Countries Without Universal Healthcare

Universal health coverage (UHC), as defined by the World Health Organization, means that everyone has access to a full range of health services without facing financial hardship to pay for them. As of 2025, 73 of the world's 195 countries had achieved UHC by the WHO and CEOWORLD measures, covering roughly 69 percent of the global population. Progress has slowed since 2015: the WHO-World Bank Universal Health Coverage Global Monitoring Report released in December 2025 found that the annual rate of improvement in the UHC service coverage index has dropped from 1.5 percent in 2000-2015 to just 0.5 percent in the decade since. The cases that follow are the most significant of the holdouts, organised by the scale of the population still uncovered rather than by any ranking of how close (or far) each country sits from UHC.

United States

The United States is the only country in the developed world (specifically, the only OECD member) without a system of universal healthcare for its working-age population. According to the US Census Bureau's Current Population Survey, 27.1 million Americans, or about 8.0 percent of the population, were uninsured in 2024, holding steady from 2023 but up from the post-pandemic low of 7.9 percent in 2022. Public coverage exists in pockets: Medicare covers near-universally for adults aged 65 and older, Medicaid covers low-income households (more broadly in the 40 states plus Washington DC that have expanded eligibility under the Affordable Care Act), CHIP covers many children, and the Veterans Health Administration covers eligible veterans. Working-age adults aged 19 to 64 have an uninsured rate of 11.3 percent and account for most of the coverage gap. The 2010 Affordable Care Act cut the uninsured population from a 2010 peak of roughly 46.5 million; enhanced marketplace subsidies enacted in 2021 brought enrolment in ACA marketplace plans to a record 24.2 million for 2025. Those enhanced subsidies expire on December 31, 2025, and the 2025 reconciliation law adds work requirements to Medicaid and tightens marketplace eligibility; the Congressional Budget Office projects roughly 10 to 14 million additional people will become uninsured by 2034.

China

The world's most populous country is closer to universal coverage than the source reading of these rankings tends to suggest, but it is not all the way there. China's two main public schemes (the Urban Employee Basic Medical Insurance for formal employees, and the Urban-Rural Resident Basic Medical Insurance for everyone else) together covered roughly 95 percent of the population as of 2024. The remaining 5 percent is concentrated in migrant workers, the homeless, and people who let their premiums lapse. Coverage gaps go beyond enrolment: the two main schemes carry significant deductibles, copayments, and reimbursement ceilings, and they differ sharply in benefit generosity between the urban employee and resident schemes. Out-of-pocket spending in China was 34 percent of total health expenditure in 2021, roughly twice the OECD average. Catastrophic illness still drives household impoverishment in many rural provinces despite the formal coverage.

India

India runs the world's largest single health insurance scheme in absolute terms: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), launched in 2018, provides up to 500,000 rupees (roughly US$6,000) per family per year in secondary and tertiary hospital coverage to the poorest 40 percent of households. Over 500 million people are technically eligible, and as of 2024 roughly 350 million had been issued PMJAY cards. Outside the scheme, however, India's healthcare picture remains dominated by out-of-pocket payments: roughly 50 to 60 percent of total health expenditure is paid by households at the point of care, one of the highest shares in the world. State-level schemes (such as Tamil Nadu's CMCHIS and Karnataka's Suvarna Arogya Suraksha Trust) add coverage in some states, but rural populations, informal-sector workers, and people requiring outpatient or chronic care remain largely outside any insurance net.

Pakistan

Pakistan, the world's fifth-most populous country with roughly 240 million people, has expanded health coverage significantly since 2019 through the federal Sehat Sahulat Program (also called Sehat Card Plus) and parallel provincial schemes, particularly Khyber Pakhtunkhwa's, which was the first province to offer universal Sehat Card coverage to all residents. As of late 2024, Sehat Card Plus covered approximately 45 million families nationally, with coverage of up to 1 million rupees (roughly US$3,600) per family per year for inpatient care. Coverage of outpatient care, medicines, and chronic disease management remains limited, however, and Pakistan's public health system remains underfunded: the country spends roughly 2.9 percent of GDP on health, well below the World Health Organization recommended minimum of 5 percent. The 2025 funding squeeze under IMF conditionality has constrained further expansion.

Nigeria

Nigeria, the most populous country in Africa with over 230 million people, passed the National Health Insurance Authority Act in May 2022, replacing the previous National Health Insurance Scheme and making health insurance enrolment formally mandatory for all residents. Implementation has been slow. As of 2024, the National Health Insurance Authority reported approximately 18 million Nigerians enrolled in any form of health insurance, about 8 percent of the population, with coverage concentrated among federal government employees and a small private-sector pool. Out-of-pocket payments still account for roughly 70 percent of total health expenditure, one of the highest rates in the world. The federal government's stated goal is to reach 50 percent coverage by 2030; most analysts treat that as aspirational rather than likely.

Egypt

Egypt passed the Universal Health Insurance Law (Law No. 2 of 2018) in January 2018 and launched its rollout in Port Said in 2019. The system is structured to expand in six geographic phases over what was originally a 15-year timeline. By July 2025, the first phase had completed implementation in six governorates (Port Said, Luxor, Ismailia, South Sinai, Suez, and Aswan), reaching approximately 5.2 million beneficiaries; the second phase began rolling out in late 2025 across Damietta, Marsa Matrouh, Kafr El-Sheikh, North Sinai, and Minya, targeting roughly 12 to 13 million additional beneficiaries. Investment in the first two phases has totalled EGP 48.5 billion. Presidential directives in 2024 and 2025 accelerated the original 2032 target to 2027-2030. The remaining 27 governorates, including the largest population centres of Cairo and Alexandria, are not yet covered, and roughly one-third of Egyptians still live in poverty, which limits their access to private-sector care in the meantime.

South Africa

South Africa's National Health Insurance Act was signed into law by President Cyril Ramaphosa on May 15, 2024, marking the formal legal commitment to universal healthcare that has been written into the country's post-apartheid constitution since 1996. The Act establishes a single National Health Insurance Fund intended to pool resources and provide free healthcare at the point of service for all South Africans. Implementation has been paused since signing because of legal challenges from private healthcare providers, medical schemes, and industry bodies, including the Board of Healthcare Funders, which has filed constitutional and procedural challenges. Court hearings were scheduled for May 2026. South Africa's existing healthcare system remains sharply two-tiered: a publicly funded sector serves roughly 84 percent of the population on around half the country's health spending; private medical schemes serve the remaining 16 percent on the other half.

Countries in Active Conflict or Collapse

Yemen, Afghanistan, and Syria belong in a separate category: countries whose health systems have been so damaged by war, sanctions, or political collapse that the question of universal coverage is not currently being debated at the national level.

Yemen. The civil war that began in 2014 has destroyed or rendered non-functional more than half of Yemen's healthcare facilities. WHO reporting through 2024 noted that less than 50 percent of facilities remained fully functional, and that healthcare workers and medical facilities have been repeatedly targeted by all parties to the conflict. The UN continues to describe Yemen as one of the world's largest humanitarian crises.

Syria. The 14-year civil war that began in 2011 has killed or displaced large numbers of Syrian healthcare workers and shuttered medical facilities, particularly in opposition-held areas during the Assad period. After Bashar al-Assad's government fell on December 8, 2024, interim president Ahmed al-Sharaa signed a temporary constitution on March 13, 2025, and a five-year transitional period began. Syria's healthcare system remains catastrophically degraded, with WHO and international NGOs continuing to provide emergency support across most of the country.

Afghanistan. The Taliban returned to power on August 15, 2021, after the US-led coalition's withdrawal. The combination of the foreign aid collapse that followed, the Taliban's bans on women's education (secondary schools in 2021, universities in December 2022, medical and midwifery institutes in December 2024), and the broader economic collapse has driven the healthcare system to the edge of failure. Pediatric emergency cases more than doubled from 53,000 in 2020 to 122,000 in 2024 per Médecins Sans Frontières reporting; 23.7 million Afghans (more than half the population) needed humanitarian assistance in 2024; and 21 of 34 provinces were classified as having critical or extreme health needs as of August 2023. The ban on women training as doctors and midwives has closed the last domestic pathway for a country where many female patients can only legally be treated by female providers.

Other Countries Without Universal Healthcare

Beyond the largest cases, the WHO and World Bank treat a long list of additional countries as not yet meeting UHC criteria. Mexico's Seguro Popular (which had covered 53 million previously uninsured Mexicans) was dissolved in 2020 and replaced by INSABI, which was itself rolled into IMSS-Bienestar in 2022; coverage remains incomplete, with roughly 30 to 35 million Mexicans without effective insurance. Indonesia's JKN scheme has enrolled approximately 270 million people on paper but suffers from chronic funding shortfalls and benefit gaps. Most countries in Sub-Saharan Africa outside South Africa lack functioning universal systems: the Democratic Republic of the Congo, Cameroon, Sudan (its civil war since April 2023 has worsened a system that was already weak), Chad, the Central African Republic, Somalia, Mali, Niger, and others rely heavily on out-of-pocket payments and external NGO support. Several South Asian and Central Asian countries are in similar positions, with formal insurance covering only a minority of the population. The Pacific island nations of Tuvalu, Marshall Islands, and the Federated States of Micronesia depend largely on Compact of Free Association arrangements with the United States rather than on a domestic UHC system.

Countries Without Universal Healthcare At A Glance

The table below summarises the major cases discussed above, with the most recent available coverage and out-of-pocket spending data. Out-of-pocket (OOP) share is the proportion of total national health expenditure paid directly by households at the point of care; the WHO treats a share above 20 percent as a marker of financial hardship risk for households.

Sources: WHO Global Health Expenditure Database (2024 update); World Bank Universal Health Coverage Global Monitoring Report 2025; US Census Bureau Current Population Survey (2024); CEOWORLD Health Care Index 2025; national statistical office releases.

What Comes Next

The WHO's December 2025 monitoring report concluded that the world is "far off track" to reach the Sustainable Development Goal target of universal health coverage by 2030. Over half of the world's population still lacked access to basic health services in 2023, and the financial protection indicator (the share of households facing catastrophic out-of-pocket spending) has worsened modestly since 2017. The countries discussed above account for the bulk of those uncovered: roughly half the world's population lives in just six of them (China, India, Pakistan, Nigeria, Bangladesh, and the United States). The trajectories vary widely. South Africa and Egypt have functioning UHC laws in implementation, even if delayed. India, China, Pakistan, and Nigeria have national schemes that have expanded substantially in the past decade but face limits in benefit depth, geographic equity, or out-of-pocket exposure. The United States is moving in the opposite direction of the global trend, with CBO projections showing the uninsured population growing through the late 2020s. Yemen, Syria, Afghanistan, and Sudan are off the framework entirely until basic political and security conditions stabilise.