Ties Boerma Director of Health Statistics and Information Systems World Health Organization Geneva

1. Universal Health Coverage: measurement and its potential role in the post 2015 development agenda Ties Boerma Director of Health Statistics and Information Systems World Health Organization Geneva

2. Outline • Post 2015 development agenda • Goal -Healthy life expectancy • Goal - Universal health coverage: general issues and financial risk protection • Goal - Universal health coverage: measurement issues

3. Health in the post-2015 agenda: the global consultation process

4. Overall consultation process:UN System Task Team established early 2012 • Task Team proposed integrated framework for realizing the "future we want for all in the post-2015 UN development agenda

5. Overall consultation process: UN Secretary-General's High-level Panel of Eminent Persons on the post-2015 UN development agenda • Established by SG mid-2012 • Output: Report that the SG will deliver to UN General Assembly by the 2nd quarter of 2013 • Input: Work based on report of UN System Task Team • Work to be informed by Rio+20 and other consultations Co-Chair: SusiloBambangYudhoyono President of Indonesia Co-Chair: Ellen Johnson Sirleaf President of Liberia Co-Chair: David Cameron Prime Minister of the UK

6. Overall consultation process:Country consultations (about 100) • Objectives • Influence the intergovernmental process by amplifying the voices of local communities • Output • Clear recommendations for governments • Coordination at country level • UN Resident Coordinators will provide overall strategic guidance • Ministries of Planning lead and line Ministries involved

7. 11 global thematic consultations, including one on health

8. Working Group on Sustainable Development Goals Mandate: Rio+20 Objective: Tasked to develop a proposal for the Sustainable Development Goals UN Secretary-General: "The Panel’s work will be closely coordinated with that of the intergovernmental working group tasked to design Sustainable Development Goals, as agreed at the Rio +20 conference. The reports of both groups will be submitted to Member States for their further deliberations." Members: Working Group comprised of 30 representatives nominated by Member States (co-chairs Brazil & Italy) Output: A report to the UNGA containing a proposal for sustainable development goals (between Sep 2013/14)

9. The global consultation on health (Health Thematic Consultation) > 100 papers contributed > Dozen consultations > Web based forum

10. Emerging themes:Lessons learnt from the health MDGs • Health MDGs success • More money for health • More progress since 2000 • Influenced political discourse at highest levels • Driven by concrete measurable goals and targets • But also shortcomings • Lack of focus on equity • Human rights aspect missing • Too much a top-down process • Contributed to more fragmented health programmes in countries

11. Emerging themes:Health priorities post-2015 • Continue the health MDGs: unfinished agenda • Address emerging noncommunicable diseases and their risk factors • Address health consequences of demographic and epidemiologic changes, environmental factors, globalization, urbanization, migration etc. • Strengthen health systems

12. Emerging themes:The place of health in the post-2015 agenda • Changes in global landscape • Post 2015 agenda is for all countries • Much greater diversity and complexity now than in 2000 (global changes, CSO, partnerships etc.) • Place of health: • Critical contributor to development in sectors other than health, • Beneficiary from development, and • Key indicator of what rights-based, sustainable and equitable development seeks to achieve • Links with many other sectors needs to be made explicit (including social determinants of health)

13. Emerging themes:Post-2015 goals • Possible goals • Long healthy lives / healthy life expectancy: is an end goal, influenced by health but also by many other aspects of development • Universal Health Coverage: contribution of health to the end goal, supported in many papers • Continued Health MDGs, with equity element • Equity and human rights as central elements

14. Measurement of healthy life expectancy

15. Possible measures of Healthy Life Expectancy • Mortality / life expectancy • Healthy life expectancy with Global Burden of Disease approach • Healthy life expectancy with survey measurement of health state

16. Mortality • Life expectancy only: attractive summary measure, well understood, used as primary measure by many countries; can be disaggregated • Age and cause-specific mortality: NCD mortality goal (25% by 2025), MDG continuation (child and maternal mortality, HIV/AIDS, TB) • Mortality rates are needed for healthy life expectancy measures • Lack of good death registration data with reliable cause in most low and middle income countries • Reliance on suboptimal measures: mortality data collection in retrospective surveys, cause of death through verbal autopsy

17. Healthy life expectancy with GBD approach • Requires age-specific mortality rates + prevalence and distribution of non-fatal conditions + disability weights. • Makes systematic use of multiple data sources and can be updated regularly. • Using extensive modelling comparable methods over time (1990-2010) and can be computed for all countries. Issues: • Data limitations: prevalence data are often lacking • Needs the use of disability weights for each non-fatal condition • Recent estimates will be heavily based on prediction • Cannot disaggregate for equity analysis except geographical differences

18. Healthy life expectancy based on survey data • Single question: self-rated health/activity limitations; EU surveys "For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do?" (3 point scale) .. Disability-free life expectancy (gain 2 healthy life years by 2020 – EU) • Focus on functioning (ICF): health score, using domains (mobility, vision, cognition etc.) • ADL, (core tasks, severe disability) and IADL (more complex tasks, mild/moderate disability), WHODAS 2.0 • Biological and clinical tests: physical and cognitive tests; hypertension, vision, anthropometry, handgrip strength; body fluid testing - CRP, IL-6, HbA1c, telomere length, lipid profile, markers of immuno-senescence Issues • Cross-cultural comparability • Ways to adjust for reporting biases (anchoring vignettes) often not successful • Health examination surveys not widely conducted

19. Universal Health Coverage General issues and financial risk protection

20. WHO's Formal Definition of Universal (Health) Coverage World Health Assembly Resolution 58.33, 2005, urged countries to develop health financing systems to: Ensureall peoplehave access to needed services Without the risk of financial ruin linked to paying at the time they receive care Defined this as achievingUniversal Coverage: coverage with health services; with financial risk protection; for all

21. UHC combines both service coverage and financial protection, explicitly • New for the public health community • Financial protection as integral to the concept of UHC • Beyond “Health for All” to Health for All with financial protection • New for (health) economists • Focus had been largely on financial protection and the “economics of health insurance” • Recognize that UHC is more than this, requiring as well a focus on services and their quality • Comprehensive: • Includes promotion, prevention, treatment, rehabilitation and palliation; focus on equity & quality of care

22. UHC: global visibility • WHO • “Universal coverage is the single most powerful concept that public health has to offer” • “Universal coverage is the hallmark of a government’s commitment, its duty, to take care of its citizens, all of its citizens” (WHO DG Acceptance Speech 23 May 2012) • UN General Assembly • Resolution on UHC adopted in December 2012 (Foreign Policy and Global Health) www.who.int/whr/2010

23. WHR 2010 Conclusions • Every country could do something to move closer to universal coverage or maintain the gains they have made, through: • Raising more funds for health AND/OR • Reducing financial barriers to access and increasing financial risk protection AND/OR • Improving efficiency and equity • Global community: • increase funding to low-income countries • become more efficient in the way it holds and channels funds to countries • support the development of domestic financing capacities

24. Dispelling Myths about UHC • UHC is only about treatment and care. FALSE • Promotion, prevention, treatment, rehabilitation, palliation • UHC is only about health financing. FALSE • Coverage of interventions with financial risk protection • UHC is not a concern for priority health programs or global health initiatives: FALSE • MDG, NCD, emergency care under one umbrella • UHC means immediate free coverage for all possible health interventions, regardless of the cost. FALSE • Progressive realization of UHC according to country situation

25. The Cube: Three dimensions (policy choices) of UHC

26. Financial risk protection Indicators: level and inequalities • Incidence of catastrophic health expenditure due to out-of-pocket payments • Incidence of impoverishment due to out-of-pocket payments • Mean positive overshoot of catastrophic payments • Poverty gap due to out-of-pocket payments • Indirect indicators of financial risk protection: • Out-of-pocket payments as a share of total health expenditure • Government health expenditure as a share of GDP • Government health expenditure as a share of general government expenditure

27. Large variations in Government health spending as a proportion of GDP Source: WHO estimates for 2008, countries with population > 600,000

28. Bottom line: where government spends more on health, people spend less out-of-pocket Source: WHO estimates for 2004, excluding countries with population < 600,000

29. UHC in India Several initiatives for UHC: JananiSurakshaYojana as conditional cash transfer mechanism for pregnant women, National Rural Health Mission for improve rural services, RashtriyaSwasthyaBimaYojna for more equitable access to hospitals Call to action in Lancet series 2011 – Integrated National Health System … UHC Increased public spending on health Ensure the reach and quality of health services to all Reduce the financial burden of health care on individuals Stronger regulation of the private sector Empower people to take care of their health and hold the health system accountable 29

30. Universal Health Coverage Measurement issues intervention coverage

31. A few definitions Access: whether the health services that people might need are available, of good quality, and close to them Coverage of interventions: whether the people who need an intervention actually receive it Effective coverage: whether the people who need health intervention obtain them in a timely manner and at a level of quality necessary to obtain the desired effect; (health gain – relevance) Obstacles to obtaining effective coverage: physical access, affordability, acceptability for reasons such as culture or religion, and poor service quality; financial affordability is not only instrumental but intrinsic goal 31

32. M&E framework for monitoring health system performance – the place of UHC measurement

33. Framework for measurement and monitoring of the service coverage component of Universal Health Coverage Levels of health system / service delivery Priority Health Conditions Non- personal Community based Primary (facility) Secondary (hospital) Tertiary (hospital) Specific coverage tracer indicators & Index MNCH HIV/TB/ malaria NCDs & risk factors Injuries Promotion, prevention, treatment, rehabilitation, palliation

34. Examples of indicators • Promotion: no smoking, normal weight, safe water & sanitary facilities etc. • Prevention: immunization coverage, skilled birth attendance, hypertension prevalence, cervical cancer screening, met need for FP etc. • Treatment: childhood illness (ARI, diarrhoea, malaria), chronic adult illness (arthritis, depression etc.), ART, TB treatment etc. (measurement of NEED) • Rehabilitation & palliation: …

35. Tracer indicators or summary measures • Tracer indicators: • selected interventions, target 100%, coverage all major intervention areas (MDG, NCD, injuries); • disaggregation must be done well (equity) • Ideally with quality component (e.g. hypertension, TB coverage) • disadvantage "gaming" • Summary measure: • based on intervention areas capturing the full range of services of UHC; • intervention areas rather than indicators – example Countdown MNCH coverage index

36. Summary measure or tracer indicators: example Coverage index gap: difference between poorest and wealthiest quintile Source: Boerma, J. T., J. Bryce, et al. (2008). "Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries." Lancet 371(9620): 1259‐1267. 36

37. Equity: major issue of UHC and for its monitoring • Where are the largest inequalities? • Between or within states; between or within districts within states • Urban (non poor and poor) and rural residence • Socioeconomic position: wealth quintile, education; caste • Demographic characteristics: sex, age • What indicators show the largest inequalities? • Deliveries and treatment >> immunization • Risk factors mixed picture: inactivity, obesity; smoking; hypertension etc. • Treatment chronic adult illnesses • Data sources • HMIS (geographic); Surveys (socioeconomic inequalities) etc.

38. Global and country perspectives Global Few indicators, lessons learnt from the MDG monitoring Uniform targets Monitoring and reporting responsibilities need to be clear Investment in measurement / monitoring Country • Global framework and guidance • Country specificity: different epidemiology, different priority interventions for UHC – flexible coverage index or different set of tracer indicators • Monitoring and reporting responsibilities through country review process (e.g. health sector reviews) 38

39. Hypothetical examples of combined summary measure results

40. Summary points Service coverage as part of UHC can be measured and monitored but there are measurement gaps especially for treatment; health examination surveys essential Range of intervention coverage measures would be a good basis in countries, guided by global standards of measurement; coverage data should be supported by input, output and health impact data Global monitoring could rely on tracer set or index with targets Combining coverage with financial protection into one summary measure would be ideal but challenging also 40

41. Overall conclusions • Post 2015 development agenda: health must be prominent, but will have to specific to define its place in broad agenda • Continue MDGs, broaden through UHC and (healthy) life expectancy end goal • UHC strong political momentum and attractive concept • Measurement must be well defined • Flexible according to country situation, strongly embedded in national M&E systems, • But with common standards for core set of indicators • Requires investment in measurement