GBD 2019 Universal Health Coverage Collaborators, et al. - Achievement of universal health coverage (UHC) involves provision of high quality of health services for all people as per their necessity, with no financial hardship experienced by them. The agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13) highlights that for both countries and global institutions, making progress towards UHC is a policy priority. In the present study, a new approach was provided to monitoring progress on UHC service coverage: estimating country-level effective coverage and thus better representing how well health systems are providing health gains relative to their populations' health needs. UHC effective coverage was determined for 204 countries and territories from 1990 to 2019 based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Drawing from a measurement framework generated through WHO's GPW13 consultation, 23 effective coverage indicators were mapped to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥ 65 years). Amid global improvements on the UHC effective coverage index since 1990, a gap of more than 70 points was identified between locations with the highest and lowest levels of UHC effective coverage in this study that remained in 2019. Especially among low-middle to middle-SDI countries, far lower performance of effective coverage indicators was observed for non-communicable diseases than levels reached for several communicable diseases and maternal and child health indicators—a pattern indicating that many countries' health systems and financing priorities are not operating as rapidly as their epidemiological and demographic transitions. Generally, higher pooled health spending per capita coincided with higher UHC effective coverage. Nonetheless, there was a wide variation in country-level performance and many countries fell well below levels attained by other countries with similar amounts of health expenditures, highlighting the significance of raising both health-system efficiencies and funding for UHC. Countries would require to reach $1,398 pooled spending per capita to attain at least 80 on the UHC effective coverage index—and would do so under maximum efficiency. Per estimates, between 2018 and 2023, 388·9 million more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Genuinely advancing toward UHC needs prioritizing—and thus monitoring—effective coverage and health systems' capacities for achieving improvement in outcomes for all individuals throughout the world.