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Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Measuring progress towards UHC

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If you missed our posts last year, remember to read GNHE’s perspective on practical approaches countries can take to measuring their progress towards UHC.

A summary of key messages on this topic is available here.

Two policy briefs that provide more details on how to measure progress towards access and financial risk protection, respectively, are available here.

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Key messages on UHC measurement

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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.
Africa Lower-middle-income countries

Achieving universal health coverage in Ghana

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Bertha Garshong and James Akazili of the Research and Development Division, and the Navrongo Health Research Centre, of the Ghana Health Service respectively, have written an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:


  • Over the past few years there has been some improvement in access to health care in Ghana. However, there are still many challenges to the achievement of universal health coverage.
  • Ghana’s National Health Insurance Scheme (NHIS) is a pro-poor policy and offers a generous benefit package to its members. Yet many poor people find it difficult to pay registration fees as well as the premiums. The Scheme also has difficulties determining the socioeconomic status of applicants: flat-rate rather then income-related premiums therefore burden poorer members disproportionately. While there have been promises by policy-makers to improve the equity of the NHIS, not much progress has been made in this regard on the ground, and proposed premium reforms remain controversial. As a consequence, the NHIS still caters more for higher-income groups, leaving many poor families without any prepaid cover, despite contributing to the VAT-funded component of the Scheme. As a result, out-of-pocket expenditure remains relatively high.
  • For Ghana to move towards universal coverage, the country needs to find more money to replace the current out-of-pocket payment system. As the relative contributions of premiums is small, tax-based funding is the obvious source. However, increasing the fiscal space to fund the NHIS requires economic growth and improved tax collection.
  • For a modest increase in fiscal space for health for 3 to 5 years, Ghana needs to achieve a revenue collection rate of 20% of GDP by 2015. Currently the collection rate of tax revenue is below 13%. A World Bank report on the NHIS states that Ghana’s macroeconomic landscape is still fragile and any move must be done cautiously. With Ghana’s oil find the growth rate was modest but steady around 6% in 2013, and this gives some fiscal space for health in the next five years. However, this will depend on government spending and revenue collection efforts and priorities. Much as Ghana is not expected to get foreign aid because of its lower-middle-income status, it could benefit if it increases its credit rating and devises a clear exit strategy from aid. Lastly, Ghana has structural inefficiency in its health system as well as in the operations of the NHIS. Tackling these inefficiencies could release some additional fiscal space.
  • Apart from strengthening the financing and coverage of the NHIS, it is vital to expand access to health care services and raise the quality of care. This would include addressing the inequitable distribution of human resources and equipment, and improving the management and administrative capacity of the NHIS. The Community Health Planning Services programme, which is designed to provide a close-to-client service, needs to be expanded. Primary health care services are closer to the people and are within reach of the poor, but confidence in these facilities has dwindled due to lack of skilled staff, equipment and supplies and the poor quality of care, particularly in rural communities. These limitations necessitate referrals but, with the lack of transport and poor roads, many referred clients are unable to access higher levels of care.
  • Information barriers are another area that requires attention. There has not been a consistent and effective communication strategy for either providers or potential clients regarding the mechanisms of the NHIS, especially with respect to the poor.


Bertha Garshong and James. 2015. Universal health coverage assessment: Ghana. Global Network for Health Equity (GNHE). Available at:

Africa Lower-middle-income countries

Financing options for universal health coverage in Zambia

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Bona Chitah and Dick Jonsson, of the Department of Economics at the University of Zambia, have written an assessment of Zambia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • Zambia is making continuous progress in all the key areas of its health system. However, there are gaps which need to be resolved for the country to be able to realise the goal of universal coverage, including universal financial protection and access to care.
  • A more equitable distribution of resources between urban and rural areas is required. Currently there is an urban bias in resource distribution. This is evidenced not only in the allocation of public health sector resources, but also in expenditures by the wealthy on private health care.
  • Resources need to be allocated to promote access to, and utilisation of, health care by the poorer socio-economic groups. The higher consumption of public inpatient health care services by wealthier groups is a striking example of inequitable utilisation, as is the relatively greater levels of government subsidy received by wealthier groups, even for primary health care.
  • The impoverishing effect of out-of-pocket payments exposes poorer households to financial risk, driving households into poverty or further into poverty. This requires reconsideration of public hospital user fees, both in terms of the level of fees and the application of bypass fees (which are charged when patients bypass primary health care facilities, including because of the severity of their conditions and their proximity to higher-level health facilities).
  • Finally, Zambia’s ambition to introduce social health insurance as a mechanism for improving the pooling and purchasing of services needs to be scrutinised for its possible impacts on equity. The proposed social health insurance scheme would require co-payments and perhaps other contributions, which would increase the financial burden on households. This means that the proposed scheme could effectively run counter to the ambition of attaining universal health coverage.
  • There should be a critical evaluation of the alternative option of simply continuing – and strengthening – the current tax-based financing system.

Chitah B, Jonsson D. 2015. Universal health coverage assessment: Zambia. Global Network for Health Equity (GNHE). Available at:

High-income countries Low-income countries Lower-middle-income countries Upper-middle-income countries

Improving the measurement of financial risk protection

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To celebrate international UHC Day on 12 December, GNHE has just published a policy brief on how to improve the measurement of financial risk protection.

This is a companion piece to a similar brief on improving the measurement of health care use (available here).

If you want to read the full financial risk protection brief, click here.


The key messages of the financial risk protection brief are:

  • A key element of Universal Health Coverage (UHC) is financial risk protection (FRP) for all
  • Equitable financial protection means that everyone, irrespective of their level of income, is free from financial hardship caused by using needed health services
  • FRP must be measured alongside, and in addition to, the other dimension of UHC, which is access to needed health services: this is because UHC can only be achieved when both dimensions are addressed
  • Assessment of FRP should go beyond the conventional measures of financial catastrophe and impoverishment from out-of-pocket spending, because these under-estimate the level of financial risk
  • Measurement should seek to be inclusive and comprehensive, covering the whole population (both those who use health services and those who are unable to afford the use of health services when needed)
  • If the traditional measures are used, they should be interpreted accordingly – as simply the proportion of the population who use health services and are consequently impoverished or face financial catastrophe


Ataguba JE, Lu JR, Muiser J, Knaul FM. Assessing progress to UHC – the GNHE perspective: Financial risk protection. Available at:


Africa Low-income countries

Achieving universal health coverage in Uganda

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Zikusooka , Kwesiga, Lagony and Abewe, of HealthNet Consult in Uganda, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • Tax-based funds contribute a relatively small share of total health financing in Uganda
  • The public sector is heavily constrained in providing an adequate range and quality of services
  • The Uganda population reverts to seeking care from the large private sector, which is perceived to have better quality services
  • The fact that patients have to pay on an out-of-pocket basis for private care intensifies the exposure to financial risk across the population
  • With very limited financial protection and highly fragmented risk pools, there is very little income and risk cross-subsidisation in Uganda
  • As a consequence, utilisation of health care services is largely dependent on the ability to pay rather than need
  • Furthermore, purchasing arrangements do not encourage efficient, high-quality service provision or the provision of services that meet patients’ needs
  • To address some of these problems, the country needs to utilise the current mechanisms put in place to ensure donor assistance is more useful by increasing its effectiveness and equity.
  • The prospects of increasing health resources through the budget seem to be dwindling as the health sector has been crowded out by other government priorities, particularly infrastructural development and the education sector
  • Leveraging other sector-specific resources through implementing mandatory health insurance is thus an area where Uganda should look to increase public sector health resources (Uganda is still considering this policy option)
  • As has been done in other countries in Africa, Uganda could also look at tax levies earmarked for the health sector
  • Finally, wastage is a major issue in use of health sector resources. Making better use of existing resources would require government to institute mechanisms for monitoring and incentivising efficient performance



Zikusooka CM , Kwesiga B, Lagony S, Abewe C. 2014. Universal health coverage assessment: Uganda. Global Network for Health Equity (GNHE). Available at:


Africa Upper-middle-income countries

Achieving universal health coverage in South Africa

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Di Mcintyre, Jane Doherty and John Ataguba, from the Health Economics Unit at the University of Cape Town in South Africa, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

In South Africa, everyone without voluntary health insurance is able to use public sector services that provide a relatively comprehensive range of care.

Although most public sector users must pay fees for hospital care, these are income-related and, more importantly, the poorest, young children and pregnant women are eligible for fee waivers.

However, the South African health system falls short of the goal of universal coverage, both in relation to some aspects of financial protection and equity in financing but particularly in terms of equitable access to needed, effective and good quality health care.

There is a six-fold difference in health care spending between voluntary health insurance members and those entirely dependent on public sector services.

There are a number of causes of these problems:

  • An onerous burden of out-of-pocket payments on some individuals due to the uneven implementation of user fee exemptions at public hospitals and for those not eligible for exemption from user fees, yet with limited ability to cover these fees on an out-of-pocket basis
  • A range of barriers to health service access other than user fees, including an under-supply and a maldistribution of health workers relative to the distribution of the population with the greatest need for health care
  • A relatively low share of mandatory pre-payment funding
  • Fragmented funding and risk pools, which limit the potential for income and risk cross-subsidies
  • Weak purchasing including a poor incentive environment

Within the context of considerable income inequalities (where the richest 10% of the population account for 51% of income and the poorest 10% for only 0.2% of income) and a far greater burden of ill-health and hence risk of needing health care on lower socio-economic groups, the importance of creating an integrated pool of mandatory pre-payment funds in order to pursue universal coverage is indisputable.

While the South African government has published a draft policy on National Health Insurance, many of the details are yet to be finalised.

Read more in: McIntyre D, Doherty J, Ataguba J. 2014. Universal health coverage assessment: South Africa. Global Network for Health Equity (GNHE). Available at:



Low-income countries

Achieving universal health coverage in Tanzania

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Gemini Mtei and Suzan Makawia, of the Ifakara Health Institute in Tanzania, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ concluding points are:

  • Despite the significant contribution of public and donor resources in Tanzania, benefit distribution is still pro-rich, even for some public providers (especially hospitals).
  • Benefits are pro-poor only in primary care facilities, which in many cases are characterized by poor quality and unavailability of certain services.
  • Out-of-pocket payments are inequitable.
  • Impoverishment due to catastrophic payments for health care translated into about 480,000 people falling into poverty in 2007.
  • The Tanzanian government has committed itself to attaining universal coverage through the expansion of health insurance coverage to 30% of the population by 2015 and increased government allocations to the health sector.
  • A challenge to the achievement of this target, though, is the high dependency on donor funding, especially as some donors are pulling out of health sector basket funding due to concerns about value for money.
  • Catastrophic health care payments and impoverishment might increase as long as donor funds remain unsustainable and if general tax allocations to the health sector do not increase.
  • More attention also has to be paid to extending coverage among the poor.
  • The range and quality of public sector services also need to be improved as this where most poor households access the health system.


Read more in: Mtei G, Makawia S. 2014. Universal health coverage assessment: Tanzania. Global Network for Health Equity (GNHE). Available at: