Monitoring Intervention Coverage in the Context of Universal Health Coverage

Evans T (2014) Monitoring Intervention Coverage in the Context of Universal Health Coverage. PLoS Med 11(9): e1001728. doi:10.1371/journal.pmed.1001728 Monitoring Intervention Coverage in the Context of Universal Health Coverage Ties Boerma 0 1 Carla AbouZahr 0 1 David Evans 0 1 Tim Evans 0 1 0 Abbreviations: MDG, Millennium Development Goal; NCD , noncommunicable disease; UHC, universal health coverage 1 1 World Health Organization , Geneva, Switzerland, 2 Independent consultant , 3 World Bank Group , Washington (D.C.) , United States of America Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups-promotion/prevention, and treatment/care-as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. - Universal health coverage (UHC) has been defined as the ability of all people who need health services to receive them without incurring financial hardship [1]. UHC consists of two inter-related components: coverage with health services, including promotion, 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. prevention, treatment, rehabilitation, and palliation, and coverage with financial protection, for everyone. The former captures the aspiration that all people obtain the health services they need, while the latter aims to ensure that they do not suffer financial hardship linked to paying for these services. For all countries, moving towards UHC is a process of progressive realization. It is about making progress on several fronts: the available range of services; the quality of the services; the proportion of the costs of those services covered; and the proportion of the population covered. For richer countries, the main challenges relate to protecting and extending past gains in the face of financial constraints, ageing populations, new health threats, continuous advances in technologies capable of extending life or improving health, and increasing expectations on the part of the public. For the poorest countries, the challenge is to initially ensure basic essential services to the whole population. The diversity in the nature of the challenge has implications for the selection of indicators for monitoring of progress towards UHC goals in countries. Overall monitoring of health progress and health system performance uses a range of indicators that measure determinants of health, health sector inputs such as finances and health workforce, outputs such as access to and quality of services, coverage of interventions, and health impact. For UHC monitoring we propose a focus on the level and distribution of coverage of health interventions and financial protection [2]. These are the most direct results of country UHC strategies and investments. This paper is part of a PLOS Collection on UHC monitoring and focuses on the measurement and monitoring of health intervention coverage in the context of UHC. Monitoring financial protection is discussed in an accompanying paper in this Collection [3]. It should be stressed, however, that UHC requires Summary Points N Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health. N Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage. N Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal. N Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and peoples expectations, the indicator sets will not be the same everywhere. N Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure. N A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights. N Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention. N Targets should be set in (...truncated)