Published Online July 16, 2021 https://doi.org/10.1016/ S0140-6736(21)01651-2

The historian Walter Scheidel has argued that reductions in inequality have often emerged after war, revolution, state collapse, and plague.1 On July 12, 2021, there were more than 4 million deaths from COVID-19 globally.2 The disproportionate and unequal impact of COVID-19 on populations has brought renewed attention to deep inequalities. Will the impacts of COVID-19 galvanise efforts to reduce inequality?

One of the greatest inequalities globally is the inequity in the access to safe, effective health care without financial burden—universal health coverage (UHC). Historically, universal health reform has often been borne out of crisis. The Overseas Development Institute reported 71% of countries made progress towards UHC after episodes of “state fragility”,3 and there are plenty of examples across the continents. In 1938, after the Great Depression, New Zealand's Social Security Act began its commitment to UHC. The National Health Service in the UK was founded in 1948 in the wake of World War 2. Similarly, France and Japan enacted universal health reform after the conflict. In the aftermath of Rwanda's genocide of 1994, the country's new leadership focused on health for all and expanded UHC.4 Sri Lanka's publicly funded UHC system emerged from a devastating malaria epidemic,5 and after the 2003 SARS pandemic, China launched health-care reform to achieve universal coverage of basic health care by the end of 2020.6 In Thailand, decades of planning were realised with the launch of the Universal Coverage Scheme in 2002 after the Asian financial crisis.7 It is therefore possible that, like other crises before it, the COVID-19 pandemic could catalyse UHC reforms, should global leaders choose to harness the opportunity.8

Indeed, some countries, such as Finland and Cyprus, are implementing ambitious reforms to extend health coverage during the pandemic. In Cyprus, the second phase of their publicly financed General Health Scheme (GHS) was launched in June, 2020. These reforms are popular, attaining an 80% approval rating in a national survey.9

US President Joe Biden has a clear opportunity to expand health-care access to more people. The USA and Ireland are the only two countries in the Organisation for Economic Co-operation and Development without a universal health system. While in Ireland attempts are being made to accelerate UHC through national Sláintecare reforms,10 in the USA Biden's election stance on health care was for slow, incremental steps towards UHC.11 But now, in 2021, there is growing momentum for UHC reforms at a state level, especially in New York. Furthermore, in 2020 63% of Americans polled agreed that it is the federal government's responsibility to make sure all people have health-care coverage.12 If Biden does not harness this momentum, he could miss this unprecedented opportunity to bring UHC to the USA.

UHC is not only an option for high-income countries like the USA. Political leadership, and not a country's wealth, is a key determining factor in progress to UHC.3 Consequently, the COVID-19 crisis might provide a political window of opportunity for leaders in low-income and middle-income countries to launch UHC reforms.

South Africa is a country where some universal health reforms already came from crisis. When the African National Congress came to power in 1994, it inherited an inequitable “two-tiered” health system.13 One of the first major social policies of the then President Nelson Mandela was to launch universal free health care for pregnant women and children younger than 6 years. Yet, despite this advance, in the first decade of post-apartheid South Africa overall inequalities grew.14 After the 2019 election, the new South African Government reaffirmed its commitments to ensuring that quality health care is available to all citizens, with National Health Insurance at the centre of policy development. Although this policy enjoys considerable public support, the financing reforms needed for wealthy citizens to subsidise the rest of the population are yet to be implemented. However, there are indications that President Cyril Ramaphosa could use the COVID-19 crisis to drive through these reforms.15