5.1 Universal Health Coverage and TB

Universal health coverage (UHC) means that everyone can obtain the health services they need without suffering financial hardship (1). Financial hardship occurs when out-of-pocket (OOP) spending reduces people’s ability to meet basic needs or to afford other goods and services.

Target 3.8 of the United Nations (UN) Sustainable Development Goals (SDGs) is to achieve UHC by 2030 (2). There are two SDG indicators for monitoring progress. Indicator 3.8.1 is a UHC service coverage index (SCI). This can take values from 0 (worst) to 100 (best) and is calculated using 14 tracer indicators, one of which is the coverage of TB treatment. Following a revision of its definition in 2025, Indicator 3.8.2 is the proportion of the population with positive OOP household expenditure on health exceeding 40% of the household discretionary budget (referred to as financial hardship) (1, 3).

The milestones and targets for reductions in TB incidence and TB mortality set in the World Health Organization (WHO) End TB Strategy can only be achieved if UHC is in place, such that everyone who develops TB disease can access high-quality treatment.

Service coverage

Estimates of the UHC SCI at global, regional and country levels were updated in 2026 and are available for 2000–2023 (1,4).

Globally, there were steady improvements in the SCI between 2000 and 2023, from a score of 54 (out of 100) in 2000 to 71 in 2023 (Fig. 5.1.1a below). Most of this progress occurred between 2000 and 2015 and was primarily due to improvements in service coverage for infectious diseases (with more limited changes for other areas of service provision).

At regional level, the SCI increased in all 6 WHO regions between 2000 and 2023; the WHO regions with the highest values in 2023 were the Region of the Americas (83), the European Region (82) and the Western Pacific Region (81); the African Region had the lowest value (51). Between 2000 and 2023, the biggest gains in SCI were in the Eastern Mediterranean Region (+33), the African Region (+21) and the Western Pacific Region (+18).

There were increases in 3 of the 4 World Bank income groups, and a decrease in lower-middle-income countries (Fig. 5.1.1b below).

Fig. 5.1.1 Trends in the UHC service coverage index in WHO regions and World Bank income groups, 2000–2023

(a) By WHO regions

(b) By World Bank income groups

All 30 high TB burden countries made progress between 2000 and 2023 and the largest gains in absolute terms (+30 index points or more) were in India (+38), Cambodia (+36), Bangladesh (+30), Sierra Leone (+30), Uganda (+30) and Zambia (+30) (Fig. 5.1.2). In 2023, 3 high TB burden countries had values of 80 or above: Brazil, China and Thailand.

Fig. 5.1.2 Trends in the UHC service coverage index in the 30 high TB burden countries, 2000–2023

Across all countries, there was a great deal of variation in the SCI in 2023 (Fig. 5.1.3). The highest values were in high-income countries in North America, western Europe and parts of the WHO Western Pacific Region. Several upper-middle-income countries also had values of 80 or above, particularly in the Region of the Americas and the Western Pacific Region. The lowest values were predominantly in countries in the WHO African Region.

Fig. 5.1.3 UHC service coverage index by country, 2023

Financial hardship

Estimates of the proportion of the population with positive OOP household expenditure on health exceeding 40% of the household discretionary budget (referred to as financial hardship) at global and regional levels are available for the period 2000–2022 (1).

Globally, financial hardship due to OOP spending on health decreased between 2000 and 2022. The percentage of the general population with OOP health expenditure exceeding 40% of the household discretionary budget declined from 34% in 2000 to 26% in 2022 (1, 5). There was also a decrease in all WHO regions between 2000 and 2022, despite an increase between 2020 and 2022 in the European Region and the Region of the Americas (Fig. 5.1.4) (5).

Fig. 5.1.4 Trends in the percentage of the general population facing financial hardship due to out-of-pocket health spending (SDG 3.8.2, 2025 definition),^a globally and for WHO regions, 2000–2022

National values are available for different years and there is more geographical variability compared with the SCI, including within regions (Fig. 5.1.5). Of the 30 high TB burden countries, 14 had particularly high levels of financial hardship (≥30% of the general population): Angola, Bangladesh, the Central African Republic, China, the Congo, the Democratic Republic of the Congo, India, Nigeria, Pakistan, the Philippines, Sierra Leone, South Sudan, the United Republic of Tanzania and Uganda.

Fig. 5.1.5 Percentage of the general population facing financial hardship^a at country level, latest available year of data^b

Service coverage and financial hardship, 30 high TB burden countries

The distribution of the two UHC indicators in the 30 high TB burden countries shows that, in general, values improve with income level; this is especially evident for the SCI (Fig. 5.1.6 below). Nonetheless, as also illustrated in Fig. 5.1.5 above, the risk of financial hardship is high (30% or above) in several middle-income countries, including Angola, China, Congo, India, Pakistan, the Philippines and the United Republic of Tanzania. Thailand stands out as a high TB burden country with both a very high SCI (80 or above) and a high level of financial protection (12% of households facing financial hardship). A UHC scheme was established in 2002, supported by domestic funding and a strong primary health care system (6).

Fig. 5.1.6 UHC service coverage index (SDG 3.8.1)^a and percentage of the general population facing financial hardship (SDG 3.8.2, 2025 definition),^b 30 high TB burden countries,^c stratified by World Bank income group^d

Current health expenditure per capita, 30 high TB burden countries

To achieve UHC, substantial increases in investment in health care are critical. From 2000 to 2023, there were striking increases in health expenditure (from all sources) per capita in a small number of high TB burden countries, notably the upper-middle-income countries of Brazil, China, South Africa and Thailand (Fig. 5.1.7). There have also been considerable increases in several lower-middle-income countries: Bangladesh, Cambodia, India, Indonesia, Kenya, Lesotho, Mongolia, Myanmar, the Philippines and Viet Nam. Health expenditure has been rising in most low-income and high TB burden countries, most noticeably in the Central African Republic, Ethiopia and Mozambique, albeit from much lower levels.

Fig. 5.1.7 Current health expenditure per capita, 30 high TB burden countries, 2000–2023, stratified by income group^a

(a) Low-income countries

(b) Lower-middle-income countries

(c) Upper-middle-income countries

References

1. Tracking universal health coverage: 2025 global monitoring report. Geneva: World Health Organization and the International Bank for Reconstruction and Development / The World Bank; 2025. Licence: CC BY-NC-SA 3.0 IGO (https://iris.who.int/handle/10665/384883).

2. Sustainable development goals: Goal 3 targets and indicators [website]. New York: United Nations (https://sdgs.un.org/goals/goal3#targets_and_indicators).

3. Financial hardship due to out-of-pocket health spending and its components (SDG 3.8.2, 2025 definition). Geneva: World Health Organization. (https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/financial-hardship-in-health-and-components-sdg-3.8.2-2025-definition).

4. Global Health Observatory. Universal health coverage (UHC), SDG Target 3.8 (https://www.who.int/data/gho/data/major-themes/universal-health-coverage-major).

5. Global Health Observatory (https://www.who.int/data/gho).

6. Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A. Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. Lancet. 2018;391(10126):1205–23 (https://pubmed.ncbi.nlm.nih.gov/29397200/).

General disclaimers
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.