Universal Health Coverage: measurement and its potential role in the post 2015 development agenda

Ties Boerma

Director of Health Statistics and Information Systems

World Health Organization

Geneva

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OutlineOutline

Post 2015 development agenda

Goal -Healthy life expectancy

Goal - Universal health coverage: general issues and financial risk protection

Goal - Universal health coverage: measurement issues

Health in the post-2015 agenda: the global consultation process

Overall consultation process:UN System Task Team established early 2012

• Task Team proposed integrated framework for realizing the "future we want for all in the post-2015 UN development agenda

Human rights

Equality

Sustainability

Environmental sustainability

Peace and Security

Inclusive social development

Inclusive economic development

Overall consultation process: UN Secretary-General's High-level Panel of Eminent Persons on the post-

2015 UN development agenda

• Established by SG mid-2012• Output: Report that the SG will

deliver to UN General Assembly by the 2nd quarter of 2013

• Input: Work based on report of UN System Task Team

• Work to be informed by Rio+20 and other consultations

Co-Chair:Susilo Bambang YudhoyonoPresident of Indonesia

Co-Chair:Ellen Johnson SirleafPresident of Liberia

Co-Chair:David CameronPrime Minister of the UK

Overall consultation process:Country consultations (about 100)

• Objectives– Influence the intergovernmental process by

amplifying the voices of local communities• Output

– Clear recommendations for governments• Coordination at country level

– UN Resident Coordinators will provide overall strategic guidance

– Ministries of Planning lead and line Ministries involved

11 global thematic consultations, including one on healthLead UN Agencies Events Government leads

Growth and employment ILO, UNCTAD, UNDP Tokyo, 15-16 May 2012 Japan

Inequalities UNICEF, UNWOMEN Global consultation in Feb/March 2013 (Denmark)

Denmark

Education UNESCO, UNICEF Global consultation in Feb/March 2013 (?Senegal)

Canada

Environmental sustainability

UNDP, UNEP, Leadership meeting February 2013 (tbc)

Food security and nutrition

FAO, WFP TBD Spain, Colombia

Governance UNDP, OHCHR Global consultation in Jan/Feb 2013 (South Africa)

Germany, South Africa

Conflict and fragility UNDP, PBSO, ISDR and UNICEF

Global consultation in Helsinki February 2013

Finland

Population dynamics UNDESA, IOM, UNFPA and UN-HABITAT

TBD Switzerland

Health WHO, UNICEF High level meeting Mar 2013 (Botswana)

Sweden and Botswana

Water UNWATER, UNICEF, UNDESA

TBD

Energy TBD

Working Group on Sustainable Development Goals

Objective:Tasked to develop a proposal for the

Sustainable Development Goals

Members:Working Group comprised of 30

representatives nominated by Member States (co-chairs Brazil & Italy)

Output: A report to the UNGA containing a

proposal for sustainable development goals (between Sep 2013/14)

Mandate:Rio+20

UN Secretary-General:"The Panel’s work will be closely coordinated with that of the intergovernmental working group tasked to design Sustainable Development Goals, as agreed at the Rio +20 conference. The reports of both groups will be submitted to Member States for their further deliberations."

The global consultation on health(Health Thematic Consultation)

>100 papers contributed >Dozen consultations

>Web based forum

Emerging themes:Lessons learnt from the health MDGs

• Health MDGs success– More money for health– More progress since 2000– Influenced political discourse at highest levels– Driven by concrete measurable goals and targets

• But also shortcomings– Lack of focus on equity– Human rights aspect missing– Too much a top-down process– Contributed to more fragmented health programmes

in countries

Emerging themes:Health priorities post-2015

• Continue the health MDGs: unfinished agenda• Address emerging noncommunicable diseases and

their risk factors• Address health consequences of demographic and

epidemiologic changes, environmental factors, globalization, urbanization, migration etc.

• Strengthen health systems

Emerging themes:The place of health in the post-2015 agenda

• Changes in global landscape– Post 2015 agenda is for all countries– Much greater diversity and complexity now than in 2000 (global

changes, CSO, partnerships etc.)

• Place of health:– Critical contributor to development in sectors other than health,– Beneficiary from development, and – Key indicator of what rights-based, sustainable and equitable

development seeks to achieve– Links with many other sectors needs to be made explicit

(including social determinants of health)

Emerging themes:Post-2015 goals

• Possible goals– Long healthy lives / healthy life expectancy: is an end

goal, influenced by health but also by many other aspects of development

– Universal Health Coverage: contribution of health to the end goal, supported in many papers

– Continued Health MDGs, with equity element

• Equity and human rights as central elements

Measurement of healthy life expectancy

Possible measures of Healthy Life Expectancy

• Mortality / life expectancy

• Healthy life expectancy with Global Burden of Disease approach

• Healthy life expectancy with survey measurement of health state

Mortality

• Life expectancy only: attractive summary measure, well understood, used as primary measure by many countries; can be disaggregated

– Age and cause-specific mortality: NCD mortality goal (25% by 2025), MDG continuation (child and maternal mortality, HIV/AIDS, TB)

• Mortality rates are needed for healthy life expectancy measures

• Lack of good death registration data with reliable cause in most low and middle income countries

• Reliance on suboptimal measures: mortality data collection in retrospective surveys, cause of death through verbal autopsy

Healthy life expectancy with GBD approach

• Requires age-specific mortality rates + prevalence and distribution of non-fatal conditions + disability weights.

• Makes systematic use of multiple data sources and can be updated regularly.

• Using extensive modelling comparable methods over time (1990-2010) and can be computed for all countries.

Issues:• Data limitations: prevalence data are often lacking• Needs the use of disability weights for each non-fatal condition • Recent estimates will be heavily based on prediction• Cannot disaggregate for equity analysis except geographical differences

Healthy life expectancy based on survey data

• Single question: self-rated health/activity limitations; EU surveys "For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do?" (3 point scale) .. Disability-free life expectancy (gain 2 healthy life years by 2020 – EU)

• Focus on functioning (ICF): health score, using domains (mobility, vision, cognition etc.)

• ADL, (core tasks, severe disability) and IADL (more complex tasks, mild/moderate disability), WHODAS 2.0

• Biological and clinical tests: physical and cognitive tests; hypertension, vision, anthropometry, handgrip strength; body fluid testing - CRP, IL-6, HbA1c, telomere length, lipid profile, markers of immuno-senescence

Issues• Cross-cultural comparability • Ways to adjust for reporting biases (anchoring vignettes) often not successful• Health examination surveys not widely conducted

Universal Health Coverage

General issues and financial risk protection

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WHO's Formal Definition of Universal (Health) CoverageWHO's Formal Definition of Universal (Health) Coverage

World Health Assembly Resolution 58.33, 2005, urged countries to develop health financing systems to:

Ensure all people have access to needed services

Without the risk of financial ruin linked to paying at the time they receive care

Defined this as achieving Universal Coverage: coverage with health services; with financial risk protection; for all

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UHC combines both service coverage and financial protection, explicitly

UHC combines both service coverage and financial protection, explicitly

New for the public health community– Financial protection as integral to the concept of UHC– Beyond “Health for All” to Health for All with financial protection

New for (health) economists– Focus had been largely on financial protection and the

“economics of health insurance”– Recognize that UHC is more than this, requiring as well a focus

on services and their quality

Comprehensive: – Includes promotion, prevention, treatment, rehabilitation and

palliation; focus on equity & quality of care

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UHC: global visibilityUHC: global visibility

WHO– “Universal coverage is the single most

powerful concept that public health has to offer”

– “Universal coverage is the hallmark of a government’s commitment, its duty, to take care of its citizens, all of its citizens” (WHO DG Acceptance Speech 23 May 2012)

UN General Assembly– Resolution on UHC adopted in December

2012 (Foreign Policy and Global Health) www.who.int/whr/2010

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WHR 2010 ConclusionsWHR 2010 Conclusions

Every country could do something to move closer to universal coverage or maintain the gains they have made, through:

· Raising more funds for health AND/OR· Reducing financial barriers to access and increasing financial risk

protection AND/OR· Improving efficiency and equity

Global community: increase funding to low-income countries become more efficient in the way it holds and channels funds to

countries support the development of domestic financing capacities

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Dispelling Myths about UHCDispelling Myths about UHC

UHC is only about treatment and care. FALSE– Promotion, prevention, treatment, rehabilitation, palliation

UHC is only about health financing. FALSE– Coverage of interventions with financial risk protection

UHC is not a concern for priority health programs or global health initiatives: FALSE

– MDG, NCD, emergency care under one umbrella

UHC means immediate free coverage for all possible health interventions, regardless of the cost. FALSE

– Progressive realization of UHC according to country situation

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The Cube: Three dimensions (policy choices) of UHC

The Cube: Three dimensions (policy choices) of UHC

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Financial risk protection Indicators: level and inequalities

Financial risk protection Indicators: level and inequalities

• Incidence of catastrophic health expenditure due to out-of-pocket payments

• Incidence of impoverishment due to out-of-pocket payments

• Mean positive overshoot of catastrophic payments• Poverty gap due to out-of-pocket payments

• Indirect indicators of financial risk protection:• Out-of-pocket payments as a share of total health expenditure• Government health expenditure as a share of GDP• Government health expenditure as a share of general government

expenditure

Large variations in Government health spending as a proportion of GDP

Large variations in Government health spending as a proportion of GDP

Source: WHO estimates for 2008, countries with population > 600,000

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Bottom line: where government spends more on health, people spend less out-of-pocket

Bottom line: where government spends more on health, people spend less out-of-pocket

Source: WHO estimates for 2004, excluding countries with population > 600,000

Armenia

Albania

Georgia

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Serbia & Montenegro

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UHC in IndiaUHC in India

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Several initiatives for UHC: – Janani Suraksha Yojana as conditional cash transfer mechanism for pregnant women, – National Rural Health Mission for improve rural services, – Rashtriya Swasthya Bima Yojna for more equitable access to hospitals

Call to action in Lancet series 2011 – Integrated National Health System … UHC

– Increased public spending on health– Ensure the reach and quality of health services to all– Reduce the financial burden of health care on individuals– Stronger regulation of the private sector– Empower people to take care of their health and hold the health system accountable

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Universal Health CoverageUniversal Health Coverage

Measurement issues

intervention coverage

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A few definitionsA 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

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

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

Levels of health system / service delivery

Non-personal

Communitybased

Primary (facility)

Secondary(hospital)

Tertiary(hospital)

Priority HealthConditions

MNCH

HIV/TB/ malaria

NCDs & risk factors

Injuries

Promotion, prevention, treatment, rehabilitation, palliation

Specific coverage

tracerindicators

&

Index

Examples of indicators• Promotion: no smoking, normal weight, safe water & sanitary

facilities etc.

• Prevention: immunization coverage, skilled birth attendance, hypertension prevalence, cervical cancer screening, met need for FP etc.

• Treatment: childhood illness (ARI, diarrhoea, malaria), chronic adult illness (arthritis, depression etc.), ART, TB treatment etc. (measurement of NEED)

• Rehabilitation & palliation: …

Tracer indicators or summary measures

• Tracer indicators: – selected interventions, target 100%, coverage all major intervention

areas (MDG, NCD, injuries); – disaggregation must be done well (equity)– Ideally with quality component (e.g. hypertension, TB coverage) – disadvantage "gaming"

• Summary measure: – based on intervention areas capturing the full range of services of

UHC; – intervention areas rather than indicators – example Countdown

MNCH coverage index

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Summary measure or tracer indicators: exampleSummary measure or tracer indicators: example

36Source: 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 quintile

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Equity: major issue of UHC and for its monitoring

Equity: major issue of UHC and for its monitoring

Where are the largest inequalities?– Between or within states; between or within districts within states– Urban (non poor and poor) and rural residence– Socioeconomic position: wealth quintile, education; caste– Demographic characteristics: sex, age

What indicators show the largest inequalities?– Deliveries and treatment >> immunization– Risk factors mixed picture: inactivity, obesity; smoking; hypertension etc.– Treatment chronic adult illnesses

Data sources – HMIS (geographic); Surveys (socioeconomic inequalities) etc.

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Global and country perspectivesGlobal 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)

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Hypothetical examples of combined summary measure results

Hypothetical examples of combined summary measure results

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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 treatment; health examination surveys essential

Range of intervention coverage measures would be a good basis in countries, guided by global standards of measurement; coverage data should be supported by input, output and health impact data

Global monitoring could rely on tracer set or index with targets

Combining coverage with financial protection into one summary measure would be ideal but challenging also

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Overall conclusionsOverall conclusions

Post 2015 development agenda: health must be prominent, but will have to specific to define its place in broad agenda

– Continue MDGs, broaden through UHC and (healthy) life expectancy end goal

UHC strong political momentum and attractive concept– Measurement must be well defined– Flexible according to country situation, strongly embedded in

national M&E systems, – But with common standards for core set of indicators– Requires investment in measurement