Effective Coverage: A Metric for Monitoring Universal Health Coverage

et al. (2014) Effective Coverage: A Metric for Monitoring Universal Health Coverage. PLoS Med 11(9): e1001730. doi:10.1371/journal.pmed.1001730 Effective Coverage: A Metric for Monitoring Universal Health Coverage Marie Ng 0 1 Nancy Fullman 0 1 Joseph L. Dieleman 0 1 Abraham D. Flaxman 0 1 Christopher J. L. Murray 0 1 Stephen S. Lim 0 1 0 Abbreviations: ANC , antenatal care; ART, antiretroviral therapy; COPD, chronic obstructive pulmonary disease; DHS, Demographic and Health Survey; DOTS, directly observed treatment, short-course; DSM , Diagnostic and Statistical Manual for Mental Disorders; GA-BW, gestational age and birth weight-adjusted; GBD 2010, Global Burden of Disease 2010 study; HAART, highly active antiretroviral therapy; IPTp, intermittent preventive therapy during pregnancy; ITN , insecticide- treated net; IV, instrumental variable; MMR, measles-mumps-rubella; SD, Symptomatic Diagnosis; STDs, sexually transmitted diseases; UHC, universal health coverage; VA, verbal autopsy; WHO , World Health Organization 1 Institute for Health Metrics and Evaluation (IHME), University of Washington , Seattle, Washington , United States of America A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric - need, use, and quality - using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations. - Strengthening health systems, ensuring affordability of care, improving access to quality services, and building capacity are core tenets of universal health coverage (UHC). In 2010, the World Health Organization (WHO) called for concerted efforts to achieve UHC, with reducing disparities and promoting opportunities for obtaining quality care with financial protection as WHOs underlying goals [1]. The ideology of UHC laid out by WHO was viewed as ambitious and noble; however, it has been criticized for the lack of specificity for defining milestones crucial for monitoring progress [2]. The importance of systematically tracking the progress in attaining UHC was highlighted in the 2013 World Health Report [3], which drew attention to the dearth of empirical evidence for assessing and informing policies related to UHC. The report identified several key research priorities, which included deepening the understanding of disease burden at the country level and identifying policy-relevant 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. metrics for tracking progress. Nevertheless, the question remains: how should progress towards UHC be monitored? As noted in a recent World Bank report on UHC [4], in order to adequately capture the spectrum of health services represented by UHC, a more holistic approach to the dimensions of access needs to be understood. In other words, the most useful metric for monitoring progress in UHC should encompass the multifaceted nature of UHC. The monitoring framework put forth by WHO and the World Bank Group in 2013 highlighted two major components critical to assessing UHC progress, namely, service coverage and financial protection coverage for all people [5]. For measuring service coverage, the concept of effective coverage was noted. In contrast to crude coverage, which focuses solely on intervention access or use, effective coverage is a measure that unites intervention need, use, and quality. The comprehensiveness of this metric makes it more suitable for monitoring UHC [69]. In this paper, we will review the concept of effective coverage and discuss a number of key issues related to its measurement. What Is Effective Coverage? Effective coverage is defined as the fraction of potential health gain that is actually delivered to the population through the health system, given its capacity. It is comprised of three components, namely, need, use, and quality. Need refers to the individual/ population in need of a particular service; use refers to the use of services; and quality refers to the actual health benefit experienced from the service. Measuring effective coverage is a significant advancement over the usual approach of measuring crude coverage, which only captures access conditional on need. In particular, given that use of service alone does not imply that the N Effective coverage unites intervention need, use, and quality into a simple but data-rich metric, reflecting the core components of UHC. N Effective coverage can be applied to understand the health gains delivered by interventions at a range of levels, from individual benefits to national impact. N Effective coverage can be measured and used across resource settings. Lower-income countries can harness data from existing survey data to feed into effective coverage estimations. N The broader use of effective coverage remains hindered by the availability and quality of health data, especially at subnational levels. full benefit of the service is being realized, it is crucial for a health performance metric to capture not only coverage but also quality. The calculation of effective coverage is summarized in Box 1. In addition to capturing quality, effective coverage has another unique strength: it is a very flexible metric that can easily be adapted for different contexts and assessed at different administrative levels. Specifically, effective coverage can be measured for one single intervention and provide information on specific intervention rollout. To the degree that data are available, effective coverage can also be aggregated across a large, diverse set of interventions and proxy the effectiveness of an entire health system. In other words, effective coverage can be adapted in a manner that reflects country needs and health priorities, hence serving as an appropriate indicator for tracking progress and benchmarking performance. Effective coverage also can be estimat (...truncated)