Monitoring Progress towards Universal Health Coverage at Country and Global Levels

et al. (2014) Monitoring Progress towards Universal Health Coverage at Country and Global Levels. PLoS Med 11(9): e1001731. doi:10.1371/journal.pmed.1001731 Monitoring Progress towards Universal Health Coverage at Country and Global Levels Ties Boerma 0 Patrick Eozenou 0 David Evans 0 Tim Evans 0 Marie-Paule Kieny 0 Adam Wagstaff 0 0 1 World Health Organization , Geneva , Switzerland , 2 World Bank Group , Washington, D.C. , United States of America Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services. Both components should benefit the entire population. This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards UHC. The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries. - A movement towards universal health coverage (UHC) ensuring that everyone who needs health services is able to get them, without undue financial hardshiphas been growing across the globe [1]. Close to half of the countries of the worldacross all income levelsare currently engaged in health reforms that aim to extend, deepen, or otherwise improve coverage with needed health services and/or financial protection. These reforms have led to a sharp increase in the demand for expertise, evidence, and measures of progress and also a push to make UHC one of the goals of the post-2015 development agenda [2]. UHC has been defined as the desired outcome of health system performance, whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship [1]. UHC has two interrelated components: the full spectrum of good-quality, Collection Review articles synthesize in narrative form the best available evidence on a topic. Submission of Collection Review articles is by invitation only, and they are only published as part of a PLOS Collection as agreed in advance by the PLOS Medicine Editors. essential health services according to need and protection from financial hardship, including possible impoverishment due to outof-pocket payments for health services. Both components should benefit the entire population. In the context of this framework, essential is used to describe the services that a country decides should be available immediately to all people who need them. The contents of the services vary by setting. The dimensions have commonly been depicted as a cube, shown in Figure 1 (adapted from [3,4]). The first axis represents the population, the people who need health services. The services axis depicts the quality health services they need. The vertical axis is the proportion of the total cost of providing services to the population that is financed through pooled financing systems as opposed to direct payments by patients, shown in Figure 1 as the box labelled current pooled funds. In this illustration, a little more than a half the population is covered for about half of the possible services they need, but only half the cost of these services is met from pooled funds. There is thus a shortfall of service coverage among those who receive services, inequity in service coverage (a large fraction of the population receives no services), and a lack of financial protection (those who receive services pay a large part out-of-pocket and hence risk financial hardship). To get closer to UHC, the country would need to provide services to the people who currently need them but dont receive any, provide more services to those who currently receive some but not the full range of services they need, and raise the fraction of health spending financed through pooled funds to improve financial protection. At the same time, health services need to be of sufficient quality to achieve the desired outcomes, so improving quality will be a priority in many settings. Each country progresses in filling the different dimensions of the box (Figure 1) according to its preferences and constraints, trading off what services are provided, who gets them, and how much they are financed out of pooled funds. As such, UHC is the ultimate objective or goal, with countries starting from different places, with N The overall goal of universal health coverage (UHC) is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship. N A global UHC monitoring framework, developed by WHO and the World Bank Group in interaction with the process that led to this PLOS Collection, was used in 13 country case studies, underpinned by five technical reviews. N The UHC monitoring framework focuses on the simultaneous monitoring of coverage of the population with essential health services and with financial protection against catastrophic out-of-pocket health payments, stratified by wealth quintile, place of residence, and sex. N Most countries focus on regular monitoring of a set of tracer indicators for priority health services, as well as the occurrence of financial hardship and impoverishment due to out-of-pocket health expenses. The indicators generally follow international standards of measurement and can be used for global comparisons. N Most countries do not have an explicit framework for UHC monitoring. The monitoring of UHC is, however, partially embedded in regular overall health sector progress and performance reviews which include health system inputs, service delivery, and health status indicators. N There are major gaps in the availability and quality of data required for monitoring progress towards UHC. Countries mostly rely on international survey programs or national surveys to obtain disaggregated data on co (...truncated)