David B Evans, Director Health Systems Financing Universal Health Coverage: Concepts and...

David B Evans, DirectorDavid B Evans, DirectorHealth Systems FinancingHealth Systems Financing

Universal Health Coverage: Concepts and

Measurement

Measuring UHC: Concepts, Indicators and ExperiencesWashington, 20 July 2012

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OutlineOutline

UHC: Definition and propositions

M&E Results Chain for UHC

Suggestions for Countries

Suggestions for post-MDG agenda


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Propositions about UHCPropositions about UHC

Two essential components – coverage with needed health services (of good quality); coverage with financial risk protection

Interrelated and not separable

Intrinsic goals – although also instrumental in obtaining better health outcomes

Note: health services included prevention, promotion, treatment, rehabilitation

Millions more suffer financially when they use health services

Millions more suffer financially when they use health services

- 30 60 90

WPRAMR

SEAEURAFR

EMRimpoverishmentcatastrophic

Number of people (million)

Millions miss out on needed health services

Millions miss out on needed health services

02

04

06

08

01

00

0 10 20 30 40 50

Q1Q5 Average

Source: Latest available DHS for each country (excl. CIS countries)

Q1, Q5 and Average - 22

Percentage of births attended by medically trained persons

Three dimensions (policy choices) of Universal Coverage

Three dimensions (policy choices) of Universal Coverage

UC with co-paymentsUC with co-payments


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OutlineOutline





UHC Results ChainUHC Results Chain

Social Determinants


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OutlineOutline





Table 1: Intervention areas, tracer indicators and additional indicators for coverage index

Table 1: Intervention areas, tracer indicators and additional indicators for coverage index

Social Determinants

Intervention area Tracer indicators Additional indicatorsChild vaccination DPT3/penta, measles BCG, polio, hepBMaternity care ANC 4 or more visits, skilled birth

attendanceANC 1+ visit, institutional delivery, postnatal care

Family planning Unmet need for FP Contraceptive useTreatment of sick children Suspected pneumonia taken to

health facility, diarrhoea with ORTSuspected pneumonia treated with antibiotics, diarrhoea treated with ORS

Malaria Children sleeping under ITN; IPT during pregnancy

Fever treated with antimalarials/ACT; households with IRS

TB TB treatment success rate; TB case detection rate

HIV prevention Condom use at higher risk sex; PMTCT among HIV positive women; ART

Male circumcision rate

Cancer HPV vaccination; tobacco use*; cervical cancer screening

5 year survival rate (specific cancer); mammography

Cardiovascular diseases Hypertension prevalence* Salt intake*; hypertension control follow-up visit; AMI survival; physical activity*

Mental healthInjuries

Other NCDAsthma (re)admission rate; cataract surgery

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Table 2: Other Indicators Linked to Coverage with Health Services

Table 2: Other Indicators Linked to Coverage with Health Services

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Availability of Health Services: InputsHealth expenditure per capitaHospital bed to population ratioHealth personnel to population ratio by typeAvailability of essential medicines (MDG 8E)% of population within 5km (or within 1 hour’s travel) of a health facility% of primary care facilities without constant supplies of medicinesInpatient and Outpatient Utilization (Output)Average number of outpatient visits per person per year (perhaps compared to an arbitrary threshold of need)Average number of inpatient days per person per year (perhaps compared to an arbitrary threshold of need)

Table 3: QualityTable 3: Quality

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Quality Indicators (Output)

Retention on antiretroviral therapy at 12 months 923

Proportion of children initially breastfed (within one hour of birth)

80

Avoidable asthma admission rates 28

In-hospital case-fatality rates within 30 days after admission for ischemic stroke

27

Postoperative pulmonary embolism or deep vein thrombosis

18

Schizophrenia re-admissions to the same hospital

16

Percentage of women aged 50-69 screened for breast cancer

29

Table 4: Financial Risk Protection: Impact IndicatorsTable 4: Financial Risk Protection: Impact Indicators

.

Number of countries with at least 2 data points

Incidence of catastrophic health expenditure due to out-of-pocket payments

112

Mean positive overshoot of catastrophic payments

112

Incidence of impoverishment due to out-of-pocket payments

112

Poverty gap due to out-of-pocket payments

112

Table 5: Input and Output Indicators. Financial Risk ProtectionTable 5: Input and Output Indicators. Financial Risk Protection

.

Countries with at least 2 data

pointsOut-of-pocket payments as a share of total health expenditure

196

Legal entitlement to health services through insurance or direct government funding/provision

NA

Government health expenditure as a share of GDP 196

Government health expenditure as a share of general government expenditure

196

Median price for generic drugs compared to international reference pricing

7

Percentage of government health expenditure for fixed costs compared to medication and equipment costs

7

EquityEquity

Average and Distribution need to be considered in almost all of the indicators


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OutlineOutline






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PropositionsPropositionsIn post MDG agenda, difficult to maintain 3 health

specific goals, plus nutrition, medicinesUHC an umbrella for the health part of post-MDG

development goals Probably won't be too difficult to get some health

service coverage indicators – much more difficult for financial risk protection

Debate will focus on how to define a goal for UHC with targets, what indicators for service coverage and financial risk protection. Health impact?


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SuggestionsSuggestionsTies will talk about health service

coverageFor financial risk protection,

exploring the idea of suggesting only 1: % of population impoverished because of OOPs.


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For DiscussionFor DiscussionWhat indicators for tracking progress to

UHC at country level?Should we move towards a UHC index –

with separate indexes for services and financial risk protection?

How to incorporate inequality?What should we be suggesting for the

post-MDG development agenda?


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Thank youThank youThank youThank you

www.who.int/whr/2010

David B Evans, Director Health Systems Financing Universal Health Coverage: Concepts and...

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