Putting health equity at heart of universal coverage—the need for national programmes of action

Abstract

Income inequality is growing,1 fuelling both right wing populism2 and demands for progressive, inclusive policies. Global disquiet over inequality prompted the United Nations to pledge in the sustainable development goals (SDGs) that “no one will be left behind.”3 Health inequities present a defining challenge of our time,4 and governments need to adopt and rigorously implement national programmes of action to respond across multiple dimensions so that economic and social status no longer determine human health and wellbeing.

Most of the data collected on health has been at national and global levels. Such aggregated data may mask deep unfairness in the distribution of good health, much as a growing gross domestic product can mask highly unequal distribution of wealth. For example, a baby born in a largely white, wealthy suburb of St Louis in the US can expect to live 35 more years than one born in a mostly black, lower income suburb a few miles away; the average life expectancy in Saint Louis County is close to 79 years, but ranges from 56 to 91across neighbourhoods.56 Globally, life expectancy is 72 years but people in the United Kingdom live an average of 81 years while those in Sierra Leone average only 54.7

There have been few actionable, inclusive national initiatives expressly designed to achieve health equity—a missed opportunity as countries create national development strategies and develop health plans that include precise national health targets. Despite some important work on health equity, international institutions have not brought equity to the centre through concrete, actionable strategies. The political declaration on universal health coverage agreed at the 2019 UN high level meeting on universal health coverage, for example, reiterated the pledge to leave no one behind. but set out neither specific targets on, nor specific strategies to achieve, health equity.60 We examine the reasons and suggest how to put health inequalities sat the centre of the agenda and fulfil the SDGs’ central promise.