Measuring Progress Towards Universal Health Coverage: Evolving Agenda - An Update

by T. Sundararaman

There is a growing volume of published literature and international interest in the question of measuring progress towards universal health coverage. One important source is the World Bank sponsored Universal Health Coverage Studies Series (UNICO) which has now brought out cross country studies 22 nations. 

The other is the Joint Learning Network- a platform funded jointly by BMGF, World Bank, Rockefeller, GTZ and WHO and managed by two Washington based organizations: Results for Development Initiative and Accord International. It defines its agenda as Information Technology, Aligning Primary Health Care to Universal Health Coverage, Poverty Targeting, Provider Payment Mechanisms, and Quality. Even a brief analysis of the content of their outputs and news reveals that its basic thrust is the adoption of health insurance as the core of health sector reforms. There is little discussion on any other approach.

One of the most useful insights in this area is the special issue of Plos Medicine (September 2013) exclusively devoted to the issue of Measuring Progress towards Universal Health Coverage. This series, which was initiated by an international workshop held in Singapore, jointly sponsored by World Bank, WHO and Rockefeller does address the problematic of measurement in a more comprehensive manner and allows for a larger set of approaches towards universal health coverage. The cross- country examples in this journal does capture how measurements change when approaches to UHC change. However the final conclusions and the overview articles still search for a common measurement tool that does not adequately factor in this diversity.

WHO has since announced a set of indicators for measuring UHC and is in the process of finalizing it. In parallel BRICS nations have proposed their own set of measurement indicators, which includes components related to social determinants of health. In parallel, the dialogue regarding the targets of the post-2015 Millennium Development Goals has also evolved. These two discourses – one on measuring progress to UHC and another on setting the post- 2015 MDGs - are now overlapping and gradually converging.

Given the rapid expansion of work in the area of measuring progress towards universal health coverage, it is difficult to formulate any simple position that will capture the political or technical essence of all the developments in this domain. Technically the indicators that are most relevant are least feasible, partly because current information systems are not geared to collect them. The measures that are most feasible tend to favor measurement of coverage in terms of few tracer indicators that favor minimalist intervention packages. Typically they measure financial protection in terms of “nominal insurance coverage.” The latter implies an assumption being made that anyone on whose behalf an insurance premium has been collected is protected from financial risk. This is far from the truth. Most approaches do not engage with free or subsidized care by public providers as legitimate forms of financial protection. Importantly, the methods of measurement are not geared to empowering communities, civil society or even the political leadership at decentralized levels to understand why gaps exist and how district level interventions could optimize the mix of services, providers and payment.

Clearly there is a need for civil society and academicians working for strengthening public health services to study and engage with this growing body of literature and then go beyond it to formulate more relevant indicators and information systems. The need to draw up, disseminate and use alternative approaches to measurement of health sector performance must be seen as part of the struggle against corporate control of health care systems and the need to build alternative community centered approaches to health care.

A more comprehensive discussion on UHC as a health policy proposal is inlcuded in the latest edition of the Alternative World Health Report, Global Health Watch 4, under the title The current discourse on Universal Health Coverage.