A novel indicator to predict countries’ likelihood of achieving universal health coverage

By Andrea B. Feigl and Eric L. Ding

While there is an increased focus on achieving universal health coverage among low and middle-income countries, empirical determinants of universal healthcare coverage are poorly understood. With the goal to study the economic, social, and political predictors of universal coverage, we systematically researched the common definition and dimensions of universal coverage and created a novel indicator that captures the most important UHC dimensions of legal coverage, universal access to services, and universal enrollment.

Utilizing and indicator that we termed Evidenced Formal Coverage (EFC), we determined that a country has achieved universal coverage if:

  1. Universal healthcare coverage is written into the country’s law
  2. At least 85% of the population is covered under the law
  3. Access to skilled birth attendance is greater than 90%

A subsequent systematic search of the social science and economic literature on universal coverage revealed the most prominent social theories and economic indicators that have been associated with universal coverage, which we then tested with a time to event analysis.

Overall, we found that 75 of 194 countries implemented legal-text UHC legislation, out of which 51 achieved EFC. Using over a century’s worth of data (from 1880 to 2008), we were able to show that countries with EFC are wealthier, have less income inequality, and reached higher educational levels than those without EFC. Democratic countries (versus dictatorships) and those with less ethnic fractionalization also reached universal coverage sooner.

In middle income countries, a doubling of GDP raised a country’s likelihood of achieving EFC by 150%. Interestingly, economic growth at the expense of income inequality could dampen this effect, as for each doubling of the GINI coefficient, the likelihood to reach universal health care development decreased by 72%. Independently of economic growth, each 20% increase in the primary school completion rate was linked to a 2.3-fold increase in the likelihood of achieving EFC; each 20% increase in the literacy rate boosted the likelihood 22-fold.

Further, our paper provides the first comprehensive set of countries and start years of universal healthcare legislation.

Our findings have immediate policy implications for transitioning countries aiming to move towards universal coverage. As such, we were able to show that a narrow focus on GDP growth alone is insufficient for achieving universal health care—as economic growth needs to be coupled with income equality, simultaneous educational attainment, and progress towards democracy. Each of these factors is important independently of GDP, and might be the best preconditions for a rising lower- or middle-income country to achieve universal health care in the future.

(Some text is adapted from

and might be the best

and might be the best preconditions for a rising lower- or middle-income country to achieve universal health care in the future.

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