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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
A few definitions
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• 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
Inputs & processes
Health Financing
Health workforce
InfrastructureMedicines & Technologies
Information
Governance
Outputs
Service accessand readiness
including medicines
Service qualityand safety
ServiceUtilization
Eligibility for a form of financial
risk protection
Outcomes
Coverage ofinterventions
Prevalence of risk
factors
Impact
Health status
Financial risk protection
Responsiveness
Level and distribution (equity)
Social determinants of health
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Indicators of financial protectionIndicators 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
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Measuring progress towards the service coverage dimension of UHC – key issues to consider
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● 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
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Contents: tracer indicators / summary measure
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● 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
Summary measure or tracer indicators
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• 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): 1259‐1267.
Coverage index gap: difference between poorest and wealthiest quintiles.
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Equity dimension
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● 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. 2012.
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Global and country perspectives
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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)
Financial riskprotection
Service coverage
MNCH
Malaria
TB
Repr. health
HIV/AIDS
Cancer
Cardiovasc. Dis.
Mental health
Injuries
Other NCD
Catastrophicexpenses
Impoverishment due to OOP
Index / tracers FRP Index /tracers SERCOV
Universal CoverageIndex / tracer indicators
Health system Input indicatorsWorkforceEssential medicinesInfrastructureHealth expenditure
Health System Output IndicatorsAccessibilityReadinessUtilizationQuality of services
Health StatusIndicatorsMortality by causeMorbidity / disability
Social Determinants
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Hypothetical examples of combined summary measure results
Hypothetical examples of combined summary measure results
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Framework for measurement and monitoring of the service coverage component of Universal Health Coverage
13 |
Summary pointsSummary points
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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