Universal Health Coverage: measurement and its potential role in the post 2015 development agenda Ties Boerma Director of Health Statistics and Information Systems World Health Organization Geneva
Jan 27, 2016
Universal Health Coverage: measurement and its potential role in the post 2015 development agenda
Ties Boerma
Director of Health Statistics and Information Systems
World Health Organization
Geneva
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OutlineOutline
Post 2015 development agenda
Goal -Healthy life expectancy
Goal - Universal health coverage: general issues and financial risk protection
Goal - Universal health coverage: measurement issues
Health in the post-2015 agenda: the global consultation process
Overall consultation process:UN System Task Team established early 2012
• Task Team proposed integrated framework for realizing the "future we want for all in the post-2015 UN development agenda
Human rights
Equality
Sustainability
Environmental sustainability
Peace and Security
Inclusive social development
Inclusive economic development
Overall consultation process: UN Secretary-General's High-level Panel of Eminent Persons on the post-
2015 UN development agenda
• Established by SG mid-2012• Output: Report that the SG will
deliver to UN General Assembly by the 2nd quarter of 2013
• Input: Work based on report of UN System Task Team
• Work to be informed by Rio+20 and other consultations
Co-Chair:Susilo Bambang YudhoyonoPresident of Indonesia
Co-Chair:Ellen Johnson SirleafPresident of Liberia
Co-Chair:David CameronPrime Minister of the UK
Overall consultation process:Country consultations (about 100)
• Objectives– Influence the intergovernmental process by
amplifying the voices of local communities• Output
– Clear recommendations for governments• Coordination at country level
– UN Resident Coordinators will provide overall strategic guidance
– Ministries of Planning lead and line Ministries involved
11 global thematic consultations, including one on healthLead UN Agencies Events Government leads
Growth and employment ILO, UNCTAD, UNDP Tokyo, 15-16 May 2012 Japan
Inequalities UNICEF, UNWOMEN Global consultation in Feb/March 2013 (Denmark)
Denmark
Education UNESCO, UNICEF Global consultation in Feb/March 2013 (?Senegal)
Canada
Environmental sustainability
UNDP, UNEP, Leadership meeting February 2013 (tbc)
Food security and nutrition
FAO, WFP TBD Spain, Colombia
Governance UNDP, OHCHR Global consultation in Jan/Feb 2013 (South Africa)
Germany, South Africa
Conflict and fragility UNDP, PBSO, ISDR and UNICEF
Global consultation in Helsinki February 2013
Finland
Population dynamics UNDESA, IOM, UNFPA and UN-HABITAT
TBD Switzerland
Health WHO, UNICEF High level meeting Mar 2013 (Botswana)
Sweden and Botswana
Water UNWATER, UNICEF, UNDESA
TBD
Energy TBD
Working Group on Sustainable Development Goals
Objective:Tasked to develop a proposal for the
Sustainable Development Goals
Members:Working Group comprised of 30
representatives nominated by Member States (co-chairs Brazil & Italy)
Output: A report to the UNGA containing a
proposal for sustainable development goals (between Sep 2013/14)
Mandate:Rio+20
UN Secretary-General:"The Panel’s work will be closely coordinated with that of the intergovernmental working group tasked to design Sustainable Development Goals, as agreed at the Rio +20 conference. The reports of both groups will be submitted to Member States for their further deliberations."
The global consultation on health(Health Thematic Consultation)
>100 papers contributed >Dozen consultations
>Web based forum
Emerging themes:Lessons learnt from the health MDGs
• Health MDGs success– More money for health– More progress since 2000– Influenced political discourse at highest levels– Driven by concrete measurable goals and targets
• But also shortcomings– Lack of focus on equity– Human rights aspect missing– Too much a top-down process– Contributed to more fragmented health programmes
in countries
Emerging themes:Health priorities post-2015
• Continue the health MDGs: unfinished agenda• Address emerging noncommunicable diseases and
their risk factors• Address health consequences of demographic and
epidemiologic changes, environmental factors, globalization, urbanization, migration etc.
• Strengthen health systems
Emerging themes:The place of health in the post-2015 agenda
• Changes in global landscape– Post 2015 agenda is for all countries– Much greater diversity and complexity now than in 2000 (global
changes, CSO, partnerships etc.)
• Place of health:– Critical contributor to development in sectors other than health,– Beneficiary from development, and – Key indicator of what rights-based, sustainable and equitable
development seeks to achieve– Links with many other sectors needs to be made explicit
(including social determinants of health)
Emerging themes:Post-2015 goals
• Possible goals– Long healthy lives / healthy life expectancy: is an end
goal, influenced by health but also by many other aspects of development
– Universal Health Coverage: contribution of health to the end goal, supported in many papers
– Continued Health MDGs, with equity element
• Equity and human rights as central elements
Measurement of healthy life expectancy
Possible measures of Healthy Life Expectancy
• Mortality / life expectancy
• Healthy life expectancy with Global Burden of Disease approach
• Healthy life expectancy with survey measurement of health state
Mortality
• Life expectancy only: attractive summary measure, well understood, used as primary measure by many countries; can be disaggregated
– Age and cause-specific mortality: NCD mortality goal (25% by 2025), MDG continuation (child and maternal mortality, HIV/AIDS, TB)
• Mortality rates are needed for healthy life expectancy measures
• Lack of good death registration data with reliable cause in most low and middle income countries
• Reliance on suboptimal measures: mortality data collection in retrospective surveys, cause of death through verbal autopsy
Healthy life expectancy with GBD approach
• Requires age-specific mortality rates + prevalence and distribution of non-fatal conditions + disability weights.
• Makes systematic use of multiple data sources and can be updated regularly.
• Using extensive modelling comparable methods over time (1990-2010) and can be computed for all countries.
Issues:• Data limitations: prevalence data are often lacking• Needs the use of disability weights for each non-fatal condition • Recent estimates will be heavily based on prediction• Cannot disaggregate for equity analysis except geographical differences
Healthy life expectancy based on survey data
• Single question: self-rated health/activity limitations; EU surveys "For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do?" (3 point scale) .. Disability-free life expectancy (gain 2 healthy life years by 2020 – EU)
• Focus on functioning (ICF): health score, using domains (mobility, vision, cognition etc.)
• ADL, (core tasks, severe disability) and IADL (more complex tasks, mild/moderate disability), WHODAS 2.0
• Biological and clinical tests: physical and cognitive tests; hypertension, vision, anthropometry, handgrip strength; body fluid testing - CRP, IL-6, HbA1c, telomere length, lipid profile, markers of immuno-senescence
Issues• Cross-cultural comparability • Ways to adjust for reporting biases (anchoring vignettes) often not successful• Health examination surveys not widely conducted
Universal Health Coverage
General issues and financial risk protection
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WHO's Formal Definition of Universal (Health) CoverageWHO's Formal Definition of Universal (Health) Coverage
World Health Assembly Resolution 58.33, 2005, urged countries to develop health financing systems to:
Ensure all people have access to needed services
Without the risk of financial ruin linked to paying at the time they receive care
Defined this as achieving Universal Coverage: coverage with health services; with financial risk protection; for all
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UHC combines both service coverage and financial protection, explicitly
UHC combines both service coverage and financial protection, explicitly
New for the public health community– Financial protection as integral to the concept of UHC– Beyond “Health for All” to Health for All with financial protection
New for (health) economists– Focus had been largely on financial protection and the
“economics of health insurance”– Recognize that UHC is more than this, requiring as well a focus
on services and their quality
Comprehensive: – Includes promotion, prevention, treatment, rehabilitation and
palliation; focus on equity & quality of care
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UHC: global visibilityUHC: global visibility
WHO– “Universal coverage is the single most
powerful concept that public health has to offer”
– “Universal coverage is the hallmark of a government’s commitment, its duty, to take care of its citizens, all of its citizens” (WHO DG Acceptance Speech 23 May 2012)
UN General Assembly– Resolution on UHC adopted in December
2012 (Foreign Policy and Global Health) www.who.int/whr/2010
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WHR 2010 ConclusionsWHR 2010 Conclusions
Every country could do something to move closer to universal coverage or maintain the gains they have made, through:
· Raising more funds for health AND/OR· Reducing financial barriers to access and increasing financial risk
protection AND/OR· Improving efficiency and equity
Global community: increase funding to low-income countries become more efficient in the way it holds and channels funds to
countries support the development of domestic financing capacities
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Dispelling Myths about UHCDispelling Myths about UHC
UHC is only about treatment and care. FALSE– Promotion, prevention, treatment, rehabilitation, palliation
UHC is only about health financing. FALSE– Coverage of interventions with financial risk protection
UHC is not a concern for priority health programs or global health initiatives: FALSE
– MDG, NCD, emergency care under one umbrella
UHC means immediate free coverage for all possible health interventions, regardless of the cost. FALSE
– Progressive realization of UHC according to country situation
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The Cube: Three dimensions (policy choices) of UHC
The Cube: Three dimensions (policy choices) of UHC
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Financial risk protection Indicators: level and inequalities
Financial risk protection Indicators: level and inequalities
• Incidence of catastrophic health expenditure due to out-of-pocket payments
• Incidence of impoverishment due to out-of-pocket payments
• Mean positive overshoot of catastrophic payments• Poverty gap due to out-of-pocket payments
• Indirect indicators of financial risk protection:• Out-of-pocket payments as a share of total health expenditure• Government health expenditure as a share of GDP• Government health expenditure as a share of general government
expenditure
Large variations in Government health spending as a proportion of GDP
Large variations in Government health spending as a proportion of GDP
Source: WHO estimates for 2008, countries with population > 600,000
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Bottom line: where government spends more on health, people spend less out-of-pocket
Bottom line: where government spends more on health, people spend less out-of-pocket
Source: WHO estimates for 2004, excluding countries with population > 600,000
Armenia
Albania
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UHC in IndiaUHC in India
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Several initiatives for UHC: – Janani Suraksha Yojana as conditional cash transfer mechanism for pregnant women, – National Rural Health Mission for improve rural services, – Rashtriya Swasthya Bima Yojna for more equitable access to hospitals
Call to action in Lancet series 2011 – Integrated National Health System … UHC
– Increased public spending on health– Ensure the reach and quality of health services to all– Reduce the financial burden of health care on individuals– Stronger regulation of the private sector– Empower people to take care of their health and hold the health system accountable
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Universal Health CoverageUniversal Health Coverage
Measurement issues
intervention coverage
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A few definitionsA few definitions
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Access: whether the health services that people might need are available, of good quality, and close to them
Coverage of interventions: whether the people who need an intervention actually receive it
Effective coverage: whether the people who need health intervention obtain them in a timely manner and at a level of quality necessary to obtain the desired effect; (health gain – relevance)
Obstacles to obtaining effective coverage: physical access, affordability, acceptability for reasons such as culture or religion, and poor service quality; financial affordability is not only instrumental but intrinsic goal
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M&E framework for monitoring health system performance – the place of UHC measurementM&E framework for monitoring health system performance – the place of UHC measurement
Framework for measurement and monitoring of the service coverage component of Universal Health Coverage
Levels of health system / service delivery
Non-personal
Communitybased
Primary (facility)
Secondary(hospital)
Tertiary(hospital)
Priority HealthConditions
MNCH
HIV/TB/ malaria
NCDs & risk factors
Injuries
Promotion, prevention, treatment, rehabilitation, palliation
Specific coverage
tracerindicators
&
Index
Examples of indicators• Promotion: no smoking, normal weight, safe water & sanitary
facilities etc.
• Prevention: immunization coverage, skilled birth attendance, hypertension prevalence, cervical cancer screening, met need for FP etc.
• Treatment: childhood illness (ARI, diarrhoea, malaria), chronic adult illness (arthritis, depression etc.), ART, TB treatment etc. (measurement of NEED)
• Rehabilitation & palliation: …
Tracer indicators or summary measures
• Tracer indicators: – selected interventions, target 100%, coverage all major intervention
areas (MDG, NCD, injuries); – disaggregation must be done well (equity)– Ideally with quality component (e.g. hypertension, TB coverage) – disadvantage "gaming"
• Summary measure: – based on intervention areas capturing the full range of services of
UHC; – intervention areas rather than indicators – example Countdown
MNCH coverage index
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Summary measure or tracer indicators: exampleSummary measure or tracer indicators: example
36Source: Boerma, J. T., J. Bryce, et al. (2008). "Mind the gap: equity and
trends in coverage of maternal, newborn, and child health services in 54 Countdown countries." Lancet 371(9620): 1259‐1267.
Coverage index gap: difference between poorest and wealthiest quintile
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Equity: major issue of UHC and for its monitoring
Equity: major issue of UHC and for its monitoring
Where are the largest inequalities?– Between or within states; between or within districts within states– Urban (non poor and poor) and rural residence– Socioeconomic position: wealth quintile, education; caste– Demographic characteristics: sex, age
What indicators show the largest inequalities?– Deliveries and treatment >> immunization– Risk factors mixed picture: inactivity, obesity; smoking; hypertension etc.– Treatment chronic adult illnesses
Data sources – HMIS (geographic); Surveys (socioeconomic inequalities) etc.
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Global and country perspectivesGlobal and country perspectives
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Global
Few indicators, lessons learnt from the MDG monitoring
Uniform targets
Monitoring and reporting responsibilities need to be clear
Investment in measurement / monitoring
Country Global framework and guidance
Country specificity: different epidemiology, different priority interventions for UHC – flexible coverage index or different set of tracer indicators
Monitoring and reporting responsibilities through country review process (e.g. health sector reviews)
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Hypothetical examples of combined summary measure results
Hypothetical examples of combined summary measure results
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Summary pointsSummary points
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Service coverage as part of UHC can be measured and monitored but there are measurement gaps especially for treatment; health examination surveys essential
Range of intervention coverage measures would be a good basis in countries, guided by global standards of measurement; coverage data should be supported by input, output and health impact data
Global monitoring could rely on tracer set or index with targets
Combining coverage with financial protection into one summary measure would be ideal but challenging also
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Overall conclusionsOverall conclusions
Post 2015 development agenda: health must be prominent, but will have to specific to define its place in broad agenda
– Continue MDGs, broaden through UHC and (healthy) life expectancy end goal
UHC strong political momentum and attractive concept– Measurement must be well defined– Flexible according to country situation, strongly embedded in
national M&E systems, – But with common standards for core set of indicators– Requires investment in measurement