Measurement of universal health coverage
A small cube nested within a larger one, as shown in Figure 8.1, usually depicts the scope of measurement for UHC. The breadth of the larger cube represents
Fig. 8.1 Scope of measurement of universal health coverage (UHC).
Reproduced with permission from wHO, Health financing for universal coverage: Universal coverage—three dimensions, http://www.who.int/health_financing/strategy/dimensions/en/, accessed 01 Feb. 2016, copyright © 2016 wHO.
the population to be covered by a service, and the breadth of the smaller cube within is the proportion of population currently effectively covered by the service. The depth of the larger cube would be ideally the entire range of quality health services required by that population, and that of the smaller cube is the priority services that are currently available. The height of the larger cube is total cost of the services, and the smaller cube represents the proportion of costs met by financial protection mechanisms, such as government subsidies or insurance. In this depiction, the ideal is the large outer cube, while the inner cube represents current reality, and the movement from the inner to the outer cube along each axis measures progress towards UHC (Boerma et al. 2014).
This depiction of progress may be deceptively simple, but in practice this measurement is complex and problematic and must satisfy two purposes (Sahay and Sundararaman 2015). One of these is to make summary assessment of the status of a nation, which finds use in cross-country comparisons and provides impetus for policy interventions to maintain or improve performance.
Most such approaches use a subset of tracer indicators for measuring coverage, and combine it with financial protection indicators available from periodic surveys; either into a single index, or a set of indicators (see Fig. 8.2). Most LMICs do not have an adequate database to calculate these coverage indicators,
Fig. 8.2 Proposed indicators for measuring progress towards UHC.
Reproduced with permission from Sundararaman T, vaidyanathan G, vaishnavi, SD, Reddy Кг, Mokashi T, Sharma J, ved R, et al. (2014). Measuring Progress towards Universal Health Coverage: An Approach in the Indian Context. Economic & Political Weekly, Volume 49, Issue 47, pp. 60-65, Copyright © 2014 Sundararaman et al.
and tend to continue to rely on the existing MDG database. Even with limited indicators, reliability is a problem.
The other purpose of measurement is to enable public health management action at subnational levels. In large nations like India, such action is primarily the responsibility of the provincial or state level, with the federal government having a role in financing and in redressing uneven development. Provincial governments require health sector performance metrics—disaggregated by districts and below—to identify those lagging behind, and provision to fill the financial, human, and knowledge-related gaps. In addition, governments need to decide priority services to be included in an insurance package or made available as assured services, and the mechanisms by which to ensure financial protection. And for all of this, accurate information is required on what services people require most, which services contribute most to costs of care, patterns of service utilization, and effective models of financial protection. It is not essential that both these purposes be served by the same approach to measurement. Survey-based approaches, which are time and cost intensive, would be useful to generate national UHC progress scores on select indicators. Measuring progress towards UHC using routine data will provide more granular and relevant information to guide policy and management choices, but would require the existing systems to be improved and expanded considerably.
With this understanding of measurement, in the next section we examine some challenges before any HIS.