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

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

3. Definitions/Concepts

5. Principles/Politics

6. 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

7. 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.

8. 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

9. 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.

10. Methods

11. Intervention Coverage

12. 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

13. 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

14. 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

15. Intervention Areas and potential tracer indicators of intervention coverage

16. Intervention Areas and potential tracer indicators of intervention coverage

17. Life Course and Level of Care Coverage

18. 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

19. Financial Protection Coverage

20. 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

21. 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

22. UHC Measures – Version 1.0

23. Figure 2. Country Example: Service Coverage in Ghana

24. Figure 3: MDG and CCI Coverage by Regions

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

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

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

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

29. Figure 6: Financial Protection Coverage by Region

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

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

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

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

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

35. Next Steps

36. 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

37. 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

38. Thank You