Introduction

Universal Health Coverage (UHC) is an integral part of the Sustainable Development Goal,

particularly SDG 3. UHC refers to the guarantee that every individual and community across the

world gets the health services they need, without forcing a household into financial jeopardy.

The big challenge, though, especially for low- and middle-income countries, lies on the world’s

agenda. Statistics underline the need for UHC. Globally, at least half of the world’s population

lacks access to essential health services, while over 930 million people face catastrophic

healthcare expenses every year, which often pushes many into poverty (Eze et al., 2022). These

disparities are even worse in Low- and Middle-Income Countries (LMICs), where health systems

are mostly underfunded and there is a severe shortage of human resources for health. This report

attempts to explain the concept of UHC and review challenges that LMICs face in achieving

UHC by proposing evidence-based solutions in strengthening health systems in these countries.

Discussion

Concept of Universal Health Coverage

UHC represents a situation whereby people across the world access quality primary health

services without facing financial hardship. UHC aligns with SDG 3 which aims to “ensure

healthy lives and promote well-being for all at all ages.” Specifically, target 3.8 of SDG 3 aims at

achieving UHC, including financial risk protection, access to essential health services, and

access to safe, effective and affordable medicines and vaccines for all (United Nations, 2024).

Universal Health Coverage (UHC) is defined as ensuring that all individuals and communities

can access essential health services without the risk of financial ruin or poverty caused by paying

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for these services (World Health Organization, 2024). This definition emphasizes equity in

access to care and financial protection as its core principles. UHC directly supports SDG 3,

enabling equitable access to health services and fostering sustainable health systems critical to

the achievement of good health and well-being around the world.

WHO Building Blocks and Their Relation to UHC

According to WHO (2010), effective health system is made of six building blocks. These

comprise of service delivery, health workforce, health information systems, access to essential

medicines, health financing, and leadership and governance. When well-integrated, they provide

a comprehensive framework in which there would be universal access by all people to well-

managed, good-quality health services without falling into poverty. This is in tandem with the

aspirations of UHC and SDG 3 that aims at ensuring healthy lives for everyone (UN, 2024).

Source: World Health Organization (2010). Designed by Author.

of services in a safe and effective timely response to needs of people. Universally, UHC stands

on the premise of strong systems that can be adapted to local contexts for service delivery while

guaranteeing the quality and efficiency of the same service. A health system that can ensure

accessible maternal and child health services will go a long way in drastically reducing mortality

rates, hence directly contributing toward the targets set under SDG 3.

The second on which quality health care is delivered is the health workforce. A well-trained,

equitably remunerated, and motivated workforce assures proper care for the patients. However,

shortage of health workers is one of the key challenges in most of the LMICs and further

exacerbates the problem of inequity in service provision. Sub-Saharan Africa, for instance, has

24% of the global burden of disease but possesses only 3% of the world’s health workforce

(Anyangwe & Mtonga, 2007).

The third element of the WHO Building Blocks is health information systems. It provides the

basis for data-driven decisions through collection and analysis of health-related data, as well as

disseminating them for policy action. More accurate health information systems contribute to

tracking progress toward UHC, including identification of gaps and disparities in service

coverage. However, most LMICs are crippled with fragmented data collection processes, making

efforts at strengthening health systems difficult (WHO, 2010).

The fourth building block concerns access to essential medicines and technologies that contribute

to the prevention and treatment of illnesses. Affordability and availability of essential medicines

are cornerstones of universal health coverage so that patients will not be financially ruined when

they have to avail themselves of life-saving therapy. Including essential medicines in the national
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health system forms the basis for SDG 3, which addresses universal access to basic health

services. In most LMICs, out-of-pocket costs very high to reduce access, which shows a dire

need for reform in procurement and process improvement with cost reduction.

The next building block is health financing. This aspect is an indication of sustainable health

financing that reduces financial barriers in accessing health care. Well channeled health

financing could help protect the population from catastrophic healthcare spending while also

provide adequate resources for service delivery. Countries would move closer to UHC with

equitable financing strategies like progressive taxation and social health insurance.

The final block is leadership and governance. Strong leadership gives assurance that policies in

health are implemented, resources utilized efficiently, and mechanisms for accountability set.

The governance structure and processes should be responsive to needs of vulnerable populations.

The governance would be effective in relation to UHC when all the elements are aligned in such

a way as to make health system able to adapt to new challenges like that of the pandemic.

Implications

Challenges of Health System Development in Low- and Middle-Income Countries

LMICs face huge challenges in terms of health system development to accommodate Universal

Health Coverage. The biggest war that most of these LMICs fight is underfunding of healthcare,

where many economies invest less than 5% of their GDP in the health sector (Human Rights

Watch, 2024). Nigeria, for instance, uses only about 3.9% of its GDP in health, far below 15% as

set by Abuja Declaration (ONE Campaign, 2022). This underinvestment deepens the problems of

inadequate infrastructure and shortages of health personnel in the country. Apart from this, the

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high out-of-pocket expenditures, accounting for over 60% of total health spending in some

LMICs, push millions of people into poverty every year (World Bank, 2023).

Moreover, there is inequity in the allocation of health resources. It is mostly easy to identify

facilities and service differences between urban and rural areas, where access to health care is not

sufficient. Geographical differences, therefore, lead to the loss of preventable deaths and

illnesses in marginally located populations against the principle of UHC. More so, systemic

inefficiencies such as corruption and poor governance impede the good use of resources

available, which lowers the capacity of health systems to meet population needs.

The COVID-19 pandemic exposed weaknesses in health systems in LMICs, where health care is

significantly disrupted. The pandemic has further strained these resources and exposed gaps in

emergency preparedness, showing the need for strong health systems that are adaptive to crises

while preserving essential services (Carter et al., 2020).

Most LMICs have poorly performing and inadequately financed PHC systems. Gaps in service

delivery, reduced access to diagnostics, and a shortage of health workers all become more

evident because of these factors. During the COVID-19 pandemic, the weakness of countries

with fragile PHC systems became much more pronounced. Inadequate PHC funding also

increases out-of-pocket spending, placing a further burden on economically fragile populations.

Digital technologies can be used to strengthen health systems and expand UHC. However, in

LMICs, the infrastructure is poor, digital literacy among health workers is limited, and there are

governance gaps. Resistance to digital tools and ethical concerns about data privacy and

accountability impede implementation. A lack of integration between digital platforms and the

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existing health systems also makes such initiatives less sustainable (Frontiers in Public Health,

2023).

Attaining UHC requires effective political will and governance structures that guide the effective

implementation of policies. Poor leadership in LMICs most often fragments health systems with

little coordination of policies. Such lack of political commitment, therefore, holds up attempts to

deal with structural inequities, including poor mobilization of the required resources for

sustainable health financing.

Evidence-Based Solutions

Interventions are essential to overcome the above challenges. For the first health issue, more

domestic health financing needs to be resolved. Governments in LMICs should make health a

priority on their national budgets. They could go for innovative financing mechanisms like

public-private partnerships. Thailand had succeeded in implementing a highly successful UHC

system through the re-allocation of resources to primary health care and progressive taxation. It

achieved UCH for 60 million people (90% of the population) through a tax-funded health

insurance scheme (Health Strategy and Delivery Foundation, 2016).

Second, investment in PHC can vastly improve access and equity. Building strong PHC systems

is fundamental to UHC, guaranteeing that key services are available at the community level. This

has been the case in Rwanda’s model of community-based health insurance with integrated

delivery of PHC—high service coverage rates, large reductions in maternal and child mortality

(Eze, Ilechukwu and Lawani, 2023). The community Based Health Insurance in Rwanda, locally

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referred to as Mutuelle de Santé, benefited mostly the poor households and households in the

informal sectors (Eze at al., 2023).

Third, the use of technology and innovations in digital health may help bridge the gaps in health

information systems and service delivery. For instance, mobile health applications and

telemedicine platforms can extend healthcare access to underserved areas. The Ayushman Bharat

Digital Mission in India uses digital means to improve the efficiency and coordination of health

service delivery (UN, 2023).

National and Local Responses to UHC

National responses to UHC have been ambitious in many LMICs but face practical limitations:

for example, Nigeria introduced the National Health Insurance Scheme (NHIS) in 2005 with two

objectives of improving financial protection and increasing access to care; it has low coverage,

below 10%, because of administrative inefficiency, lack of adequate funds, and low awareness of

the existence of such an insurance package among the target population (NBS, 2023).

An healthcare example is Kenya’s UHC pilot program which was launched in 2018. It was

aimed at eliminating user fees for essential health services. While showing promising initial

outcomes, the challenges of health worker shortages and supply chain disruptions continue to

persist. In order to sustain the program, systemic inefficiencies need to be addressed, and

sustainable financing secured by Kenya (WHO, 2023).

In addition to the above, stable power supply and strong internet connection in rural settlements

could help in strengthening digital infrastructure for digital health solutions. An example of this

is M-TIBA platform in Kenya which allows support service delivery to reach remote areas.

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Equally important are the digital literacy programs, which prepare health workers with the skills

to use digital tools. For example, India’s eSanjeevani offers telemedicine consultations, ensuring

that everyone gets equal access to healthcare. To keep innovations like these running,

governments must put in place strong data protection laws to safeguard patient data and build

public trust in the system.

Effective governance and leadership are at the core of UHC. Institutional capacity building

includes strengthening regulatory bodies, thus enhancing transparency in resource allocation and

reducing corruption. Lessons learned from successes of governance reforms within the National

Health Insurance Scheme of Ghana provide a case study for other LMICs (Badu et al., 2021).

This kind of coordination among governments, non-governmental organizations, and private

sector actors is an example of UHC efforts.

UHC Responses in Nigeria: Financing, Service Provision, and Primary Health Care

Financing Arrangements

Financing is one of the important elements of Universal Health Coverage; however, the

commitment of Nigeria to 3.9% of GDP to health is less than the targeted 15% as declared in

Abuja (ONE Campaign, 2022). The health financing of the country is also heavily reliant on out-

of-pocket expenditure, and pushing millions into poverty every year. While schemes like the

National Health Insurance Scheme are supposed to bring down these costs, coverage is really

limited to formal sector workers, excluding the huge majority of the informal workforce. A

decentralized model has further created disparities between states in health budget allocations.

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Service Provision

The inadequacy in infrastructure and unequal distribution of resources is also reflected in service

delivery in Nigeria, as is common in most developing countries. Most rural populations rarely

get access to functional health facilities; hence, preventable morbidity and mortality are rife.

Further, only 43% of rural dwellers have basic health services compared to 84% recorded for

urban areas (Abdullahi & Gunawardena, 2021). These gaps have also been filled with the help of

existing public-private partnerships, which are poorly regulated and supervised in general. In this

regard, service provision has to be reorganized in order to ensure equal access. Regarding this,

the two key strategies will be the implementation of mobile health clinics and the strengthening

of rural health centers. Secondly, accountability policies regarding quality standards should be

prioritized.

Primary Health Care

PHC, the backbone of the UHC aspirations of Nigeria, is underfunded and underperforming. In

fact, by 2023, most PHC centers lacked basic drugs, health infrastructure, equipment, and human

resources with necessary training. These have shown great promise for scaling up policies on

task-shifting and piloting community health insurance schemes in states like Kano and Lagos,

which do need to be scaled up and sustained. To enhance PHC systems, Nigeria should adopt the

model of Rwanda, which combines community participation and insurance mechanisms in order

to increase access and reduce out-of-pocket costs. This will be further supported by a higher

percentage of health budgets allocated to PHC, investment in training programs for rural health

workers to address workforce shortages, and raise the quality of service delivery.

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Azeez et al. (2021) state that among the inhibitors to Nigeria’s progress towards UHC are weak

governance structures, weak political will, poor funding, lack of proper orientation and systemic

inefficiencies. Corruption (being the most significant problem) contributes to misallocation and

mismanagement of resources. More than half (above 50%) of the essential health services are

disrupted by the COVID-19 pandemic, hence underlining these weaknesses more strongly.

Solutions to such calls for reforms in health governance that involve all levels for increasing

transparency and accountability. The assurance of strengthened leadership and a uniform

framework for health policy fosters coordination. Establishment of an emergency health fund

and building resilient supply chains would be other measures to continue care during crises.

Another related idea is the integration of digital solutions in health, including telemedicine

platforms, based on rigid data governance policies.

Conclusion

Of all the key goals of reducing health inequity in global health, Universal Health Coverage is

very important, particularly to low- and middle-income countries. Obstacles to UHC are many,

from weak primary health care, resistance to digital health innovation, deficits in governance,

and fragility of health systems facing external shocks. In overcoming these barriers, evidence-

based solutions like investing in primary healthcare infrastructure, enhancing digital health

capacity, strengthening health governance, and building resilient systems can be important.

Countries like Rwanda, India, and Ethiopia offer lessons to be utilized in the successful

execution of reforms in the paths to increased access to care and the sustainability of health

systems. These solutions, however, do require long-term commitment by the government,

stakeholders, and international organizations.

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