Towards a meaningful measure of universal health coverage for the next billion
Authors: Nancy Fullman, Rafael Lozano
Journal: The Lancet Global Health (2017)

Effectively monitoring universal health coverage (UHC) has become increasingly important, especially given the centrality of UHC in the Sustainable Development Goal (SDG) era and its ascent in policy dialogues. Further, a pillar of WHO's Global Programme of Work for 2019–231World Health OrganizationDraft thirteenth general programme of work, 2019-2023: promote health, keep the world safe, serve the vulnerable. WHO, Geneva, Switzerland2017http://apps.who.int/gb/ebwha/pdf_files/EBSS4/EBSS4_2-en.pdf?ua=1&ua=1Google Scholar is the provision of universal health coverage (UHC) to 1 billion more people. Yet without greater consensus on what set of health services should comprise an ideal measure of UHC, we lack a roadmap for achieving and monitoring these aims. Now is the time to unite and establish a cohesive, meaningful metric of UHC—a way to understand whether people throughout the world are truly receiving the services they need to live long, healthy lives. In The Lancet Global Health,2Hogan DR Stevens GA Hosseinpoor AR Boerma T Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2017; (published online Dec 13.)http://dx.doi.org/10.1016/S2214-109X(17)30472-2Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar Daniel Hogan and colleagues used 14 tracer indicators to construct such an index of UHC service coverage in 183 countries for 2015. Similarly to that of other recent efforts,3World Health OrganizationWorld BankTracking universal health coverage: first global monitoring report. WHO, World Bank, Geneva, Switzerland and Washington, DC2015http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/Google Scholar, 4Lim SS Allen K Bhutta ZA et al.Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1813-1850Summary Full Text Full Text PDF PubMed Scopus (330) Google Scholar, 5Fullman N Barber RM Abajobir AA et al.Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1423-1459Summary Full Text Full Text PDF PubMed Scopus (196) Google Scholar the study's overarching approach is to combine many intervention coverage or health indicators to create a single UHC metric. Hogan and colleagues grouped these indicators by four health focus areas—reproductive, maternal, neonatal, and child health; infectious diseases; non-communicable diseases (NCDs); service capacity and access—and took geometric means across these areas to arrive at the UHC service coverage index. Reported performance varied from 22 to 86 across countries, highlighting major inequalities in the baseline estimates for monitoring UHC in the SDG era. This study's strengths in measuring UHC service coverage are framed in terms of its methodological simplicity, relevance, and use of currently available data; however, some analytical decisions may hinder its utility for effectively monitoring UHC across all countries and over time. First, included tracer indicators were primarily determined by interventions or measures covered by multicountry household survey series (eg, Demographic and Health Surveys). While these data may be easily accessible, limiting UHC indicators to what these household surveys cover unduly narrows the potential for optimally assessing service provision across key health domains. Second, Hogan and colleagues also use estimates of risk prevalence as proxies to assess coverage of intervention measures for tobacco control, diabetes, and hypertension. This approach implicitly impedes the calculation of how many people receive health services. Third, by combining a range of country-year estimates for each indicator, Hogan and colleagues approximated a 2015 baseline; it is therefore challenging to attribute differences in UHC service coverage to actual differences in UHC performance rather than differences in survey questions, timing, and data availability. Finally, to avoid unmeaningful comparisons, UHC service coverage index values for countries with scores higher than 80 are not reported. But equating the performance of Japan—a country widely lauded for its UHC accomplishments6Ikegami N Universal Health Coverage for Inclusive and Sustainable Development : Lessons from Japan. A World Bank study. World Bank, Washington, DC2014https://openknowledge.worldbank.org/handle/10986/20412Google Scholar— with that of the USA, which is known for its unexceptional record in health service provision among higher-income countries, raises other questions about how all countries, across the development spectrum, can have meaningful measures of UHC in the SDG era. Potential solutions currently exist for improving UHC measurement. First, expand the pool of data sources from which UHC metrics are derived, including claims or cause-specific registry data, and initiatives and surveys focused on NCDs and related risks (eg, STEPS surveys7World Health OrganizationThe WHO STEPwise approach to surveillance of noncommunicable diseases (STEPS). WHO, Geneva, Switzerland2003http://www.who.int/ncd_surveillance/en/steps_framework_dec03.pdfGoogle Scholar). Drawing from a broader range of data would strengthen country estimates and better represent key health services within UHC. Second, focus UHC metrics around intervention coverage or indicators that reflect access to quality services for high-burden causes requiring specialised care (eg, cancers or injuries).8Barber RM Fullman N Sorensen RJD et al.Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 390: 231-266Summary Full Text Full Text PDF PubMed Scopus (367) Google Scholar This approach would enable a more direct calculation of people with UHC service coverage. Third, harness all available data for each UHC indicator to produce the best possible estimates over place and time within a consistent, systematic analytical framework. Modelled estimates already inform a subset of tracer indicators in the present study (eg, immunisation coverage or antiretroviral therapy coverage), and are widely accepted for other high-priority health indicators (eg, under-5 mortality or maternal mortality).9Alkema L Chou D Hogan D et al.Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.Lancet. 2016; 387: 462-474Summary Full Text Full Text PDF PubMed Scopus (1096) Google Scholar, 10You D Hug L Ejdemyr S et al.Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation.Lancet. 2015; 386: 2275-2286Summary Full Text Full Text PDF PubMed Scopus (448) Google Scholar Fully adopting this approach to measure each UHC indicator and overall UHC would allow for greater comparability across countries, and ultimately better capture population-level changes in response to UHC policy and investments. Today's obstacles in UHC measurement do not originate from insufficient knowledge or methods; rather, they mainly stem from a lack of consensus on how to best track UHC progress. Establishing a single, interpretable UHC metric for coverage of essential health services is far from an easy task, and any resulting measure will inevitably be imperfect, especially given the vast array of candidate indicators. But until we collectively tackle this challenge, what it means to achieve UHC—and what it takes to get there—will remain unclear. Going forwards, a vital step is recalibrating the focus towards an ideal measure of UHC—a defined set of essential health services—rather than what is easiest to track. An overall UHC measure that encompasses both health service delivery and financial risk protection must also be developed; otherwise, it will be increasingly difficult to arrive at realistic costing estimates for achieving UHC. Multiplying population-level metrics of coverage by financial risk protection might be a viable approach, as experiencing catastrophic medical expenditures is conditional upon receiving care. Collaboration will underpin the accomplishment of these aims, and thus will require leveraging the expertise and analytical capacities of country partners, international agencies such as WHO and the World Bank, and extensive collaborations like the Global Burden of Disease study. The global health community faces a crucial turning point on the road to achieving UHC—a chance to collectively chart a new path on effective UHC measurement and action in the SDG era. By establishing a cohesive, meaningful UHC metric sensitive to policy change, we can provide the atlas for making UHC within reach of all populations worldwide. We declare no competing interests. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health servicesService coverage within universal health coverage can be measured with an index of tracer indicators. Our universal health coverage service coverage index is simple to compute by use of available country data and can be refined to incorporate relevant indicators as they become available through SDG monitoring. Full-Text PDF Open Access