Barriers to achieving universal health coverage

What are the major barriers to achieving universal health coverage (UHC) in low and middle-income countries?

At least half of the world’s population don’t have access to UHC.
Here are some causes in LMIC:
1- Weak Governence of healthcare system.
2- Poor financial resources.
3- Workforce challenges: both quantity and quality.
4- Lack of essential health services.
5- Poor Quality and Patient Safety

@a1m2r3h4 - Thanks Dr. Alhawsawi for sharing your thoughts.

Hi @Mellie64 and @shihei - It would be great to hear your thoughts on major barriers to achieving universal health coverage. Thanks.

Hi @VTod and @jessgong - we would love to know what you think about the major barriers to achieving universal health coverage. Thanks.

Major barriers to achieving universal health coverage are:

  1. Ignorance and health illiteracy
  2. Poor or inadequate implementation of health policies
  3. Poor monitoring and evaluation of health services/programs

We carried out the largest cross sectional survey in a slum of India - the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the ‘‘Tablet’’ to collect information and stress-free workflow in field. Results Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in ‘‘unmet need.’’ Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care.

Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city.

Here is the full manuscript:

The issues raised by our study are:

  1. What is the underlying reason for 50% of people not utilizing UHC, despite obtaining a consultation?
  2. Is there a trust deficit in government UHC vs. private doctors in India?
  3. Ignorance of the law was not an issue as most people got a free consultation.

We need to set up a study to examine these factors:

  1. Create an App to educate the people about the benefits and UHC.
  2. Create a surgical community worker on the lines of ASHA community workers or Dr Bang’s work in Maharashtra?
  3. Study the patient-doctor and patient-hospital interaction by several instruments available in the literature, but tailored to India.

Measurement Scale Commentary

Any number of studies have established that here is significant unmet surgical need in India. Most patients attend out-patient assessment with view to surgery, but the subsequent take up rate for surgery is low. Therefore, it is prudent to assume that given that patients are well motivated enough to attend for the initial consultation, patients make the decision not to proceed at some point during the initial consultation-either as a result of the consultation itself, and/or the healthcare system in which the consultation is embedded. Hence, the focus amongst authors to date on the doctor patient relationship and broader social considerations, which may impact their risk taking and decision making. Focus on the doctor patient relationship has primarily manifested in the form of trust (3, 5), control (5, 7), and patient perceptions of satisfaction and quality (8) with health literacy issues as an underlying current which potentially need to be factored into studies going forward. Socially, it has been hypothesised that childcare, loss of income, travel to and from the hospital, fear of anaesthesia, lack of social support and confidentiality issues and impact upon the low uptake of surgery (7).

The initial Trust in the Physician Scale (1) was later modified for application in India and named the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting (2, 3). This would be an excellent tool to establish further clarity relating to the micro aspects of surgeon-patient interaction and issues which impact upon the low uptake of surgical intervention. However, in order to develop a more applied research agenda, we would need to better understand the patient’s broader psychosocial perspective, namely patient centred care. The Person-Centred Coordinated Care (P3C) (4) used in conjunction with the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting (2,3) would provide a deep dive into this issue. It would also generate a novel approach in India and although developed in the United Kingdom, it is a universal tool. We have already reached out to the team who generated the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting with a view to collaboration on our proposed grant application.

It has been widely acknowledged that India has a multifaceted health governance and a large public health delivery system. But there have been a number of calls to better connect this system to a delivery and financing provision, which better represents the living reality of most Indians (6). The Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting combined with the Person-Centred Coordinated Care (P3C) would yield such data, which could ultimately be used to strengthen surgical systems in a patient friendly manner. Patient centred care by its very nature requires cross agency collaboration. Therefore, its application would facilitate collaboration of local, regional and global partnerships, which in turn would generate applied global health research of interest to any number of stakeholders.


  2. doi: 10.1136/bmjopen-2014-007305
  7. 1007/s10865-012-9419-z

It may be worth field testing an ideal instrument/survey for LMIC to study patient-centered data and create an App for convenience. This could be used by various NGOs and governmental ministries of Health to study outcomes.

@RahulJindal - Thanks Dr. Rahul for sharing insights into barriers to achieving UHC and for the informative resources. All strong points, which we have taken a note of.

@angelfoster and @cimdal2 - Hi Dr. Angel and Dr. Claudia,
Given your experience, you both may have thoughts on barriers to achieving UHC. Please join the discussion to share your experience and thoughts. Thanks.

@RahulJindal Thank you Dr. Rahul for sharing your research findings. We will review these as they apply to the current scope of our research. Please share any additional research that you think would be beneficial to us. Thank you!

@Lizzy_2020 Thank you for your feedback. I think you made some great points. I’m especially interested in your comment about the poor implementation of health policies. In your opinion, why does this happen? Please share any relevant research links. Thank you!

@a1m2r3h4 Thank you Dr. Alhawsawi for your feedback. I’m interested to hear more about these workforce challenges. Specifically, do you think that digital tools like artificial intelligence could compensate for the lack of quality and quantity you mentioned? If so, which countries are best positioned to implement these digital tools? Thank you!

In response to our work here:, the team from Mumbai in collaboration with the WHO responded by their data showing that their experience is different due to higher education and maturity of the workforce ( Therefore, one size does not fit all. We need to examined the role of patient-centered medicine and how it can work in different populations within the same country.

The key to achieving universal health care in low- and middle-income countries communities lies is in task shifting. There aren’t enough doctors and specialists, so the right knowledge, at the right time, in the right place doesn’t exist.

Therefore, we need to enable existing players - Community Health Workers (CHW’s), nurses, etc., that can educate the community in the prevention of disease.

As part of this strategy, an effective triage system needs to be put in place, so that only those who really need to see a doctor, see one. We also need to train CHW’s to help provide access to vaccines.

A platform like Project ECHO ( is needed to mentor and support these workers so they have the knowledge and skills needed to deliver quality and cost-effective healthcare to the last mile.

Thank you @SArora for sharing your thoughts.
Hi @Lauren and @barati - We would love to hear your thoughts on barriers to achieving UHC. Thanks.

On this issue, I would ask that you study what happened to the Obamacare.

Maybe what we need is no so much a Universal Health Coverage but an Affordable Insurance. Swedish startup Bima already brings affordable health insurance to 30 million users in 15 countries across Africa, Asia, and Latin America, 93% of whom living on less than $10 a day.

Very happy to be part of this community discussion. UHC requires a multifaceted approach and partnerships. We also need innovative solutions that are affordable and scale-able. I am with the George Institute for Global Health. Our mission is to improve the lives of millions of people globally by providing the best evidence and most innovative affordable health solutions that address major health issues. We partner with governments, health facilities, communities and industry. We scale our impact by partnering with researchers, entrepreneurs and organisations to develop innovative health solutions. For more information please see our websites and
Parisa Glass

Slightly dated article from early 2019 but still quite relevant - private sector engagement is critical to UHC achievement, yet the enabling environment is still quite poor for local private sector healthcare development.