Measurement matters: who and what counts on the road to universal health coverage
Authors: Nancy Fullman, Rafael Lozano
Journal: The Lancet Global Health (2019)

Advancing towards universal health coverage (UHC)—whereby all people receive the health services they need without financial hardship—is viewed as a primary way for countries to improve health and equity.1UN General AssemblyResolution 74/2: political declaration of the high-level meeting on universal health coverage. United Nations, New York2019https://undocs.org/en/A/RES/74/2Date accessed: November 15, 2019Google Scholar, 2WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization, Geneva2019Google Scholar Although UHC is often framed as bold yet achievable, questions remain on how best to monitor country-level gains and challenges. To make progress on the ground, we must understand where countries are today—in terms of both service coverage and financial risk protection—and what is needed to bring UHC closer to reality in the future. In The Lancet Global Health, Adam Wagstaff and Sven Neelsen construct an overall UHC index for 111 countries by combining measures of service coverage and incidence of catastrophic health expenditure to represent financial risk protection.3Wagstaff A Neelsen S A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2019; (published online Dec 11)https://doi.org/10.1016/S2214-109X(19)30463-2Google Scholar Drawing from previous studies,4Wagstaff A Dmytraczenko T Almeida G et al.Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712Google Scholar, 5Wagstaff A Flores G Hsu J et al.Progress on catastrophic health spending in 133 countries: a retrospective observational study.Lancet Glob Health. 2018; 6: e169-e179Google Scholar they define service coverage as a weighted geometric mean of four prevention and four treatment indicators (ie, child vaccination, acute respiratory infection and diarrhoea treatment, antenatal care and skilled birth attendance, breast and cervical cancer screening, and inpatient admissions), and catastrophic health expenditure exceeding 10% of household annual consumption or income. Indicators are mostly assessed from household survey microdata, although typically different sources for service coverage and expenditures, and the geometric mean of the two UHC components comprises the overall index. The authors also do secondary analyses, including adjusting service coverage for survey-based sociodemographic inequalities and examining UHC trends for 12 countries. This study takes an important step in measuring overall UHC, aiming to quantify both service coverage and financial risk protection for as many countries as possible. However, some choices could impede its uses for tracking UHC progress. First, despite the study's principle of representing “a wide range of services relevant to a wide range of users”,3Wagstaff A Neelsen S A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2019; (published online Dec 11)https://doi.org/10.1016/S2214-109X(19)30463-2Google Scholar the included coverage indicators reflect a narrow set of services and people who need them (ie, primarily children under 5 years of age and pregnant women). Omitting key health priorities (eg, non-communicable diseases [NCDs] and sexual and reproductive health) and population groups from UHC measurement risks extrapolating observed gains to non-represented services and people across the life course.6Ataguba JE Ingabire MG Universal health coverage: assessing service coverage and financial protection for all.Am J Public Health. 2016; 106: 1780-1781Google Scholar Second, heavily weighting inpatient admissions (50%) and treatment (75%) seems counter to calls for strengthening primary care to accelerate UHC progress2WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization, Geneva2019Google Scholar—and could obscure country-level advances on primary care and reducing preventable hospitalisation. For instance, Thailand and Japan, two countries touted for improving UHC and primary care,7Tangcharoensathien V Witthayapipopsakul W Panichkriangkrai W Patcharanarumol W Mills A Health systems development in Thailand: a solid platform for successful implementation of universal health coverage.Lancet. 2018; 391: 1205-1223Google Scholar, 8Ikegami N Universal health coverage for inclusive and sustainable development: lessons from Japan. A World Bank study. World Bank, Washington, DC2014https://openknowledge.worldbank.org/handle/10986/20412Date accessed: November 23, 2019Google Scholar have lower overall UHC scores as a result of having lower levels of inpatient admissions. Third, by restricting analyses to survey-based estimates and mainly avoiding imputing missing information, only 11% of countries, all low-to-middle income, met the criteria for trend assessment (ie, at least three datapoints per indicator). Furthermore, combining indicator and UHC point estimates across years makes it difficult to distinguish reported country-level heterogeneities on service coverage and financial risk protection from potential differences arising from survey timing (eg, a 7-year difference on China's reported sources across UHC dimensions). Such limitations are not unique to this study, and, although their origins vary, two shared principles underlie their perpetuation: use of indicators derivable from multicountry survey series' microdata; and avoidance of data triangulation or modelling to generate trends. These principles are not inherently problematic, especially when strengthening national health information systems and recognising data gaps are high priorities on both country and global agendas. However, steadfast adherence to these principles also has drawbacks, from possibly fettering UHC measurement to costly survey data (which are at best collected every 3–5 years and are largely funded by international agencies) to minimising countries' advances in health information systems and their work on synthesising myriad data to inform UHC needs.9Barreto ML Rasella D Machado DB et al.Monitoring and evaluating progress towards universal health coverage in Brazil.PLoS Med. 2014; 11e1001692Google Scholar Analytical trade-offs are inevitable, as the authors acknowledge preferring to exclude surveys such as the STEPwise Approach to NCD Risk Factor Surveillance—and thus indicators like hypertension or diabetes treatment—in favour of surveys with fewer services measured but more sociodemographic data for inequality analyses. Assessing inequalities is vital for UHC monitoring; nonetheless, such narrow inclusion criteria could introduce other facets of inequality regarding who and what counts on the road to UHC. Better supporting UHC progress in the future requires a willingness to try different measurement approaches today. Appropriate proxy indicators should be carefully tested to bridge our imperfect data realities and meet demands for better representing the services needed across the life course. We must move towards measurement of effective coverage of health services; after all, if health outcomes do not improve alongside gains in services received, advances toward UHC are meaningless. For both UHC dimensions—service coverage and financial risk protection—estimates of past trends through the present are required to provide insights into current progress and challenges, as are estimates of potential projections and scenarios that can chart the possible effects of country investments or policy changes. Clearly reporting data inputs, assumptions, and uncertainty for these analytical approaches, per the WHO-led GATHER criteria,10Stevens GA Alkema L Black RE et al.Guidelines for accurate and transparent health estimates reporting: the GATHER statement.Lancet. 2016; 388: 19-23Google Scholar bolsters the potential benefits of data-driven models and of producing trends, especially against the alternative: a less complete understanding of UHC progress throughout the world. At the crux of UHC measurement matters are two key questions: are we, collectively, moving towards tracking of what is valued in UHC, reflecting all countries' priorities? And are we capturing the measurable progress that we, as global citizens and not solely analysts, would want to experience for health services and financial risk protection received? Country and global leadership stress that business as usual will not deliver on UHC—staying the course on its measurement is unlikely to yield different results. We declare no competing interests. A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational studyProgress towards UHC can be tracked using an index that captures both service coverage and financial protection. Although per-capita income is a good predictor of a country's UHC index score, some countries perform better than others in the same income group or even in the income group above their own. Strong UHC performance is correlated with the share of a country's health budget that is channelled through government and social health insurance schemes. Full-Text PDF Open Access