Monitoring Universal Health Coverage in Low and Middle Income Countries

Monitoring Universal Health Coverage (UHC) in
Low- and Middle-Income Countries
Ajay Tandon
Lead Economist
Global Practice on Health, Nutrition, and
Population
World Bank
1818 H Street, NW
Washington, DC, USA
Indonesia Health Economics Association Annual Meeting

Yogyakarta, Indonesia
July 2016

What is UHC?
Earlier UHC definition: “… ensuring all people receive all the health
services they need, without suffering financial hardship.”
Recently updated/elaborated UHC definition: “… ensuring that all
people can use the promotive, preventive, curative,
rehabilitative, and palliative health services they need, of
sufficient quality to be effective, while also ensuring the use of

these services does not expose the user to financial hardship.”




What sets UHC apart from some previous global objectives (e.g.,
“health for all”) is the explicit focus on financial protection.
UHC is about progressively reducing both the ill-health burden and the
economic burden of disease.
Increasing effective coverage of health interventions and reducing
dependence on OOP payments as well as increasing financing from
prepaid/pooled sources is key to making progress towards to UHC.

Reduce
OOP
Increase
prepaid/
pooled
health
financing

share

UHC

Increase
effective
coverage

“The Four U’s”: Health Shocks…


…are unwanted/undesirable.
 unlike many other goods/services, people
do not generally choose to consume
medical care.



…are uncertain/unpredictable.



…are uncommon, usually concentrated in
a relatively small share of the population.



…occur in unison with financial shocks.
 direct OOP health-related expenditures.
 indirect costs due to inability to work, etc.



UHC recognizes this health shockfinancial shock duality and these
characters make health amenable to
financing from prepaid/pooled sources.
3

More Than a 100 Countries Globally Have
Attained or Have Committed to Attaining UHC

Bangladesh
2032

Myanmar
2030

Lao PDR
2025

India
2022

Vietnam
2020

Indonesia
2019

Philippines
2016

Thailand
2002

Korea
1989

UHC is One of the Sustainable Development
Goals (SDGs)
SDG 3.8: “achieve universal health coverage, including financial risk protection, access to quality essential health-care
services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

Conceptualizing UHC
Total health expenditure

1.

Population Coverage (“BREADTH”)

2.

Service Coverage (“SCOPE”)

3.

Financial Coverage (“DEPTH”)

Prepaid/pooled financing

WHO-WB Recommended UHC Monitoring
Indicators
Preventive/Promotive:
 Access to modern contraceptives
 ANC coverage
 Skilled birth attendance
 DPT3 immunization
 Non-smoking rates
 Access to improved water sources
 Access to improved sanitation

Treatment:

Catastrophic and Impoverishing OOP Health
Expenditures
Consumption (C) = Medical (M) + Non-Medical (NM)

Catastrophic payments:

Non-catastrophic OOP

Catastrophic OOP

Percentage of households whose OOP
health expenditure exceeds 25% of
total consumption

M0.25(C)
Poverty
line

NM
Cumulative % of households

Percentage of households who are
impoverished and pushed deeper into
poverty by OOP heath expenditures,
using US$1.90 and US$3.10 poverty
lines

More People Access Essential Health Services
Than Ever Before

Source: 2015 WHO-WB Global Monitoring Report

Not Only are Levels Improving, but Inequalities
are Narrowing
PRO-RICH INEQUALITIES

EQUALITY

PRO-POOR INEQUALITIES

However, Coverage is Far from Universal…Both
for Ex-MDGs…

Currently 400 million people
lack at least one of these
seven essential services

Source: WHO-WBG Global Monitoring Report Data: 2013

… and for NCDs.
Hypertensive adults disaggregated by diagnosis and treatment status
Effective coverage is low

And Substantial Inequalities Persist …
Ex-MDGs
Coverage of selected interventions in selected LICs and
LMICS, by wealth quintile

NCDs
Share of hypertensive adults on medication in selected LICs
and LMICs, by wealth quintile

Global Averages Mask Substantial Regional
Variation
Regional coverage in 2000 (baseline) and 2013 (endline)

WHO-WB UHC Monitoring Framework Results
UHC Preventive/Promotive Indicators
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia

South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income

Family
planning

ANC

80%
51%
85%
55%
62%
50%
49%
49%
68%
60%
68%
79%
78%
48%
46%

96%
89%
95%
75%
96%
53%
97%
95%
100%
97%
99%
98%
96%
90%
86%

Source: World Development Indicators

Skilled
birth
attendance
99%
71%
100%
67%
83%
40%
99%
73%
100%
94%
99%
100%
94%
83%
74%

DPT3

Tobacco
non-use

Water

Sanitation

93%
97%
99%
83%
78%
88%
97%
79%
97%
70%
99%
99%
95%
86%
86%

83%
76%
75%
87%
62%
65%
77%
73%
59%
80%
85%
78%
76%
71%
78%

98%
71%
92%
93%
85%
72%
100%
92%
97%
95%
94%
96%
95%
87%
83%

81%
37%
65%
36%
59%
65%
96%
74%
70%
74%
92%
93%
75%
67%
59%

WHO-WB UHC Monitoring Framework Results
UHC Treatment Indicators
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income

ARV
46%
71%
52%
36%
8%
30%
21%
24%
29%
45%
19%
61%
37%
38%
29%

UHC Financial Protection
TB
72%
94%
95%
88%
86%
90%
78%
88%
69%
77%
86%
81%
91%
88%
82%

Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle-income

Prepaid/pooled OOP