From commitment to action: why 2027 must mark the turning point for universal health coverage

First published in The Lancet Global Health

When the son of a 48-year-old man living in a rural community in Africa was diagnosed with a hernia, the father had to postpone his son's surgery until his pay cheque came in, recalling, “I could not borrow money, and the doctor wouldn't do it on credit. I was forced to wait.” This testimony is just one of many in UHC2030's 2025 report From commitment to action: a global UHC action tracker (ACT for UHC).

The data and testimonials in this report show that, although political commitment for universal health coverage (UHC) is strengthening, it is time for a fundamental transformation of health systems to make them equitable and resilient. During the 2023 High-Level Meeting on UHC, world leaders renewed their commitment to UHC, pledging that by 2030, everyone, everywhere would have access to quality health services without financial hardship. 3 years later, the evidence is stark: we are not on track.

Although the proportion of the global population not covered by essential health services decreased by 20% between 2000 and 2023, some 4.6 billion people worldwide still lack access to essential health services. Despite a decrease in the rate of financial hardship driven by a reduction in global poverty, population growth has driven a net increase in the number of people who are in financial hardship. In 2022, about 2.1 billion people worldwide belonged to households that were in financial hardship due to out-of-pocket health expenditures.

The 2025 ACT for UHC report documents genuine advances. Nearly all WHO member states have placed UHC at the centre of national health policies. Today, 140 countries recognise the right to health in their constitutions. Legislation protecting health workers is now widespread. Countries are strengthening their capacity to prevent, detect, and respond to public health emergencies, and 91% of national climate strategies now recognise health as a priority.

However, these achievements have yet to translate into equitable access to quality health services and adequate financial protection, and strong disparities persist. High-income countries spend US$2678 per capita on health compared with just $8·70 in low-income countries. Out-of-pocket spending accounts for 43% of national health expenditure in low-income countries and 39% in lower-middle-income countries—trapping millions in poverty when illness strikes. And medicines still account for more than half of out-of-pocket health spending in most countries.

Perhaps most concerning are the deepening inequalities. Although service coverage gaps between countries are narrowing, inequalities in access to care remain entrenched within countries. Gender equality in health has seen little progress and even reversal of previous gains, with women living in poverty in rural areas and with lower education levels reporting more difficulties in accessing care compared with other groups, and little has changed over the past decade. Gaps persist between wealthy and poor households and between urban and rural populations.

A health workforce crisis is compounding these challenges. Whereas the density of nursing personnel in high-income countries increased from 98 per 10 000 people to 105 per 10 000 people between 2019 and 2022, in low-income countries it declined from 9.6 per 10 000 people to 8.1 per 10 000 people. The projected 11.1 million global health workforce shortage is clustered in 55 countries, 37 of which are in Africa.

These inequalities are the predictable result of systems that do not prioritise inclusion and equity. Only 20% of countries are now classified as having an open civic space for participation in governance, down from 22% in 2018, whereas those with civic spaces categorised as repressed have increased from 18% to 26%. Digital health strategies—which could bridge access gaps—are least advanced in the countries that need them most: only 38% of low-income countries are developing these strategies with equity and human rights considerations.

A crucial barrier to progress is the paucity of disaggregated data. Only half of WHO member states report inequality data in their health statistics, making it impossible to identify who is left behind and to design targeted interventions. Without data disaggregated by gender, socioeconomic status, geographical location, and other key stratifiers, women, low-income households, rural communities and marginalised populations will continue to remain invisible in health system planning and delivery of care.

The 2027 UN High-Level Meeting on UHC will determine whether the promise of health for all remains credible. More than a reaffirmation of past pledges, it must produce an ambitious and action-oriented Political Declaration with measurable targets, investment commitments, and accountability mechanisms. To that end, UHC2030 has identified six priority areas: 

1. Advancing a new generation of equity-driven and people-centred primary health-care reforms;
2. Expanding financial protection through sustainable domestic financing and addressing high out-of-pocket spending on medicines;
3. Addressing the health workforce shortfall;
4. Making health systems resilient to climate change, pandemics and conflicts;
5. Leveraging digital transformation and artificial intelligence in ways that reduce inequality and increase access; and
6. Institutionalising inclusive, participatory governance that gives communities a voice in decisions affecting their health.

The foundations for UHC are set—it is time to build on them for equitable and sustainable results. Achieving this goal requires prioritising equity and inclusion, investing in systems that serve everyone, and measuring progress not by policies adopted, but by lives transformed.

We declare no competing interests and thank Laetitia Bosio for her writing support.