Coordination of policies within and beyond the health sector
Universal Health Protection 49
relative deficit in per capita health
spending can be established by calculating the relative difference between total per capita health spending except OOP in a specific
country and the population-weighted median value of total per capita health spending except OOP in a group of countries. This group consists of countries where
sufficient national revenues can be raised through fair health financing mechanisms to reach levels of health-care spending that would be adequate to establish equitable
access to quality services for all in need.
The maternal mortality ratio − the death of a woman while pregnant or within 42 days of termination of pregnancy – is expressed as maternal mortality per 10,000 live
births. This indicator is suggested because it reflects access to and quality of maternal care services and the general health service, following the logic that pregnancy should
not be a cause of death.
The availability of health care can be measured using the ILO Staff Access Deficit Indicator SAD
which reflects the share of people not having access to essential care due to lack of skilled health workers. The SAD uses a relative threshold currently
amounting to 41.1 health professionals per 10,000 population. This threshold derives from the population-weighted median of a group of countries that have the potential
to provide universal coverage ILO, 2014. It provides information on the density of skilled health workers to ensure the provision of services, and indirectly it also
reflects quality and accessibility of services within the health sector. In this context, decent working conditions − particularly wages − play a key role. If wages are too
low, services will lack quality and health workers may be tempted to migrate or accept under-the-table payments.
In order to monitor progress based on quantitative data and using the indicators, it is suggested that countries collect, compile, analyse and publish data, statistics and indicators
on social protection in health on a regular basis. Given the high costs associated with data development, it is recommended that – as far as possible – existing databases be used,
including national health surveys. When information contained in national surveys is not sufficient, the databases referred to in figure 4.1 can be of use. The Resolution concerning
the development of social security statistics adopted by the Ninth International Conference of Labour Statisticians can also provide some guidance in this endeavour.
4.3.2. What thresholds can be used?
Among the indicators described above, two are of relative nature: the relative deficit in per capita health spending and the Staff Access Deficit Indicator. In order to calculate the
deficit between the status quo and the level striven for, it is necessary to develop thresholds that are considered adequate for achieving universal social protection in health.
As shown above, the key determinants of a country’s ability to provide its inhabitants with adequate care and thus to establish universal social protection in health relate to the levels
of poverty and formal employment. On the one hand, both poverty and the extent of the informal economy strongly influence a country’s potential to collect taxes, premiums and
contributions to finance health care to a level in which at least essential health services of adequate quality can be delivered to those in need. On the other hand, both poverty and
informal economy levels represent challenges in reaching out to often vulnerable groups. Further, it is important that OOP are minimized and not used as health financing
mechanism given their impoverishing impacts.
Against this background, it is suggested that in developing thresholds, countries that perform well in these respects be chosen. Countries can be grouped by levels of
vulnerability, defined by their existing extent of poverty, informal economy as well as the extent of OOP used for financing health care ILO 2014; Scheil-Adlung et al., 2010:
50 Universal Health Protection
Poverty levels are based on a poverty line of US2 a day, using as a database World Development Indicators, ADB or ECLAC.
Non-wage workers as a share of total workers is used as a proxy for informality, using as a database ILO LABORSTA, ILO KILM and national sources.
Regarding countries with low vulnerability, health expenditure not financed by OOP to a level above 40 percent of total health expenditure.
Four levels of country vulnerability can be distinguished, ranging from very low vulnerability e.g. Hungary to very high vulnerability e.g. Benin. See Annex V for
complete list of countries categorized according to vulnerability.
The thresholds suggested by the ILO refer to those countries that are characterized by low poverty levels, relatively small informal economies and acceptable financing mechanisms.
Thus it is the group of low-vulnerability countries that is used for calculating both the relative deficit in per capita health spending and the SAD.
Threshold for calculating the relative deficit in per capita health spending : The
population-weighted median value of per capita health spending in low-vulnerable countries serves as this threshold. Subsequently, the relative difference between this value
and the per capita health spending in a given country is calculated, resulting in the country’s relative deficit in per capita health spending.
Threshold for calculating the Staff Access Deficit Indicator SAD: This threshold is based
on deficits in the density of health workers per population and is calculated as the population-weighted median value of qualified health staff, i.e. nurses, midwifery
personnel and physicians per 10,000 population. Currently this threshold amounts to 41.1 qualified health workers per 10,000 population. The SAD uses the relative difference
between the national density of health professionals in a given country and the population- weighted median value in low-vulnerability countries amounting to 41.1 health workers
per 10,000 population. The advantage of using such a relative threshold relates to its regular adjustment to changes in the workforce density, whereas absolute values might
become outdated.