Measurement of Universal Health Coverage Based on meeting at Rockefeller Center, Bellagio, September 2012

A few definitions 2 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 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

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

4 |4 | Indicators of financial protection Incidence of catastrophic health expenditure due to out-of- pocket payments Mean positive overshoot of catastrophic payments Incidence of impoverishment due to out-of-pocket payments Poverty gap due to out-of-pocket payments

5 |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 |6 | Contents: tracer indicators / summary measure 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 Criteria for selection Public health priority Proven interventions with large health impact Measurable: numerator & need Target – 100% Understandable / communicable Universality Equity Data availability

7 |7 | Framework for measurement and monitoring of the service coverage component of Universal Health Coverage

Summary measure or tracer indicators 8 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 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 ‐ Coverage index gap: difference between poorest and wealthiest quintiles.

9 |9 | Equity dimension 9 ● 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 Source: Country profile. Countdown 2015 for Maternal Newborn and Child Health

10 | Global and country perspectives 10 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)

11 | Financial risk protection Service coverage MNCH Malaria TB Repr. health HIV/AIDS Cancer Cardiovasc. Dis. Mental health Injuries Other NCD Catastrophic expenses Impoverishment due to OOP Index / tracers FRPIndex /tracers SERCOV Universal Coverage Index / tracer indicators Health system Input indicators Workforce Essential medicines Infrastructure Health expenditure Health System Output Indicators Accessibility Readiness Utilization Quality of services Health Status Indicators Child mortality Maternal mortality NCD mortality Morbidity / disability Equity & Social Determinants Economic development

12 | Hypothetical examples of combined summary measure results

13 | Summary points 13 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