David B Evans, Director Health Systems Financing Universal Health Coverage: Concepts and Measurement

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July |2 | Outline UHC: Definition and propositions M&E Results Chain for UHC Suggestions for Countries Suggestions for post-MDG agenda

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July |3 | Propositions about UHC Two essential components – coverage with needed health services (of good quality); coverage with financial risk protection Interrelated and not separable Intrinsic goals – although also instrumental in obtaining better health outcomes Note: health services included prevention, promotion, treatment, rehabilitation

Millions more suffer financially when they use health services Number of people (million)

Millions miss out on needed health services Percentage of births attended by medically trained persons

Three dimensions (policy choices) of Universal Coverage

UC with co-payments

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July |8 | Outline UHC: Definition and propositions M&E Results Chain for UHC Suggestions for Countries Suggestions for post-MDG agenda

UHC Results Chain Social Determinants

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | Outline UHC: Definition and propositions M&E Results Chain for UHC Suggestions for Countries Suggestions for post-MDG agenda

Table 1: Intervention areas, tracer indicators and additional indicators for coverage index Social Determinants Intervention areaTracer indicatorsAdditional indicators Child vaccinationDPT3/penta, measlesBCG, polio, hepB Maternity careANC 4 or more visits, skilled birth attendance ANC 1+ visit, institutional delivery, postnatal care Family planningUnmet need for FPContraceptive use Treatment of sick childrenSuspected pneumonia taken to health facility, diarrhoea with ORT Suspected pneumonia treated with antibiotics, diarrhoea treated with ORS MalariaChildren sleeping under ITN; IPT during pregnancy Fever treated with antimalarials/ACT; households with IRS TBTB treatment success rate; TB case detection rate HIV preventionCondom use at higher risk sex; PMTCT among HIV positive women; ART Male circumcision rate CancerHPV vaccination; tobacco use*; cervical cancer screening 5 year survival rate (specific cancer); mammography Cardiovascular diseasesHypertension prevalence*Salt intake*; hypertension control follow-up visit; AMI survival; physical activity* Mental health Injuries Other NCD Asthma (re)admission rate; cataract surgery.

Table 2: Other Indicators Linked to Coverage with Health Services. Availability of Health Services: Inputs Health expenditure per capita Hospital bed to population ratio Health personnel to population ratio by type Availability of essential medicines (MDG 8E) % of population within 5km (or within 1 hours travel) of a health facility % of primary care facilities without constant supplies of medicines Inpatient and Outpatient Utilization (Output) Average number of outpatient visits per person per year (perhaps compared to an arbitrary threshold of need) Average number of inpatient days per person per year (perhaps compared to an arbitrary threshold of need)

Table 3: Quality. Quality Indicators (Output) Retention on antiretroviral therapy at 12 months92 3 Proportion of children initially breastfed (within one hour of birth) 80 Avoidable asthma admission rates28 In-hospital case-fatality rates within 30 days after admission for ischemic stroke 27 Postoperative pulmonary embolism or deep vein thrombosis 18 Schizophrenia re-admissions to the same hospital 16 Percentage of women aged screened for breast cancer 29

Table 4: Financial Risk Protection: Impact Indicators. Number of countries with at least 2 data points Incidence of catastrophic health expenditure due to out-of-pocket payments 112 Mean positive overshoot of catastrophic payments 112 Incidence of impoverishment due to out-of-pocket payments 112 Poverty gap due to out-of-pocket payments 112

Table 5: Input and Output Indicators. Financial Risk Protection. Countries with at least 2 data points Out-of-pocket payments as a share of total health expenditure 196 Legal entitlement to health services through insurance or direct government funding/provision NA Government health expenditure as a share of GDP196 Government health expenditure as a share of general government expenditure 196 Median price for generic drugs compared to international reference pricing 7 Percentage of government health expenditure for fixed costs compared to medication and equipment costs 7

Equity Average and Distribution need to be considered in almost all of the indicators

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | Outline UHC: Definition and propositions M&E Results Chain for UHC Suggestions for Countries Suggestions for post-MDG agenda

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | Propositions In post MDG agenda, difficult to maintain 3 health specific goals, plus nutrition, medicines UHC an umbrella for the health part of post-MDG development goals Probably won't be too difficult to get some health service coverage indicators – much more difficult for financial risk protection Debate will focus on how to define a goal for UHC with targets, what indicators for service coverage and financial risk protection. Health impact?

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | Suggestions Ties will talk about health service coverage For financial risk protection, exploring the idea of suggesting only 1: % of population impoverished because of OOPs.

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | For Discussion What indicators for tracking progress to UHC at country level? Should we move towards a UHC index – with separate indexes for services and financial risk protection? How to incorporate inequality? What should we be suggesting for the post-MDG development agenda?

Measuring UHC: Concepts, Indicators and Experiences Washington, 20 July | Thank you