Measuring Progress Toward UHC WHO-WB Joint Paper Singapore, September 17, 2013

Outline Definition / Concepts Principles / Politics Methods Measures Intervention Coverage Financial Protection Coverage Measures Next Steps

Definitions/Concepts

Principles/Politics

Foundational Principles Measure coverage of interventions that make a proven difference to health and wealth Measure coverage to capture the age/sex structure of the population Measure coverage to capture the structure of the health system Measure coverage to reflect social inequities

Country Measures of UHC Drawing on framework, two set of measures, and foundational principles Adapted to local context Set in the larger results framework – inputs, outputs, outcomes, impacts Measures constitute important components of framework to assess progress on reforms towards UHC.

Health Goals in the Post 2015 Development Agenda DEVELOPMENT GOAL Sustainable wellbeing for all Wealth, gender equity, education, nutrition, environmental, security etc. Accelerate the MDG agenda Reduce the NCD burden Ensure Universal Health Coverage HEALTH GOAL Maximizing healthy lives at all stages of life Contributions of other sectors to health

The Emerging Context of the Post 2015 Development Goals Eliminating Extreme Poverty Financial protection + coverage of health services matter! Growing demand for UHC as a goal Two priority groups of health conditions MDGs – infectious killers, MNCH focus Chronic Conditions and Injuries (CCIs) – mainly affecting adolescents, adults + elderly Consensus on measures: MDGs, CCIs Hardwiring of equity into all targets 40% lowest part of income distribution, gender etc.

Methods

Intervention Coverage

Preferred Attributes of Intervention Coverage Indicators  Is a health priority based on burden of disease addressed by an intervention Is a cost-effective intervention Includes a measure of quality (sometimes referred to as “effective coverage”) Credible methods exist to identify the population needing the intervention i.e. the denominator

Preferred Attributes of Intervention Coverage Indicators Credible methods exist to identify the population receiving the intervention i.e. the numerator Can be routinely measured: health management information systems or periodic household survey Equity disaggregation is possible by household wealth/income, gender, residence and other key stratifiers Measureable in comparable way across countries

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) Coverage tracer indicators & Index MNCH HIV/TB/ malaria NCDs & risk factors Injuries Promotion, prevention, treatment, rehabilitation, palliation Coverage tracer indicators

Intervention Areas and potential tracer indicators of intervention coverage

Intervention Areas and potential tracer indicators of intervention coverage

Life Course and Level of Care Coverage

Composite Measures of Coverage  Two groups of interventions MDGs and CCIs Two broad age groups mothers/children and adults/elderly Two levels of the health system Population/ambulatory; facility-based Weighting in Aggregation Equal Unequal

Financial Protection Coverage

Two measures of financial protection coverage incidence of catastrophic out-of-pocket spending, i.e. spending exceeding a threshold of a household's 'ability-to-pay’ the incidence of 'impoverishment' arising from out-of-pocket spending** Both measures: re-scaled to 100%: - 100% = no catastrophic expenditure - 100% = no impoverishing payments

Targets for UHC Service Coverage: Financial Protection: 80:40 100% 80% coverage in aggregate 80% coverage in bottom 40% of income distribution Financial Protection: 100% Zero persons/households with catastrophic payments Zero persons/households impoverished due to medical expenditure** Proxy measure: <20% THE from OOPs

UHC Measures – Version 1.0

Figure 2. Country Example: Service Coverage in Ghana

Figure 3: MDG and CCI Coverage by Regions

Figure 4 (a): MDGs by Regions – equally and unequally weighted

Figure 4 (b): CCIs by Region – equally and unequally weighted

Figure 5 (a): MDG coverage – population aggregate and poorest 40%

Figure 5 (b): CCIs by Region – population aggregate and poorest 40 %

Figure 6: Financial Protection Coverage by Region

Figure 7: Catastrophic Payments by Regions: 25% and 40% thresholds

Figure 8 (a): Catastrophic Payments by Region: population aggregate and poorest 40%

Figure 8 (b): Impoverishing Payments by Region: population aggregate and poorest 40%

Figure 9a: All UHC Measures by Region: population aggregate and poorest 40%

Figure 9b: All UHC Measures by Country Income Group: population aggregate and poorest 40%

Next Steps

Assessing the value of these measures Are they accurate, reliable? Do they measure what needs to be measured? Are they helpful to assessing the big picture with respect to UHC? Services coverage Financial protection

Indicator, Instrument Development Indicators: Service Coverage Measures of “effective” coverage for specific interventions self-report vs observed (clinical tests, bio-markers etc) ? capturing quality Aggregation criteria Groupings: conditions, life course, level of care Weighting: equal/unequal Financial Coverage Indicators of care not sought due to financial deterrents Indicators of services that drive financial risk Instruments: Household surveys intervention coverage beyond MNCH Expenditures that link to specific types of services Facility surveys and HMIS Identifying population numerators/denominators

Thank You