Monitoring Universal Health Coverage (UHC) in high Tuberculosis burden countries: Tuberculosis mortality an important tracer of UHC service coverage

RESEARCH ARTICLE Monitoring Universal Health Coverage (UHC) in high Tuberculosis burden countries: Tuberculosis mortality an important tracer of UHC service coverage Michael Reid ID1,2*, Glenna Roberts2, Eric Goosby1,2, Paul Wesson1,3 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 University of California, San Francisco, School of Medicine, San Francisco, California, United States of America, 2 University of California, San Francisco, Institute for Global Health Sciences, San Francisco, California, United States of America, 3 University of California, San Francisco, Center of AIDS Prevention Studies, San Francisco, California, United States of America * Abstract Background OPEN ACCESS Citation: Reid M, Roberts G, Goosby E, Wesson P (2019) Monitoring Universal Health Coverage (UHC) in high Tuberculosis burden countries: Tuberculosis mortality an important tracer of UHC service coverage. PLoS ONE 14(10): e0223559. https://doi.org/10.1371/journal.pone.0223559 Editor: João Pedro Silva, UCIBIO-REQUIMTE, Faculty of Pharmacy, University of Porto, PORTUGAL Received: July 5, 2019 Accepted: September 23, 2019 Published: October 30, 2019 Copyright: © 2019 Reid et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data underlying this study are third-party data which are publicly available from a separate manuscript published by Hogan et al https://www.thelancet.com/journals/ langlo/article/PIIS2214-109X(17)30472-2/fulltext. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. There is a paucity of empiric data evaluating whether Tuberculosis (TB) is a useful surrogate measure for Universal Health Coverage (UHC), despite recognition of the importance of TB control efforts as part of the broader UHC agenda. We hypothesized that indicators of TB burden and coverage are sensitive tracers of UHC, when compared to other disease-specific indicators of service provision. Methods Linear regression models were used to determine the extent to which variability in UHC Service Coverage Index (SCI) was accounted for by (1) TB incidence rates and (2) TB mortality rates across 183 countries. Dominance analyses, stratifying countries by World Bank income criteria and TB burden, were used to determine the importance of TB treatment coverage in predicting UHC SCI scores, relative to other disease-specific indicators of service provision. Results Across 183 countries, TB incidence rate and TB mortality rate were negatively correlated, with UHC SCI score, (r = -0.67 and r = -0.74, respectively). In linear regression models including all 183 countries, TB incidence rates explained 45% of the variability in SCI scores; TB mortality rate explained 55% of variability. Restricting models to the 30 highest TB burden countries, both incidence and mortality explained less of the variability in SCI score (16% and 36%, respectively). In dominance analysis, comparing 13 disease-specific indicators of service provision, TB effective treatment coverage, ranked ninth overall. In dominance analysis stratified by TB burden, the TB treatment coverage estimate was ranked ninth in the 30 high burden countries and sixth in the 153 non-high burden countries. In separate analyses stratified by world bank income status, TB coverage ranked as third most PLOS ONE | https://doi.org/10.1371/journal.pone.0223559 October 30, 2019 1 / 10 Tuberculosis mortality is an important tracer of UHC service coverage important variable in LICs and fifth in LMICs and UMICs, but was less important in analysis restricted HICs (ranked seventh). Conclusions Compared to other disease-specific indicators of service provision, TB coverage was an important indicator of overall UHC service coverage, especially in low-income countries. These findings highlight that national-level inequities in TB-coverage may be an important tracer of universal health coverage. Introduction Universal health coverage (UHC) is the goal that all people receive the essential health services that they need, without being exposed to financial hardship.[1,2] It is a central target of the Sustainable Development Goals (SDG).[3] While there are numerous proposed strategies for achieving UHC[4] the objectives of UHC are the same, regardless of approach: improving access to health services, improving the health of individuals covered and providing financial risk protection.[5] Recent reports have sought to determine which health interventions should be included in any definition of UHC, especially because many low and middle income countries have limited resources to deliver the breadth of services offered in many high income settings.[6,7] Furthermore, much work has been done to determine what the cost of implementing an essential UHC package will look like for countries of different income categories.[1,2,6] Unfortunately, data describing country progress towards implementing an essential UHC package of services is sparse, limited by data quality and diversity of definitions of what range of indicators of service coverage would be most representative. Recently, World Health Organization (WHO) and the World Bank proposed the use of a UHC Service Coverage Index (UHC SCI) tool to assess country-coverage with a range of different interventions. [5] This tool summarizes country-level coverage of 16 essential service indices across four core domains; (a) reproductive, maternal, newborn and child health, (b) infectious diseases, (c) non-communicable diseases and (d) service capacity and access, among the general population and the most disadvantaged populations.[5] While, the SCI offers a useful means of comparing essential health coverage across countries, the index is challenging to calculate, based on asynchronously collected and highly variable data, and offers limited utility for tracking prospective progress on quality or coverage. By contrast, indicators of tuberculosis (TB) burden, in particular TB incidence and mortality, are reported annually for all countries providing accurate information on trends in disease burden.[8] Tuberculosis disproportionately impacts vulnerable communities, and trends in TB incidence and mortality are also sensitive surrogates of health inequity.[2,9] Thus, geographical and financial access barriers for general health services are invariably access barriers for TB services as well. We hypothesize that indicators of TB epidemiologic control can serve as useful, simple surrogates for more complex indices of UHC, such as the UHC SCI, especially in countries with a high TB burden. To determine if this is the case, we evaluated the extent to which TB incidence and mortality explain the variability in UHC SCI sc (...truncated)