Framework for Measurement of Universal Health Coverage

1. Framework for Measurement of Universal Health Coverage Ties Boerma, WHO Beijing, 3 November 2012 Based on meeting at Rockefeller Center, Bellagio, 17-21 September 2012

2. A few definitions Tanahashi T. Health service coverage and its evaluation. Bull WHO1978;56(2):295. Shengelia B, Murray CJL, Adams OB. Beyond Access and Utilization: Defining and Measuring Health System Coverage. Health Systems Performance Assessment: Debate, New Methods, and New Empiricism. Geneva: World Health Organization; 2003 • 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 • UHC: People receive the services they need without incurring financial hardship 2

3. Impact Health status Financial risk protection Responsiveness Inputs & processes Health Financing Health workforce Infrastructure Medicines & Technologies Information Governance Outputs Service access and readiness including medicines Service quality and safety Service Utilization Eligibility for a form of financial risk protection Outcomes Coverage of interventions Prevalence of risk factors Level and distribution (equity) Social determinants of health

4. Indicators of financial protection

5. Measuring progress towards the service coverage dimension of UHC – key issues to consider 5 Tracer indicators or summary measures Contents of the indicators/index Equity dimension Output / proxy indicators and quality of services Measurement gaps Global and country perspectives Combining service coverage and financial protection

6. Contents: tracer indicators / summary measure Criteria for selection Public health priority Proven interventions with large health impact Measurable: numerator & need Target – 100% Understandable / communicable Universality Equity Data availability 6 • Should cover all major health areas: • MDG related interventions / communicable diseases: MNCH, HIV/TB/malaria • NCD and other interventions; risk factors • Injuries: emergency care, preventive measures • Identify key intervention areas rather than indicators

7. Summary measure or tracer indicators Coverage index gap: difference between poorest and wealthiest quintiles. 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. • Tracer indicators: selected interventions, target 100%, equity can be done well; disadvantage "gaming" • Summary measure based on intervention areas capturing the full range of services of UHC; intervention areas rather than indicators – Countdown MNCH coverage index 7

8. Equity dimension Source: Country profile. Countdown 2015 for Maternal Newborn and Child Health. 2012. 8 UHC is about equity: should include levels and distribution according to key stratifiers Intervention coverage among the poorest (or other disadvantaged population) could be a good tracer indicator of progress towards UHC Limits the usefulness of statistical modeling to arrive at estimates

9. Global and country perspectives 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) 9 Global Few indicators, lessons learnt from the MDG monitoring Uniform targets Monitoring and reporting responsibilities need to be clear Investment in measurement / monitoring

10. Universal Coverage Index / tracer indicators Index / tracers FRP Index /tracers SERCOV Financial risk protection Service coverage Health System Output Indicators Accessibility Readiness Utilization Quality of services Health system Input indicators Workforce Essential medicines Infrastructure Health expenditure MNCH Catastrophic expenses Repr. health Malaria Impoverishment due to OOP TB HIV/AIDS Health Status Indicators Mortality by cause Morbidity / disability Cancer Social Determinants Cardiovasc. Dis. Mental health Injuries Other NCD

11. Hypothetical examples of combined summary measure results

12. 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 Health system inputs Outputs: availability, readiness, quality, utilization

13. Summary points Service coverage as part of UHC can be measured and monitored but there are measurement gaps especially for NCD and treatment in general; health examination surveys essential Coverage summary measure based on intervention areas for countries would be a good basis, guided by global standards of measurement; support with service output and health impact data Global monitoring could rely on tracer set with targets, but will be challenging to define Combining coverage with financial protection into one summary measure would be ideal but challenging also Only if the resulting measure(s) is (are) simple and appealing, UHC stands a chance of being included at a high level in the post 2015 development agenda monitoring 13