Achieving universal health coverage through public health expenditure: an analysis of trends in 187 countries between 2000 and 2021

BACKGROUND: Universal health coverage (UHC) is a concept that includes-protection from financial risks for all; access to quality primary health services; and, access to essential medicines and vaccines that are safe, effective, high quality, and inexpensive. Public health expenditure (PHE) is expected to improve healthcare delivery in terms of access, quality and financial risk protection. To this end, this study aims to explore the relationship between progress in UHC and PHE across various countries. METHODS: We analyzed the trends in UHC and PHE between 2000 and 2021 in 187 countries, using the UHC service coverage index(UHC-SCI), a composite measure of 14 indicators spanning reproductive, maternal, newborn and child health, infectious disease, non-communicable disease, service capacity and access. Data on UHC-SCI and public health expenditure (PHE) was obtained from the WHO Global Health Observatory and the Organization for Economic Cooperation and Development. Pearson's correlation coefficient was calculated, and a fixed-effects panel regressionmodel was used to explore the association between UHC-SCI and public health expenditures, while adjusting for economic, governance and health system factors. RESULTS: Between 2000 and 2021, change in UHC-SCI was positively correlation with change in PHE(r = 0.845;p-value = 0.017), explaining 66.9% of the variability in UHC-SCI. Mean public health expenditure as a % of CHE(PHE-CHE) increased by 3.08% and 1% increase in PHE was associated with 2.71-point increase in UHC-SCI. A panel regression model consisting of economic, governance and health system indicators explained 90% of variability in UHC-SCI between 2000 and 2021. Overall UHC-SCI progress between 2015 and 2021 was associated with only 7.9% of the UHC progress since 2000, with poor progress in upper-middle-income countries despite increased PHE. CONCLUSION: The analysis revealed a strong positive association between public health expenditure and progress in UHC-SCI across income groups, with public funding likely playing a pivotal role in advancing universal health coverage in addition to economic development, and governance. However, the limited progress in UHC-SCI since 2015, particularly in UMICs, despite increased public expenditure, underscores the need for policies that prioritize efficient resource allocation, equity, and access to essential health services through transparent and accountable governance mechanisms, so that the allocated public health funds are efficiently used for maximum effect.