Service Coverage and Financial Hardship Under Universal Health Coverage: Uneven Associations Across 159 Countries...

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-year 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, -0.707 to -0.175; p = 0.001). Mean poorest-richest and rural-urban 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.