保健医療科学

2017Vol.66 No.4 p.367－372

特集：持続可能な開発目標（SDGs）に基づく今後のグローバルヘルス＜ Review ＞
Global arguments about monitoring the progress of Universal Health
Coverage and health financing measures
Naoko Tomita 1), Akihito Watabe 2）
1）

Department of International Health and Collaboration, National Institute of Public Health2）

Health System Governance and Financing Department, World Health Organization

Abstract
Universal Health Coverage (UHC) is a key target of Sustainable Development Goal (SDG) 3. UHC
is a comprehensive approach to improving access to health without financial burden, which is afundamental human right and provides the basis for economic and social development, as well associal stability. Three key components of UHC, namely population coverage, service coverage, andfinancial protection, are inextricably associated with health financing.
In the SDGs, one of two indicators for monitoring UHC progress is financial protection, whichhelps individuals decrease the risk of catastrophic expenditure in health. Although further discussion
is possible on the threshold of catastrophic payment, this is an important, imperative step towards
UHC achievement.
This paper presents an overview of trends in strengthening health financing and monitors its
progress in the context of UHC.
keywords: universal health coverage (UHC), health financing, financial protection, monitoring indicator(accepted for publication, 11th July 2017)

I.

Sustainable Development Goals anduniversal health coverage

Subsequent to the Millennium Development Goals(MDGs), 193 member states of the United Nations adopted
the Sustainable Development Goals (SDGs) in September
2015. The SDGs are composed of 17 goals and 169 targets,
aiming, by 2030, to address issues such as poverty andhunger, inequalities within and among countries, andprotection of the Earth and its natural resources [1]. While
the SDGs are not legally binding, all member states are
expected to frame their national plans in line with these.
Some notable characteristics of SDGs, compared to
MDGs, are universality—not only developing countries
but all member states abide by them, more comprehensive
targets, shifting from reliance on foreign aid to self-sustaining funding, and introducing monitoring systems.
From the perspective of public health, health targets
are grouped under SDG 3 "Ensure healthy lives andpromote well-being for all at all ages," with 13 targets and
26 indicators (Table 1). Other health-related targets, suchas nutrition, water and sanitation, air pollution, poverty,
education, and inequality are part of other goals.
While some health targets, such as child and maternalmortality (targets 3.1 and 3.2) and HIV/AIDS (target 3.3),
have been already included in the MDGs, others, including
universal health coverage (UHC) (target 3.8), have been
newly specified in the SDGs. The definition of UHC is "allpeople and communities can use the promotive, preventive,
curative, rehabilitative and palliative health services
they need, of sufficient quality to be effective, while also
ensuring that the use of these services does not expose

Corresponding author: Naoko TOMITA
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: +81 (0)48-458-6132
E-mail: tomita.n.aa@niph.go.jp

J. Natl. Inst. Public Health, 66 (4) : 2017367

Naoko Tomita, Akihito Watabe
Table1. Targets and Indicators of Sustainable Development Goal 3
3.1
3.2

3.3

TargetBy 2030, reduce the global maternal mortality ratio to lessthan 70 per 100,000 live births
By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to
reduce neonatal mortality to at least as low as 12 per 1,000
live births and under-5 mortality to at least as low as 25
per 1,000 live births
By 2030, end the epidemics of AIDS, tuberculosis, malaria
and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

3.4

By 2030, reduce by one third premature mortality from
non-communicable diseases through prevention and treatment and promote mental health and well-being

3.5

Strengthen the prevention and treatment of substanceabuse, including narcotic drug abuse and harmful use ofalcohol

3.1.1
3.1.2
3.2.1
3.2.2

3.3.1
3.3.2
3.3.3
3.3.4
3.3.5
3.4.1
3.4.2
3.5.1
3.5.2

3.6
3.7

3.8

By 2020, halve the number of global deaths and injuries
from road traffic accidents
By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning,
information and education, and the integration of reproductive health into national strategies and programmes

3.6.1

Achieve universal health coverage, including financial risk
protection, access to quality essential health-care services
and access to safe, effective, quality and affordable essential medicines and vaccines for all

3.8.1

3.7.1
3.7.2

3.8.2
3.9

3.a
3.b

3.c

3.d

By 2030, substantially reduce the number of deaths andillnesses from hazardous chemicals and air, water and soil
pollution and contamination

Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all
countries, as appropriate
Support the research and development of vaccines andmedicines for the communicable and non‑communicablediseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines,
in accordance with the Doha Declaration on the TRIPS
Agreement and Public Health, which affirms the right ofdeveloping countries to use to the full the provisions in
the Agreement on Trade-Related Aspects of Intellectual
Property Rights regarding flexibilities to protect publichealth, and, in particular, provide access to medicines forall
Substantially increase health financing and the recruitment, development, training and retention of the healthworkforce in developing countries, especially in least developed countries and small island developing States
Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction andmanagement of national and global health risks

3.9.1
3.9.2
3.9.3
3.a.1
3.b.1
3.b.2
3.b.3

Indicator
Maternal mortality ratio
Proportion of births attended by skilled health personnel
Under-five mortality rate
Neonatal mortality rate

Number of new HIV infections per 1,000 uninfected population, by sex, age and key populations
Tuberculosis incidence per 100,000 population
Malaria incidence per 1,000 population
Hepatitis B incidence per 100,000 population
Number of people requiring interventions against neglected tropical diseases
Mortality rate attributed to cardiovascular disease, cancer,
diabetes or chronic respiratory disease
Suicide mortality rate
Coverage of treatment interventions (pharmacological,
psychosocial and rehabilitation and aftercare services) for
substance use disorders
Harmful use of alcohol, defined according to the national
context as alcohol per capita consumption (aged 15 years
and older) within a calendar year in litres of pure alcohol
Death rate due to road traffic injuries
Proportion of women of reproductive age (aged 15-49
years) who have their need for family planning satisfied
with modern methods
Adolescent birth rate (aged 10-14 years; aged 15-19
years) per 1,000 women in that age group
Coverage of essential health services (defined as theaverage coverage of essential services based on tracer interventions that include reproductive, maternal, newborn
and child health, infectious diseases, non-communicablediseases and service capacity and access, among the general and the most disadvantaged population)
Proportion of population with large household expenditures on health as a share of total household expenditure
or incomeMortality rate attributed to household and ambient air
pollution
Mortality rate attributed to unsafe water, unsafe sanitationand lack of hygiene (exposure to unsafe Water, Sanitationand Hygiene for All (WASH) services)
Mortality rate attributed to unintentional poisoning
Age-standardized prevalence of current tobacco use
among persons aged 15 years and older
Proportion of the target population covered by all vaccines
included in their national programme
Total net official development assistance to medical research and basic health sectors
Proportion of health facilities that have a core set of relevant essential medicines available and affordable on asustainable basis

3.c.1

Health worker density and distribution

3.d.1

International Health Regulations (IHR) capacity andhealth emergency preparedness

Source: Economic and Social Council. 2017 [2]368

J. Natl. Inst. Public Health, 66 (4) : 2017

Global arguments about monitoring the progress of Universal Health Coverage and health financing measuresthe user to financial hardship," thus making it fundamental
among the 13 targets in SDG 3 [3].

II. Importance of strengthening healthfinancing for UHC
1. Key components of UHC
Health is a fundamental human right that provides thebasis for economic and social development, as well associal stability. There is probably no objection against theidea of UHC as a comprehensive framework to improve
people’s health. However, the UHC concept is often
considered too diffused and, therefore, difficult to transcribe
into measurable indicators. In fact, to set indicators formonitoring UHC, several discussions have taken place
among stakeholders over time.
Regarding UHC achievements, the World HealthOrganization (WHO) has stressed developing capacities inthree aspects: population coverage, service coverage, andfinancial protection. Population coverage bears on equity
in access to health services, since not all individuals canafford to pay the full cost at the point of service. Service
coverage affects quality and volume of health services
provided within an establishing/established health system.
Financial protection impinges significantly on people’s lifeand household. Thus, to pave the way towards UHC, it isimperative to balance between these three aspects.
Considering the sustainability of UHC, population
coverage has a unique status between the three aspects,
as it can be fully achievable. In contrast, given theadvancements in technology and corresponding risingexpenditures, ageing population, changes in disease
structures, people’s preferences, and others, service
coverage and financial protection should continuously
evolve in a seemingly endless process.
2. Why is strengthening health financing importantfor UHC?
The reason behind the several discussions on how

to strengthen health financing for UHC is that the
aforementioned three aspects of UHC tightly connect withhealth financing. When a country increases its population
coverage rate, the total health budget, whether from public
or private funds, or tax-based or health insurance-based
schemes, increases. If the covered services are extended,
more pooling is needed, as is financial protection. The more
people are protected from catastrophic payments that resultin bankruptcy, the larger the pooled funds.
Meanwhile, regardless of revenue type, the financial
resources that can be dedicated to health are limited. Thereis no magic number for an appropriate public spending
level required for moving towards UHC, but some studies
suggest a minimum of 5–6% of the GDP [4,5]. However,the budget for health systems from public sources iscompetitive with other sectors, and the total revenue ofa country fluctuates depending on its economic situation.
For countries that adopt health insurance schemes, thepremiums are another funding source. Although premiums
are less influenced by the economic situation than tax
revenue and more flexible to increasing according to thetotal health expenditure in previous years, it is impossible
to simply raise premium rates unlimitedly to respond to thedemand of all beneficiaries.
Therefore, every country needs to expand its capacity
for population coverage, service coverage, and financial
protection considering limited financial resources. As
such, the effective and efficient use of these limited
financial resources is indispensable for moving towards andsustaining UHC.

III. Monitoring progress in health financing
1. Monitoring UHC indicators
Two indicators monitor the progress towards UHC in
SDGs: one indicator is about access to essential services(indicator 3.8.1) and the other is about financial protection(indicator 3.8.2). Given the importance of strengthening
health financing on one hand and protecting people against

Table 2. Changes in Two Indicators for Monitoring the Progress of UHC
47th session of the United Nations Statistical
Commission (2016)

48th session of the United Nations Statistical
Commission (2017)

3.8.1

Coverage of tracer interventions (e.g. child full immunization,
antiretroviral therapy, tuberculosis treatment, hypertension
treatment, skilled attendant at birth, etc.)

Coverage of essential health services (defined as the averagecoverage of essential services based on tracer interventions
that include reproductive, maternal, newborn and child health,infectious diseases, non-communicable diseases and service
capacity and access, among the general and the most disadvantaged population)

3.8.2

Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure

Proportion of population with large household expenditures on
health as a share of total household expenditure or income

Source: Economic and Social Council. 2016, 2017 [2,6]J. Natl. Inst. Public Health, 66 (4) : 2017369

Naoko Tomita, Akihito Watabe
financial risk on the other, it seems commendable that oneof two indicators for UHC is financial protection.
Due to the "diffused" nature of the UHC concept anddifferences in opinion among stakeholders, both indicators
have been under the discussion for a long period of time.
In accordance with the discussion after adapting the initial
indicators during the 47th session of the United Nations
Statistical Commission in 2016, both indicators 3.8.1 and3.8.2 were further modified at the 48th session of theUnited Nations Statistical Commission in 2017, as shownin Table 2. Indicator 3.8.1 changed its wording from "tracer
interventions" to "essential health services," and defined
more clearly the services that should be monitored.
Changes in indicator 3.8.2 are described in detail in the next
subsection.
2. Monitoring progress in financial protection
Prior and parallel to the SDG indicators for UHC, there
have been several potential indicators for monitoring
the progress of UHC. Table 3 compares health financing
indicators in the Global Reference List of 100 Core HealthIndicators by WHO [7] and in Tracking Universal Health
Coverage, the first global monitoring report by WHO andthe World Bank [8].
The initial proposal on indicator 3.8.2 for the 47th
session of the UN Statistical Commission in March 2016of the Inter-Agency and Expert Group on SDG Indicators(IAEG-SDGs), which was set up under the United Nations

Statistical Commission, was "(n)umber of people coveredby health insurance or a public health system per 1,000
population" [9]. As the IAEG-SDGs abandoned and changed
the previous discussions in the technical meetings by WHO
and World Bank to support "(t)he fraction of population
experiencing catastrophic health expenditures and thefraction of population experiencing impoverishing healthexpenditures" [10], the draft received criticism from various
experts, academia, and civil society as being an insufficientmeasure for financial protection [11,12]. The main point ofcriticism is that availability of insurance does not reduce
out-of-pocket payments nor guarantee financial protection.
Finally, following a specific request from some UN
Statistical Commission members, such as Japan and theUnited Kingdom, the 47th session of the United Nations
Statistical Commission requested IAEG-SDGs to refine
indicator 3.8.2. Further revisions have been discussed
after the 47th session of the United Nations Statistical
Commission and indicator 3.8.2 was refined to "(p)roportionof population with large household expenditures on healthas a share of total household expenditure or income," andwas adopted during the 48th United Nations Statistical
Commission in March 2017.
Now there is ongoing debate on the term "large"—howlarge is "large" as catastrophic payment? WHO and WorldBank are offering examples of thresholds of 10% and 25%of total household expenditure or income [13,14]. However,since the economic status of member states varies, more

Table 3. Comparison Table of Health Financing Indicators
WHO (2015) Global Reference List of 100 Core Health Indicators

WHO and World Bank (2015) Tracking universal health coverage:
first global monitoring report

Catastrophic health expenditures
・Headcount ratio of catastrophic health expenditure・Budget share approach・Capacity to pay based on subsistence needs (WHO approach)・Capacity to pay based on food expenditure

Impoverishing health expenditures
・Headcount ratio of impoverishing health expenditure・Absolute approach using the international poverty line
・WHO approach using subsistence food expenditure・Absolute approach using different international poverty lines

Others・Total current expenditure on health (% of gross domestic
product)
・Current expenditure on health by general government andcompulsory schemes (% of current expenditure on health)・Out-of-pocket payment for health (% of current expenditureon health)・Externally sourced funding (% of current expenditure on
health)・Total capital expenditure on health (% current + capital
expenditure on health)
Source: WHO. 2015, WHO and World Bank 2015 [7,8]370

J. Natl. Inst. Public Health, 66 (4) : 2017

Global arguments about monitoring the progress of Universal Health Coverage and health financing measures
discussions are possible on this point.

References

3. O ther indicators to monitor progress in healthfinancing[1] United Nations. Transforming our world: the 2030
agenda for sustainable development. 70th session of
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universal_coverage_definition/en/ (accessed 2017-0630)[4] McIntyre D, Meheus F, Røttingen J-A. What levelof domestic government health expenditure should
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[5] The Pan American Health Organization. Strategy
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In addition to the indicators for financial protection, WHOsuggests other indicators for monitoring progress in healthfinancing (Table 3). To nurture progress towards UHC,
indicators to gauge health financing from the input side,
such as total current expenditure on health (% of GDP),
current expenditure on health by general government andcompulsory schemes (% of current expenditure on health),and externally sourced funding (% of current expenditureon health), are also helpful. Along with indicator 3.8.2 of
the SDGs, such indicators are expected to be applied bynational governments, international NGOs, donors, andothers.

IV. Conclusion
UHC is a key target of SDG 3, offering a comprehensive
approach to improve access to health without financial
burden, which is a fundamental human right, and providing
the basis for economic and social development, as well associal stability. Three key components of UHC, namely
population coverage, service coverage, and financial
protection are inextricably associated with health financing.
In the SDGs, one of the two indicators for monitoring
UHC progress is about financial protection, which helps
increase people’s access to health services with affordable
costs. Although further discussions are needed on thethreshold of catastrophic payments, this is a significant,imperative step towards achieving UHC.
To further strengthen health financing, and ultimately
promote UHC, utilizing other indicators that gauge healthfinancing from the input side will be helpful. The second
Global UHC monitoring report will be release in December
2017. The authors expect that recent discussions on
strengthening health financing will continue and movement
towards UHC will accelerate.

Acknowledgement
This research was partly supported by the Research on
Global Health Issues, Health and Labour Sciences Research
Grants (Grant No. H27-地球規模-一般-002).

Disclaimer
The views and opinions expressed in this article arethose of the authors and do not necessarily represent thoseof the National Institute of Public Health or WHO.

J. Natl. Inst. Public Health, 66 (4) : 2017371

Naoko Tomita, Akihito Watabe(accessed 2017-06-30)[10] World Health Organization. Meeting report: monitoring
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Rockfeller Centre, Bellagio: WHO. 2015. http://www.
who.int/healthinfo/universal_health_coverage/UHC_
Meeting_Nov2015_Report.pdf?ua=1 (accessed 201706-30)[11] Ravelo J. How should we measure access to healthcare? Devex News. 11 March 2016. https://www.devex.
com/news/how-should-we-measure-access-to-healthcare-87862 (accessed 2017-06-30)[12] I H P + . U H C i n d i c a t o r s f o r S D G m o n i t o r i n gframework agreed. https://www.uhc2030.org/newsevents/uhc2030-news/article/uhc-indicators-for-sdg-

monitoring-framework-agreed-398330/ (accessed2017-06-30)[13] World Health Organization. Health financeing foruniversal health coverage: monitoring Sustainable
Development Goals. http://www.who.int/health_financing/topics/financial-protection/monitoring-sdg/
en/ (accessed 2017-06-30)[14] Refinement of indicators. Agenda item 9. 4th
meeting of the inter-agency and Expert Group on
Sustainable Development Goal Indicators (IAEGSDGs); 2016.11.17-18; Geneva, Switzerland. https://
unstats.un.org/sdgs/files/meetings/iaeg-sdgsmeeting-04/9.%20Refinement%20of%20Indicators%20
plenary.pdf (accessed 2017-06-30)

ユニバーサル・ヘルス・カバレッジ（UHC）達成に向けた保健財政の強化とモニタリング指標についての動向
冨田奈穂子 1），渡部明人 2）
1）国立保健医療科学院国際協力研究部
2）世界保健機関保健システムガバナンス財政部門

抄録
ユニバーサル・ヘルス・カバレッジ（universal health coverage: UHC）は国連の持続可能な開発目
標（Sustainable Development Goal: SDG）の目標3において要となるターゲットである．各人が経済的な困難に陥ることなく保健医療へアクセスできることは基本的人権であり，社会の安定と共に経済的，社会的な開発の基礎となるが，UHCはそのようなアクセスを改善するための包括的アプローチである．UHCの3大構成要素である対象となる人口，対象となるサービス，経済的保護は，保健財政と密接に関連している．
SDGsでは，UHCに向けた進捗状況をモニタリングするための2つの指標のうち，1つが経済的保護に関する指標である．この指標は，保健医療における人々の経済的な破綻リスクを低減することに役立つものである．経済的な破綻となる域値については更なる議論の余地があるが，経済的保護に関する指標が採択されたことはUHCの実現に向けた大きく，重要な一歩である．
本稿ではUHCとの関係において，保健財政の強化とその進捗状況のモニタリング指標策定の動向を述べる．
キーワード：ユニバーサル・ヘルス・カバレッジ（universal health coverage: UHC），保健財政，経済的保護，モニタリング指標

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J. Natl. Inst. Public Health, 66 (4) : 2017