Health service access, utilization and prevailing health problems in the urban vulnerable sections of Ethiopia

Background: Currently, one-third of urban residents in Africa and Asia reside in slum settings with a compromised state of health, and this proportion is increasing at an alarming rate. In Ethiopia, it is estimated that 70-80% of the urban population lives in settings that are believed to be slums and most of the urban population has no access to improved sanitation. Though there is still a limitation on proper urban health profile data, there is evidence of vulnerability to a wide range of health-related problems in the country, including HIV. Hence, this study aimed to generate evidence on access to and utilization of health services, particularly by mothers and children, and the prevailing health problems of vulnerable sections of the urban population. Methods: A total of 115 urban vulnerable sections were identified in 46 towns in five regions (Amhara; Oromia; Tigray; Southern Nations, Nationalities, and Peoples’ (SNNP); and Harari) and two city administrations (Addis Ababa and Dire Dawa) where John Snow Inc. (JSI) urban centers are located. A cross-sectional household survey design was conducted among identified urban vulnerable sections of the population on 10–20 May 2017. A total of 1,220 households were included, based on a two-stage stratified sampling method. The analysis used mainly descriptive statistics and SPSS version 21 software was used for the analysis. Results: The mean age of the respondents was 43.2 (SD=14.8) years, and females accounted for 75% of all participants. The average time (SD) from the households to the health facility is 18 (±11) minutes. One month prior to the study, 32.6% of the household members reported having had some form of illness and 44% of them visited a health center and 36% a hospital. More than two thirds (68.6%) of women gave birth at a health facility and most (70.1%) births were assisted by a skilled provider. Nearly two thirds (63.4%) of women received a postnatal check-up. In 7.6% of the households, diarrhea occurred among children under 5 in the past two weeks, and 88% sought advice or further treatment. Non-communicable diseases (NCDs) account for the largest share of causes of morbidity among adults (29%) and death was observed in 8.4% of the households in the last three-year period prior to the survey. The most perceived causes of death in households were kidney disease, hypertension, heart disease, and other NCDs (65%). Conclusions: Health facilities are located near households. However, a significant proportion of mothers are still giving birth at home and more than a third of the births are attended by non-skilled attendants. Postnatal care utilization remained a challenge. NCDs were found to be the most prevailing problem among adults in the households and most of the deaths were also related to NCDs. Social changing interventions are recommended so that women have trust to deliver at facilities and postnatal visits are increased. Targeted preventive interventions are also essential to avert the growing burden of NCDs and others in the urban vulnerable sections. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):12-23] Keywords: Health service, access, health problem, vulnerable sections, Ethiopi

Community members’ views on Addis Ababa University’s rural community health training program: A qualitative study

AbstractBackground: Community-Based Education (CBE) is an educational process aiming to ensure educational relevance to community needs, thereby contributing to improved community health needs. Addis Ababa University runs a six-week long Rural Community Health Training Program at Adami Tulu District, East Shoa Zone. In the program, the final year medical students are attached to the community to apply their theoretical training and address the community’s health problems. This study explored views of the local community about the program.Methods: A descriptive qualitative study was carried out in Adami Tulu District of East Shoa Zone – the district is the site of the training program. Data was collected from community members, local administrators, health extension workers, school principals and opinion leaders selected from three kebeles within the attachment area. A total of five FGDs and six key informant interviews were conducted using a semi-structured interview guide. The audio-taped data was later transcribed verbatim and translated into English. Themes were developed guided by the objective of the study with the application of Open Code Version 4.02.Results: The finding of the study revealed that the local community, beyond recognizing the participants as some kind of medical professionals from Addis Ababa University, knew very little about the program and its objectives. For example, the only benefit all the participants rightly mentioned in common, as evidence of their knowledge the program is free treatment for sick children by the students. Lack of communication between the university and local administration; absence of community involvement in the planning, execution and evaluation of the program; and problems related to language were identified as key areas for improvement.Conclusion: The Rural Community Health Training Program (RCHTP) is an important resource for both the university and the local community. It is therefore important that the university take proactive measures and optimize the involvement of local leaders and community members to enhance their sense of ownership of the program. [Ethiop. J. Health Dev. 2018;32(1):10-17

Maternal health service utilization in urban slums of selected towns in Ethiopia: Qualitative study

Introduction: Although Ethiopia is one of the least urbanized countries in the world, the pace at which urbanization increases is unprecedented. During the last twenty years, urbanization has expanded rapidly and is estimated to be at 38% in 2050 from the current proportion of 19%. Despite the fact that urbanization is associated with relatively, better access to social services including health, residents in urban setting are believed to suffer from health disparities in health indicators such as use of Antenatal care (ANC), institutional delivery and postpartum care (PNC). This study aims to identify reasons why urban women fail to use available maternal health services in selected urban settings in Ethiopia.Methods: A qualitative study using focus group discussions and in-depth interview was conducted in six purposively selected urban settings such as Adama, Dire Dawa, Hawassa, Debre Berhan, Gondar, and Mekelle. A total of 11 Focus Group Discussions and 40 in-depth-interviews were completed with residents of these urban settings who were living in the section of urban setting characterized as slum. The data collected were categorized in to themes and analyzed using thematic method.Results: Study participants anonymously argued that there are positive changes in maternal health service utilization in all study settings over the years. However, students, daily laborers, widows, divorced and separated women, commercial sex workers, house maids, and migrants were found to be reluctant in using maternal health services such ANC follow-up, institutional delivery and PNC. Reasons were found to be attributed to individual characteristics, perceived capacities of health facilities and friendliness of service providers and socio-cultural factors including socially sanctioned expectations at community level in connection with pregnancy, delivery and postpartum.Conclusion: Although service utilization in urban setting is believed to have been relatively better over the years, still women in urban settings do not use available maternal health services. Especially women living in slum areas tend to neglect use of available health services. This study suggests that blanket programmatic approach should give way to intervention that target specific section of population. Furthermore, programs are expected to be tailored to addresses individual, institutional and socio-cultural factors in tandem to improve maternal health service utilization in urban setting. [Ethiop. J. Health Dev. 2017;31(2):96-102]Keywords: Maternal Health Services, Urban Health, Social Determinant of Health, Ethiopi

Perceived barriers to health care for residents in vulnerable urban centers of Ethiopia

Background: Slums in urban settings are fast expanding and unprecedented proportions of urbanites are now living in slums, with the compromised provision of health services. Slum-dwellers in urban settings often face multifaceted barriers to accessing available health services. There is a paucity of evidence on identifying barriers in vulnerable urban centers of Ethiopia. This study aims to explore the barriers to the use of health services in slum urban settings of Ethiopia. Methodology: A qualitative study using in-depth and key informant interviews were conducted in 13 selected John Snow, Inc. (JSI) program operational urban areas of Ethiopia. Data were collected from community members, community opinion leaders, Urban Health Extension Professionals, and urban area health office representatives. The interviews were transcribed by data collectors and analyzed using a thematic content analysis approach. Accordingly, individuals, community- and health facility-level barriers were key themes under which findings were categorized. Results: Findings revealed that barriers to health service use at the individual level include limited awareness about health problems, competing priorities and limited capacity to pay for services when referred. Institutional-level barriers include limited medical supplies, and a lack of passion, respect, and positive attitudes on the part of health service providers. Barriers at the community level include a lack of shared understanding of the problems, services, and the community’s established values in relation to the problems and services. Conclusions: The provision of (maternal) health services in slums in Ethiopia’s urban settings is affected by different barriers that work in tandem. The improvement of health service provision in slum settings requires multiple interventions, including strengthening the health system’s responsiveness to health care demand. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):04-11] Keywords: Barriers, slum sections of urban centers, community, service provider

A qualitative study of vulnerability to HIV infection: Places and persons in urban settings of Ethiopia

Background: HIV continues to differentially affect specific population group and geographic locations in the world. Often individual risk behaviors are associated with vulnerability to HIV infection. However, such notion often overlooks the broader context of social determinants of the infection. Such determinant is broader than personal attributes and includes diverse social factors that contribute to vulnerability to as well as prevention of HIV infection. This study explores the social determinants for HIV infection in urban settings of Ethiopia.Methods: A qualitative study employing Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs) was conducted in six purposively selected cities of Ethiopia. FGDs and IDIs were tape recorded and fully transcribed. Transcripts were coded, categorized and analyzed using thematic analysis.Results: Findings show that it is not only people who are vulnerable, but specific places in urban settings where they reside. Vulnerability of places are linked to overcrowding, being hub of in-migrants and transistors, and with limited availability of services and infrastructure for its residents Majority of residents in such places were daily laborers, female sex workers, students who are living away from family, widows, separated and divorced women, those who work in restaurants and engaged in petty trade were found to be relatively more vulnerable group of population. They were also found to have weakened social controls and restraints that facilitate vulnerability.Conclusion: Every city has settings that are relatively more vulnerable as compared to others and there are population groups that are particularly vulnerable to HIV infection. Mitigating the spread of HIV infection requires mapping vulnerable section of the city and targeting vulnerable group of population makes interventions effective. Moreover, HIV intervention in urban settings calls for a multi-sectoral response. [Ethiop. J. Health Dev. 2016;30(3):105-111]Keywords: HIV, social determinant of health, place, person, JS

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

© 2020 Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods: Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings: Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation: The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Funding: Bill & Melinda Gates Foundation

Contribution of PEPFAR-Supported HIV and TB Molecular Diagnostic Networks to COVID-19 Testing Preparedness in 16 Countries.

The US President's Emergency Plan for AIDS Relief (PEPFAR) supports molecular HIV and tuberculosis diagnostic networks and information management systems in low- and middle-income countries. We describe how national programs leveraged these PEPFAR-supported laboratory resources for SARS-CoV-2 testing during the COVID-19 pandemic. We sent a spreadsheet template consisting of 46 indicators for assessing the use of PEPFAR-supported diagnostic networks for COVID-19 pandemic response activities during April 1, 2020, to March 31, 2021, to 27 PEPFAR-supported countries or regions. A total of 109 PEPFAR-supported centralized HIV viral load and early infant diagnosis laboratories and 138 decentralized HIV and TB sites reported performing SARS-CoV-2 testing in 16 countries. Together, these sites contributed to >3.4 million SARS-CoV-2 tests during the 1-year period. Our findings illustrate that PEPFAR-supported diagnostic networks provided a wide range of resources to respond to emergency COVID-19 diagnostic testing in 16 low- and middle-income countries

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019 : a systematic analysis for the Global Burden of Disease Study 2020, Release 1

Background Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time. Methods For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dosespecific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in countryreported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development. Findings By 2019, global coverage of third-dose DTP (DTP3; 81.6% [95% uncertainty interval 80.4-82 .7]) more than doubled from levels estimated in 1980 (39.9% [37.5-42.1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38.5% [35.4-41.3] in 1980 to 83.6% [82.3-84.8] in 2019). Third- dose polio vaccine (Pol3) coverage also increased, from 42.6% (41.4-44.1) in 1980 to 79.8% (78.4-81.1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56.8 million (52.6-60. 9) to 14.5 million (13.4-15.9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019. Interpretation After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019 : A systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC