{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T10:24:44Z","timestamp":1787135084732,"version":"build-2736575974"},"reference-count":39,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Int. J. Environ. Res. Public Health","IJERPH"],"abstract":"<jats:p>Universal health coverage requires simultaneous progress in service coverage and financial protection, yet these dimensions are commonly assessed separately. We conducted a secondary ecological panel analysis using official World Health Organization\/World Bank indicators. A document-oriented workflow preserved irregular subgroup structures before conversion to an unbalanced country\u2013year panel comprising 981 observations from 159 countries\/economies between 2000 and 2023. The primary inferential specification was a two-way fixed-effects model with country and year effects and country-clustered standard errors; a country fixed-effects model with a linear time trend, a random-intercept model, and generalized estimating equations were complementary robustness analyses. We also examined service domains, wealth- and rural-urban inequalities, beta convergence, and exploratory country typologies. Mean service coverage rose from 58.9 in 2000 to 74.0 in 2023, whereas mean financial hardship fell from 24.0% to 17.3%. In the primary model, each one-point increase in service coverage was associated with a 0.441-percentage-point reduction in hardship (95% confidence interval, \u22120.707 to \u22120.175; p = 0.001). Mean poorest\u2013richest and rural\u2013urban hardship gaps were 53.7 and 12.5 percentage points, respectively. The inverse association was largest in low-income settings, where socioeconomic gradients were also steepest. Service coverage gains should therefore not be interpreted as sufficient evidence of equitable universal health coverage; monitoring systems and financing reforms should jointly target access, financial protection, and distributional gaps.<\/jats:p>","DOI":"10.3390\/ijerph23081069","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T08:08:41Z","timestamp":1787040521000},"page":"1069","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Service Coverage and Financial Hardship Under Universal Health Coverage: Uneven Associations Across 159 Countries (2000\u20132023)"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2448-0953","authenticated-orcid":false,"given":"Anderson","family":"D\u00edaz-P\u00e9rez","sequence":"first","affiliation":[{"name":"Centro de Investigaciones en Ciencias de la Vida (CICV), Departamento de Ciencias Sociales y Humanas, Universidad Sim\u00f3n Bol\u00edvar, Barranquilla 080002, Colombia"},{"name":"Programa de Enfermer\u00eda, Facultad de Ciencias de la Salud, Corporaci\u00f3n Universitaria Rafael N\u00fa\u00f1ez, Cartagena de Indias 130001, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7755-8588","authenticated-orcid":false,"given":"Wendy","family":"P\u00e9rez","sequence":"additional","affiliation":[{"name":"Programa de Enfermer\u00eda, Facultad de Ciencias de la Salud, Corporaci\u00f3n Universitaria Rafael N\u00fa\u00f1ez, Cartagena de Indias 130001, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"125","DOI":"10.3961\/jpmph.21.542","article-title":"Challenges to achieving universal health coverage throughout the world: A systematic review","volume":"55","author":"Darrudi","year":"2022","journal-title":"J. Prev. Med. Public Health"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Ranabhat, C.L., Acharya, S.P., Adhikari, C., and Kim, C.-B. (2023). Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review. Front. Public Health, 11.","DOI":"10.3389\/fpubh.2023.1041459"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Endalamaw, A., Mengistu, T.S., Khatri, R.B., Wolka, E., Erku, D., Zewdie, A., and Assefa, Y. (2025). Universal health coverage\u2014Exploring the what, how, and why using realist review. PLoS Glob. Public Health, 5.","DOI":"10.1371\/journal.pgph.0003330"},{"key":"ref_4","unstructured":"World Health Organization (2026, March 14). Universal Health Coverage (UHC). Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/universal-health-coverage-%28uhc%29."},{"key":"ref_5","unstructured":"World Health Organization, and World Bank (2025). Tracking Universal Health Coverage: 2025 Global Monitoring Report, World Health Organization. Available online: https:\/\/www.who.int\/publications\/i\/item\/9789240117808."},{"key":"ref_6","unstructured":"World Health Organization (2026, March 14). Financial Hardship in Health and Components (SDG 3.8.2, 2025 Definition), % of the Population. Available online: https:\/\/www.who.int\/data\/gho\/indicator-metadata-registry\/imr-details\/376."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Takura, T., and Miura, H. (2022). Socioeconomic determinants of universal health coverage in the Asian region. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19042376"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e715","DOI":"10.1016\/S2214-109X(22)00005-5","article-title":"The Lancet Global Health Commission on financing primary health care: Putting people at the centre","volume":"10","author":"Hanson","year":"2022","journal-title":"Lancet Glob. Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e1675","DOI":"10.1016\/S2214-109X(22)00341-2","article-title":"Pandemic preparedness and response: Exploring the role of universal health coverage within the global health security architecture","volume":"10","author":"Lal","year":"2022","journal-title":"Lancet Glob. Health"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"100313","DOI":"10.1016\/j.lansea.2023.100313","article-title":"Advancing universal health coverage in the WHO South-East Asia Region with a focus on human resources for health","volume":"18","author":"Dhillon","year":"2023","journal-title":"Lancet Reg. Health Southeast. Asia"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"04037","DOI":"10.7189\/jogh.15.04037","article-title":"Synergising universal health coverage and global health security in the Western Pacific Region","volume":"15","author":"Lai","year":"2025","journal-title":"J. Glob. Health"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Hajjar, K., Lillo, L., Martinez, D.A., Hermosilla, M., and Risko, N. (2023). Association between universal health coverage and the disease burden of acute illness and injury at the global level. BMC Public Health, 23.","DOI":"10.1186\/s12889-023-15671-2"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"268","DOI":"10.34172\/hpp.025.43192","article-title":"Impact of health expenditure on universal health coverage (composite index): Global evidence","volume":"15","author":"Khan","year":"2025","journal-title":"Health Promot. Perspect."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"643","DOI":"10.2147\/CEOR.S380900","article-title":"Effect of primary health care expenditure on universal health coverage: Evidence from Sub-Saharan Africa","volume":"14","author":"Arhin","year":"2022","journal-title":"Clin. Outcomes Res."},{"key":"ref_15","first-page":"690","article-title":"Universal health coverage for non-communicable diseases and health equity: Lessons from Australian primary healthcare","volume":"11","author":"Fisher","year":"2022","journal-title":"Int. J. Health Policy Manag."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e010552","DOI":"10.1136\/bmjgh-2022-010552","article-title":"Tracking progress towards universal health coverage for essential health services in China, 2008\u20132018","volume":"7","author":"Feng","year":"2022","journal-title":"BMJ Glob. Health"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2189764","DOI":"10.1080\/16549716.2023.2189764","article-title":"The impact of community-based health insurance on universal health coverage in Ethiopia: A systematic review and meta-analysis","volume":"16","author":"Bayked","year":"2023","journal-title":"Glob. Health Action"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e8","DOI":"10.1016\/S2468-2667(22)00315-2","article-title":"Universal health coverage cannot be universal without oral health","volume":"8","author":"Winkelmann","year":"2023","journal-title":"Lancet Public Health"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Hajji, O., El Abbadi, B., and Akhnif, E.H. (2025). Systematic review of financing functions for universal health coverage in low- and middle-income countries: Reforms, challenges, and lessons learned. Public Health Rev., 46.","DOI":"10.3389\/phrs.2025.1607745"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"118709","DOI":"10.1016\/j.socscimed.2025.118709","article-title":"Factors influencing the adoption of universal health coverage in Africa: Insights from a realist synthesis","volume":"387","author":"Langat","year":"2025","journal-title":"Soc. Sci. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e018562","DOI":"10.1136\/bmjgh-2024-018562","article-title":"Identifying implementation science research and policy priorities to advance universal health coverage: A multi-country modified Delphi study","volume":"10","author":"Namyalo","year":"2025","journal-title":"BMJ Glob. Health"},{"key":"ref_22","unstructured":"World Bank (2026, March 14). Universal Health Coverage (UHC) Service Coverage Index. Data360. Available online: https:\/\/data360.worldbank.org\/en\/indicator\/UHC-SCI."},{"key":"ref_23","unstructured":"World Bank (2026, March 14). Universal Health Coverage (UHC) Dataset. Data360. Available online: https:\/\/data360.worldbank.org\/en\/dataset\/WB_UHC."},{"key":"ref_24","unstructured":"World Bank Data Help Desk (2026, March 14). How Does the World Bank Classify Countries?. Available online: https:\/\/datahelpdesk.worldbank.org\/knowledgebase\/articles\/378834-how-does-the-world-bank-classify-countries."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"100826","DOI":"10.1016\/j.lanepe.2023.100826","article-title":"Monitoring progress towards universal health coverage in Europe: A descriptive analysis of financial protection in 40 countries","volume":"37","author":"Thomson","year":"2024","journal-title":"Lancet Reg. Health Eur."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1186\/s12939-024-02257-6","article-title":"Revisiting a decade of inequality in healthcare financial burden in Cambodia, 2009\u20132019: Trends, determinants and decomposition","volume":"23","author":"Antunes","year":"2024","journal-title":"Int. J. Equity Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s13561-023-00475-2","article-title":"Universal health coverage in the context of population ageing: Catastrophic health expenditure and unmet need for healthcare","volume":"14","author":"Okamoto","year":"2024","journal-title":"Health Econ. Rev."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e015179","DOI":"10.1136\/bmjgh-2024-015179","article-title":"Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand\u2019s universal health coverage scheme","volume":"9","author":"Damrongplasit","year":"2024","journal-title":"BMJ Glob. Health"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e085903","DOI":"10.1136\/bmjopen-2024-085903","article-title":"Social health insurance for universal health coverage in low- and middle-income countries: A retrospective policy analysis of attainments, setbacks and equity implications of Kenya\u2019s social health insurance model","volume":"14","author":"Nungo","year":"2024","journal-title":"BMJ Open"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e019150","DOI":"10.1136\/bmjgh-2025-019150","article-title":"Financial protection and universal health coverage in Georgia: An analysis of impoverishing healthcare costs using household income and expenditure surveys","volume":"10","author":"Gorgodze","year":"2025","journal-title":"BMJ Glob. Health"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1186\/s12939-025-02568-2","article-title":"Providing financial protection in health for low-income populations: A comparison of health financing designs in East Asia","volume":"24","author":"Zhang","year":"2025","journal-title":"Int. J. Equity Health"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"100631","DOI":"10.1016\/j.lansea.2025.100631","article-title":"Health insurance coverage, healthcare use, and financial protection amongst people with disabilities in Indonesia: Analysis of the 2021 National Socioeconomic Survey","volume":"39","author":"Probandari","year":"2025","journal-title":"Lancet Reg. Health Southeast. Asia."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Hussein, N., Ng, C.W., Ramli, R., Liew, S.M., Hanafi, N.S., Lee, P.Y., Cheong, A.T., Ghazali, S.S., Pinnock, H., and Stoddart, A. (2024). Assessing catastrophic health expenditure and impoverishment in adult asthma care: A cross-sectional study of patients attending six public health clinics in Klang District, Malaysia. BMC Health Serv. Res., 24.","DOI":"10.1186\/s12913-024-10731-8"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"06044","DOI":"10.7189\/jogh.13.06044","article-title":"Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic","volume":"13","author":"Contreras","year":"2023","journal-title":"J. Glob. Health"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1186\/s13561-026-00717-z","article-title":"Catastrophic and impoverishing health expenditures in fragmented public health systems: Lessons from Mexico, 2000\u20132022","volume":"16","author":"Hone","year":"2026","journal-title":"Health Econ. Rev."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1186\/s12939-025-02659-0","article-title":"Progress and inequalities in financial risk protection toward universal health coverage: Insights from Vietnam","volume":"24","author":"Nguyen","year":"2025","journal-title":"Int. J. Equity Health"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"115367","DOI":"10.1016\/j.socscimed.2022.115367","article-title":"Global, regional, and national progress in financial risk protection towards universal health coverage, 2000\u20132030","volume":"312","author":"Rahman","year":"2022","journal-title":"Soc. Sci. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e020052","DOI":"10.1136\/bmjgh-2025-020052","article-title":"Progress towards universal health coverage in South Asia, 2000\u20132030: An examination of the twin elements of primary healthcare provision and financial protection","volume":"10","author":"Rahman","year":"2025","journal-title":"BMJ Glob. Health"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"The Lancet Regional Health\u2014Europe (2024). Strengthening primary health care to achieve universal health coverage. Lancet Reg. Health Eur., 39, 100897.","DOI":"10.1016\/j.lanepe.2024.100897"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/8\/1069\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T09:33:59Z","timestamp":1787132039000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/8\/1069"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,18]]},"references-count":39,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["ijerph23081069"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23081069","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,18]]}}}