With the inclusion of universal health coverage (UHC) in the Sustainable Development Goals (SDGs), there is considerable discussion on how best to measure progress to UHC. This note summarises the perspective of the Global Network for Health Equity (GNHE), a network that brings together the views and experience of a diverse network of researchers based at country level in Africa, Asia and Latin America.
Guiding principles
- Our concern is with UHC as defined according to outcomes, namely access to needed health services of sufficient quality to be effective, and financial risk protection for all. Within this context, measurement of these outcomes must be independent of the structure of financing and provision in a health system.
- In order to allow comparison across all countries irrespective of their income level, UHC measures must use data that are likely to be available across a diverse range of health systems, or for which there are reasonable substitutes.
- GNHE supports the use of a small number of key indicators rather than a single composite UHC indicator, which obscures the multi-dimensionality of UHC as a concept. However, indicators of the two key elements of UHC should be assessed and interpreted together.
- Monitoring of progress towards UHC should not only be measured in terms of each indicator’s overall average, but also the narrowing of differentials across socio-economic groups to take account of equity.
UHC goal of access to health services for all
- Due to the complexity of measuring access directly, we propose measuring actual use of services.
- Instead of focusing on a few services (such as antenatal care and immunisations), GNHE proposes assessing the adequacy and equity of overall service utilisation.
- We recommend a minimum average utilisation rate of 4 outpatient visits per person per year; utilisation rates below this threshold suggest that a country is unlikely to have adequate access to services.
- For inpatient services, a minimum threshold of 100 inpatient discharges per 1,000 population per year is recommended.
- To assess equity, these minimum thresholds should be achieved in all socio-economic groups. Given that service utilisation should be according to need, the difficulty of accurately measuring need for health care and the generally greater burden of ill health among lower-income groups, utilisation rates should be at least equal across socio-economic groups.
- Further work is required to develop an appropriate means of assessing quality and effectiveness of services used.
UHC goal of financial risk protection
- Indicators of catastrophic levels of out-of-pocket health expenditure and impoverishment from making out-of-pocket payments for health services should be used to assess financial risk protection.
- Constraints on currently available data limit refinements to these existing measures. Priorities for improved data collection and future refinement of these measures include:
- Including all direct costs related to using health services when needed (e.g. costs of transport to the health care provider) and possibly also health insurance contributions
- Developing a common methodology to measure country-specific basic needs’ thresholds for use in impoverishment analyses instead of the global, minimalistic poverty lines (e.g. $1 per day)
- It is important to recognise that these measures only reflect the proportion of the population who actually use health services and are impoverished or face financial catastrophe as a result. They do not take account of those who do not use health services due to a lack of financial resources. It is for this reason that measures of financial risk protection must be assessed together with measures of service utilisation; where utilisation rates are below the minimum threshold, this is likely to reflect the existence of unmet need.