Service Coverage Does Not Uniformly Translate into Financial Protection Under Universal Health Coverage: A Multicountry Panel Analysis, 2000–2023

Universal health coverage (UHC) requires simultaneous gains in service coverage and financial protection, yet these dimensions are often analysed separately. We conducted a secondary ecological panel study using two public indicator files (UHC-SCI and UHC-FH40). Records were first harmonized through a document-oriented non-relational workflow that preserved irregular subgroup structures before flattening to a country-year panel. The analytic sample comprised 981 observations from 159 countries/economies between 2000 and 2023. We estimated pooled trends, correlations, country and two-way fixed-effects models with clustered standard errors, a random-intercept model, a generalized estimating equation, domain-specific models, wealth- and urbanization-based inequality metrics, beta-convergence models, and country typologies. Mean service coverage rose from 58.9 to 74.1, whereas mean financial hardship fell from 24.0% to 17.3%. Each 1-point increase in the service coverage index was associated with a 0.441 percentage-point reduction in hardship (95% CI: -0.707 to -0.175; p = 0.001). The mean poorest-richest and rural-urban hardship gaps were 53.7 and 12.5 percentage points. Low-income settings showed the steepest inequities and the strongest negative slope. UHC progress therefore remains incomplete unless service expansion, financial protection, and inequality monitoring are interpreted together.