Healthcare Advances Leave the Poorest Behind
Geneva: Progress in global healthcare is a strange thing to measure. On paper, the world has never had more clinics, more diagnostics, more trained workers and more coverage than today. Yet beneath the averages lies a quieter reality: even as millions step closer to care, millions still step back from it. The result is not a world standing still, but a world moving forward unevenly, with some groups gaining more, some gaining less, and a few gaining almost nothing at all.
The divergence became sharper after 2015. Service coverage continued to rise in most countries, but financial protection did not rise with it. In the years before 2015, progress usually meant that more people were receiving care without facing economic strain. In the years after, progress meant that more people were receiving care while the risk of financial hardship stayed the same or worsened. The global picture did not reverse but split, with access moving forward and affordability falling behind.
This unevenness becomes visible only when the averages are broken open. Women face the steepest gradient. Even where coverage indicators are strong, women consistently report greater difficulty obtaining care than men, and the gap widens among women who are poor, rural or less educated. The distance between women in the richest and poorest households has barely narrowed in a decade. For many women, a clinic within reach exists in a technical sense, but not in a usable sense. The cost of transport, medicines, consultation or missing a day’s earnings can outweigh the urgency of treatment. A service available on paper can become inaccessible in practice.
The generational divide tells a parallel story. Older people face higher exposure to financial hardship because their illnesses are more likely to require repeated, long-term treatment, often centred on medicines rather than procedures. Younger populations absorb the consequences when maternal and newborn services stagnate, because delays or gaps in maternal care reverberate into outcomes for infants and children. Health systems treat these as separate categories, but for families, they accumulate within the same household.
Disability amplifies inequality further. Even in regions with wide service availability, people with disabilities report substantially higher levels of unmet care needs, not because facilities are missing but because the cost and logistics of accessing them are steeper. The requirement for multiple visits, specialised equipment or paid assistance increases both direct expenditure and opportunity cost. The result is a quiet form of exclusion: the services exist but remain disproportionately harder for disabled people to use.
The economic divide deepens the picture. Among the poorest households worldwide, the proportion spending out-of-pocket on health has grown steadily over the past two decades, even as the total number of people in poverty has declined. Households that are poor today are more likely to be pushed further into deprivation by health costs than those who were poor twenty years ago. The appearance of progress at the population level conceals the growing intensity of hardship among those at the bottom. Women within these households are more likely than men to postpone or forego care when income is limited and more likely to carry the unpaid labour burden of caregiving, which amplifies the economic toll of treatment interruptions.
Middle-income households are not insulated either. A rising share of families that are not classified as poor are also being drawn into hardship, not through dramatic hospital bills but through the slow accumulation of outpatient visits and medicine purchases. Many are not counted as financially harmed but are financially vulnerable, maintaining basic living standards only so long as no serious illness occurs. Their budgets balance on margins thin enough that a single chronic diagnosis, pregnancy complication or hospitalisation could trigger hardship. This group is structurally important because it indicates that the boundary of economic risk is shifting more rapidly than the frameworks used to measure it.
Urban and rural differences remain, but they are not simply geographic. Rural households usually face higher rates of financial hardship and lower utilisation because distance, transport cost, lost wages and logistics create multiple layers of friction. In urban areas, facilities are close but often financially out of reach. In both settings, a household may know exactly where to find care and exactly why it cannot afford to pursue it. The lived reality is not defined by the presence or absence of infrastructure, but by the economic conditions required to use it.
Regional contrasts reflect this same structural pattern with different textures. In Sub-Saharan Africa and South-East Asia, service coverage has increased, and financial hardship has fallen overall, but the poorest women remain largely excluded from improvements. In Latin America and the Caribbean, expansive infectious disease control has not translated into affordability for chronic illness treatment. In South Asia, noncommunicable disease care benefits higher-income households much more than lower-income ones because the highest costs fall on medicines. In the Western Pacific, financial hardship has declined unevenly, leaving particular population groups behind even where national progress is strong. In high-income Europe, services are widely available, yet unmet needs remain concentrated among low-income people and people with disabilities.
One of the least visible forms of inequality is forgone care. National estimates count people who spend on health and measure whether that spending pushes them into hardship. But the number of people who avoid or delay care because they know they cannot afford it is much larger. A household that chooses not to seek treatment for economic reasons does not show up in hardship statistics and does not contribute to utilisation figures. Instead, it disappears into silence. The scale of forgone care suggests that economic harm from illness is not captured only by what families spend, but also by what they decide not to spend.
Two forms of financial hardship shape this landscape. The first is when households continue treatment but must reduce spending on basic needs such as food, school fees or transport. A household may keep buying medicines by cutting meals thinner, suspending a child’s schooling expenses or eliminating non-essential daily items to free income for health. These reductions are not counted as poverty, yet they have immediate human consequences and can push households toward worsening deprivation over time. The second form of hardship is when households fall below the poverty line because of health payments, a scenario that receives more policy attention because it satisfies statistical criteria. Both forms are harmful, but only one is recorded.
Capacity is another limiting factor. Growth in infrastructure does not automatically translate into adequate staffing, diagnostic access or system readiness. When a system becomes stretched, the households with the least resources are the first to experience reduced utilisation because they have the weakest margins to absorb delays, travel, repeat consultations or multiple transactions. During shocks — whether caused by emergencies, epidemics or climate-related disruptions — this fragility deepens. Access tends to decline first for marginalised groups and is restored last for them once the system stabilises. The widening of inequality during disruptions is not exceptional but patterned, revealing that progress is most fragile precisely where need is highest.
Across all of these patterns, one component appears repeatedly: the weight of medicine costs. Medicines now make up the largest share of household spending on healthcare in most monitored countries, and more than half of total expenditure among households already facing hardship. Among the poorest households, the share is even higher. The affordability problem facing women, older adults, disabled people, rural populations and middle-income households is not mainly one of catastrophic hospital events but of continuous medication over months and years. It is not the decision to begin care that poses the biggest risk, but the inability to sustain it.
The global projections to 2030 show service coverage rising steadily, with a composite score expected to reach the mid-70s. At the same time, almost one in four people worldwide is projected to remain exposed to financial hardship due to healthcare payments. A world that looks close to universal on paper may still feel far from universal to the groups consistently at the margin. Universal health coverage was conceived as an equal promise of access and protection. Access has grown. Protection has not grown equally.
The next decade will be defined not by whether services expand, but by whether those who have long hesitated at the clinic door because of cost no longer need to hesitate. Women in low-income and rural households, older people managing chronic illness, disabled people facing multiplied barriers, families balancing budgets against medicines, and middle-income workers vulnerable to hardship despite not being counted in it — these are the people whose experience will determine whether universal health coverage becomes real. A world that counts progress only in averages will continue to improve faster on paper than it improves in lived reality. A world that measures progress by whether those with the least protection gain the most will be far closer to the health systems it set out to build.
– global bihari bureau
