20). In low- and lower middle-income countries, communicable diseases and RMNCAH remain the main priorities. Although most countries in these income groups are projected to make substantial gains in their UHC index, more than 50% of people in these countries may still lack access to essential health services in 2023. Implementing existing cost-effective public health interventions provides clear opportunities to advance towards UHC (21,22,23,24,25,26). Countries in the Region may be able to plan for more ambitious targets in certain areas of care and thereby accelerate further towards UHC.
32. UHC is not, of course, limited to the conditions and services reflected in the tracer indicators listed in the UHC index. UHC requires that all population groups be covered for all their health needs by services of good quality. Defining a set of interventions as part of a UHC priority benefits package, and ensuring its effective coverage of all population groups, has been described as the approach for “progressive universalism” (27). Priority benefits packages are based on cost-effective interventions, corresponding to priority health needs, economic reality and people’s preferences, which are delivered in the expected manner at different levels of the health care system.
33. Equitable health systems and financial protection of populations need to be ensured. Health systems have an important though indirect role in fighting poverty and fostering development. Expansion of health services in several lower and upper middle-income countries of the Region has been accompanied by high out-of-pocket costs and the impoverishing effects of health care use. The role of health systems in addressing widening inequities across the world is crucial, as an estimated 100 million people are pushed into poverty each year due to out-of-pocket payments for health. WHO is working with Member States to reorient health systems through strengthened participatory, accountable and responsive governance, coordinated intersectoral action, appropriate legislative frameworks, and participation by patients and civil society.
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Recommendations to Member States
34. Formulate a UHC vision and a roadmap towards its realization, taking into account country-specific health system challenges, the macroeconomic outlook and people’s preferences.
35. Define a context-specific and cost-effective national essential or priority health service package, based on globally and regionally identified UHC priority benefit packages, and develop appropriate people- centred, integrated models of care with functioning referral systems.
36. Expand prepayment arrangements to ensure full population coverage through the use of multiple financing sources in order to reduce out-of-pocket payments for health care and promote equity and financial protection.
37. Strengthen national capacity to enhance routine health information systems, including civil registration and vital statistics, as a main source of data for monitoring health system performance and advancement towards UHC and measuring efficiency and quality of service provision.
38. Develop national plans to conduct household surveys. Analysis of date from population-based surveys should include data disaggregation by gender, location, socioeconomic group, ethnicity and residency status to allow monitoring of equity and access to care.
39. Increase workforce availability, performance and relevance, and improve access to essential medicines, vaccines and health technologies, considering available resources.
40. Institutionalize mechanisms for multisectoral collaboration through a Health in All Policies approach to facilitate implementation of a package of essential or high-priority intersectoral interventions to address environmental and behavioural risks to human health.
41. Strengthen governance arrangements to improve performance, accountability, responsiveness and participation, including efforts to raise awareness and create positive behavioural change.
Recommendations to WHO
42. Support national efforts in the context of regional framework for action on advancing UHC (5), Salalah Declaration for UHC 2018 and UHC 2030 International Health Partnership.
43. Facilitate development of UHC vision and roadmaps by sharing global and regional experiences and good practices, building national capacities, supporting inclusive policy dialogue on strengthening health systems and facilitating resource mobilization to implement agreed strategies.
44. Strengthen health governance by institutionalizing accountability and transparency, leadership development and institutional strengthening to ensure sustainable and progressive implementation of UHC roadmaps.
45. Strengthen national health information systems to generate high-quality data. This requires comprehensive assessments of health information systems, development of national strategies for health information systems, strengthening of civil registration and vital statistics, and implementation of the regional framework for health information systems and core indicators for monitoring the health situation and health system performance and progress towards UHC.
46. Generate robust, country-specific research evidence on the impact of policies to expand UHC, including identification of less effective/costly solutions and implementation challenges. Evidence generation should also focus on institutional modalities and regulatory frameworks that enhance the sustainability of national movement towards UHC.
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Table 1. Definition of UHC tracer indicators, based on the 2017 global monitoring report for UHC Tracer area Tracer indicator
(with abbreviations) Reproductive, maternal, newborn and child health
Family planning Demand satisfied with modern method among women 15–49 years who are married (%) (FP)
Pregnancy and delivery care Antenatal care, four or more visits (%) (ANC4) Child immunization 1-year-old children who have received 3 doses of diphtheria-tetanus-
pertussis vaccine (%) (DTP3) Child treatment Care-seeking behaviour for children with suspected pneumonia (%) (PNE)
Infectious diseases
Tuberculosis treatment Tuberculosis effective treatment coverage (%) (TB)
HIV treatment People living with HIV receiving ART (%) (ART)
Malaria prevention Population at risk sleeping under insecticide-treated bednets (%) (INT)
Water and sanitation Households with access to at least basic sanitation (%) (WASH)
Noncommunicable diseases
Prevention of cardiovascular disease Prevalence of normal blood pressure, regardless of treatment status (%) (BP)
Management of diabetes Mean fasting plasma glucose (mmol/L) (FPG)
Cancer detection and treatment* Cervical cancer screening among women aged 30–49 years (%)
Tobacco control Adults aged ≥15 years not smoking tobacco in last 30 days (%) (TOB)
Service access and capacity
Hospital access Hospital beds per capita (w/threshold) (HOSP)
Health worker density
Physicians density Physicians per 1000 population (PHYS)
Psychiatrists density Psychiatrists per 100 000 population (PSYC)
Surgeons density Surgeons per 100 000 population (SURG)
Access to essential medicines* Proportion of health facilities with WHO-recommended core list of essential medicines available
Health security IHR core capacity index (IHR)
* Indicator is not included in current calculation of the UHC index, at the global level and in the Region, due to unavailability of data Source: (7).
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Table 2. Levels of service coverage in countries of the Eastern Mediterranean Region as measured by the UHC index
Country
U H
C
in de
x
FP
A N
C 4
D TP
3
PN E
TB
A R
T
IT N
W A
SH
B P
FP G
TO B
H O
SP
PH YS
PS YC
SU R
G
IH R
Afghanistan 34 43 18 65 62 51 5 _ 39 69 5.4 87 5 0.3 0.1 0.9 43
Bahrain 72 59 100 98 90 38 42 _ 100 79 5.8 79 20.3 0.9 4.8 15.1 96
Djibouti 47 43 23 84 94 65 22 30 51 73 5.4 87 14.0 0.2 0.1 1.5 46
Egypt 68 80 83 93 68 50 21 _ 93 75 5.1 75 15.6 0.8 0.9 26.8 93
Iran (Islamic Republic of) 65 76 84 98 76 70 11 _ 88 80 5.7 89 15.0 1.5 1.8 1.6 85
Iraq 63 62 50 58 74 48 43 _ 86 75 5.8 81 13.8 0.9 0,4 12.6 91
Jordan 70 62 95 99 77 70 50 _ 97 79 6.3 73 14.0 2.7 1.3 10.8 97
Kuwait 77 67 71 99 82 84 71 _ 100 77 6.1 80 20.4 1.9 3.3 106 86
Lebanon 68 61 71 81 74 66 44 _ 95 79 5.7 66 28.5 2.4 1.4 45.4 76
Libya 63 45 71 97 81 22 43 _ 100 76 5.9 81 37.0 2.1 1.0 15.6 65
Morocco 65 78 55 99 70 71 41 _ 84 74 5.6 77 11.0 0.6 0.5 7.8 95
Oman 72 35 71 99 56 84 43 _ 99 76 5.7 92 15.8 1.5 2.3 14.2 94
Pakistan 40 49 37 72 64 59 5 _ 58 70 5.8 80 6.0 0.8 0.3 1.3 43
Palestine 60 59 28 90 78 73 34 _ 93 78 5.8 73 26.3 2.6 1.4 1.3 70
Qatar 77 62 85 99 87 74 85 _ 100 79 5.7 86 12.0 2.0 3.0 3.5 97
Saudi Arabia 68 45 71 98 82 54 54 _ 100 77 6.6 87 26.5 2.6 2.1 61.6 99
Somalia 22 45 6 42 13 40 10 23 16 67 5.2 87 8.7 <0.05 <0.05 0.1 6
Sudan 43 31 51 93 48 44 8 42 35 70 5.2 87 8.2 3.1 0.1 0.8 71
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Country
U H
C
in de
x
FP
A N
C 4
D TP
3
PN E
TB
A R
T
IT N
W A
SH
B P
FP G
TO B
H O
SP
PH YS
PS YC
SU R
G
IH R
Syrian Arab Republic 60 60 64 41 77 56 43 _ 93 76 5.8 81 15.0 1.5 0.3 3 63
Tunisia 65 75 85 98 60 73 27 _ 93 77 5.8 67 22.9 1.3 2.6 7.3 65
United Arab Emirates 63 60 71 99 88 35 43 _ 100 80 6.0 81 11.5 1.6 0.1 11 91
Yemen 39 48 25 69 34 52 15 _ 60 69 5.6 81 7.1 0.3 0.2 0.4 46
Note: Full definitions of tracer indicators are shown in Table 1. Source: (7) and WHO [unpublished data].
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Table 3. UHC population coverage, by groups of countries
2015 2023
UHC service coverage index
Countries UHC population coverage estimate
(thousands)
Countries UHC population coverage estimate
(thousands)
75 and above Kuwait Qatar
5 238 Bahrain Iran (Islamic Republic of)
Kuwait Oman Qatar
79 816
70–74 Bahrain Jordan Oman
11 023 Egypt Jordan
Lebanon Saudi Arabia
United Arab Emirates
122 702
60–69 Egypt Iran (Islamic Republic of)
Iraq Lebanon
Libya Morocco Palestine
Saudi Arabia Syrian Arab Republic
Tunisia United Arab Emirates
217 977 Iraq Libya
Morocco Palestine Tunisia
73 480
50–59 – – Afghanistan Sudan
Syrian Arab Republic
56 950
Below 50 Afghanistan Djibouti Pakistan Somalia Sudan Yemen
115 871 Djibouti Pakistan Somalia Yemen
125 991
Estimated total population with UHC
53.5% 350 million 60.2% 459 million
Source: (7) and WHO [unpublished data].
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Table 4. UHC index and estimated population coverage 2015 and 2023, by country
Country
2015 2023
Estimated population
(thousands)
UHC index
UHC estimated population coverage
(thousands)
Projected
population (thousands)
Projected UHC index
UHC estimated population coverage
(thousands)
Afghanistan 29 200 34 9 928 40 649 53 21 544 Bahrain 1 370 72 986 1 808 80 1 446 Djibouti 860 47 404 1 042 41 427 Egypt 91 023 68 61 896 108 117 72 77 844 Iran (Islamic Republic of) 79 926 65 51 952 85 609 80 68 487 Iraq 37 883 63 23 866 48 875 64 31 280 Jordan 9 798 70 6 859 10 474 70 7 332 Kuwait 4 184 77 3 222 4 484 77 3 453 Lebanon 4 356 68 2 962 5 783 70 4 048 Libya 6 384 63 4 022 6 895 61 4 206 Morocco 34 125 65 22 181 38 320 68 26 058 Oman 4 414 72 3 178 5 440 75 4 080 Pakistan 189 900 40 75 960 219 509 48 105 364 Palestine 4 816 60 2 890 5 460 64 3 494 Qatar 2 618 77 2 016 2 937 80 2 350 Saudi Arabia 31 742 68 21 585 36 311 72 26 144 Somalia 12 316 22 2 710 17 601 36 6 336 Sudan 39 599 43 17 028 46 761 50 23 381 Syrian Arab Republic 22 712 60 13 627 21 475 56 12 026 Tunisia 11 154 65 7 250 12 235 69 8 442 United Arab Emirates 9 121 63 5 746 10 186 72 7 334 Yemen 25 235 39 9 842 32 239 43 13 863
Total 652 736 53.5 350 108 762 210 60.2 458 939
Source: (7) and WHO [unpublished data].
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