The Problems with the Proposed Indicators for Monitoring Universal Health Coverage in the Sustainable Development Goals

Audrey R. Chapman

Writing in 2014, Alicia Ely Yamin and Vanessa Boulanger showed how the global approach to women’s sexual and reproductive health was skewed by the selection of targets and indicators chosen to measure Millennium Development Goal 5.¹ The narrow focus of these targets and indicators on maternal healthcare and on maternal mortality in particular was converted into national planning tools and priorities for international aid. In the process, broader dimensions of gender equality and women’s sexual, reproductive, and health rights were sidelined. I fear that the same type of narrowing, counterproductive to human rights, is happening with the measurement of universal health coverage for the Sustainable Development Goals.

Universal health coverage is a component of the omnibus Goal 3, “ensure healthy lives and promote well-being for all at all ages,” of the Sustainable Development Goals (SDGs) adopted in September 2015 by the UN General Assembly. Specifically, the wording of Goal 3.8 is to “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.”² Of the various components of Goal 3, the universal health coverage target arguably tracks the right to health the most closely. Indeed some of the high level staff working in multilateral and associated agencies of the UN who were interviewed as to why the right to health was not explicit in key preparatory documents for the formulation of the SDGs, including the guiding document for interstate negotiations, argued that the right to health was already encapsulated in the sub-goal of universal health coverage.³

Various indicators proposed to measure universal health coverage in the SDGs have sought to be inclusive of all of its components and to incorporate equity measures. Consistent with the human rights emphasis on disaggregation, the World Health Organization’s proposed monitoring framework for universal health coverage sought to produce statistics to highlight health inequalities by major stratifiers, including demographic (age, sex/gender), socioeconomic status (wealth, education), geography (province/district) and other characteristics (migration, minorities, etc).⁴

The global monitoring framework for universal health coverage coordinated by WHO and the World Bank Group, which involved broad consultation with many stakeholders through the web and multiple multi-stakeholder meetings, including member state briefings, incorporated the following indicators:

Health services coverage

• Prevention
  • Coverage with a set of tracer interventions for prevention services including (effective) family planning, antenatal care (four or more visits), immunization coverage, non-tobacco use, and adequate water source and sanitary facilities (covered under another goal).
  • Equity: a measure of prevention service coverage as described above, stratified by wealth quintile, place of residence, and sex.
• Treatment
  • Coverage with a set of tracer interventions for treatment services including skilled birth attendance, coverage of TB treatment, ARV therapy, diabetes treatment, and hypertension treatment.

Financial protection coverage

• Impoverishing expenditure
  • Aggregate: fraction of the population protected against impoverishment by out-of-pocket health expenditures, comprising two types of households: families already below the poverty line who incur out-of-pocket health expenditures that push them deeper into poverty; and families for which out-of-pocket spending pushes them below the poverty line.
  • Equity: fraction of the population protected against impoverishment or further impoverishment by out-of-pocket health expenditures, stratified by wealth quintile, place of residence, and sex.
• Catastrophic expenditure
  • Aggregate: fraction of households protected from incurring catastrophic out-of-pocket health expenditure.
  • Equity: fraction of households protected from incurring catastrophic out-of-pocket health expenditure stratified by wealth quintile, place of residence, and sex.

It is therefore very disturbing that the monitoring framework developed by the Inter-Agency and Expert Group on SDG Indicators, dominated by representatives of national statistical offices, which is to be adopted by the UN in early April, has only two very inadequate indicators for achieving universal health coverage:

• Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged population).
• Number of people covered by health insurance or public health system per 1,000 population.⁵

Although the Report of Inter-Agency and Expert Group states that SDG indicators should be disaggregated, where relevant, in accordance with the fundamental principles of official statistics, the indicators proposed for universal health coverage discourage or preclude disaggregation and do not incorporate any of the equity measures built into the WHO/World Bank proposal.⁶

So why were such inappropriate indicators adopted? Some health advocates reported that UN Member States had raised concerns about the difficulty of collecting data for earlier proposed indicators.⁷  Reluctance to release disaggregated data that would have revealed a more accurate profile of the absence of coverage and financial risk protection may have also been a factor.

A comment posted by Save the Children characterized the indicator adopted for the number of people covered by health insurance or a public health system as meaningless.⁸ It also warned that without a more meaningful measure of financial risk protection, one that takes out-of-pocket expenditures into account, the impoverishing effect of health spending on some of the poorest and most marginalized groups is not captured nor addressed. Global Health Check, a coalition of 303 organizations, including NGOS, academic institutions, foundations, and patient groups, which has been monitoring the development of health indicators, has reacted with alarm and called for urgent action to revoke the indicators for universal health coverage.⁹ It warns that if left unchanged, these proposed indicators could lead to more exclusion of women, marginalized groups, and people living in poverty.

It is therefore important that health and human rights advocates support efforts to promote adoption of more meaningful health indicators that measure fulfillment of all people’s right to health.

Audrey R. Chapman is Healey Professor of Medical Ethics, UConn Health. Please address correspondence to achapman@uchc.edu.

Professor Chapman is also the Guest Editor of the special issue of Health and Human Rights Journal, December 2016, “Universal Health Coverage and Human Rights”. The deadline for this issue has been extended to 31 March 2016

References

1. Alicia Ely Yamin and Vanessa M. Boulanger, “Who Global Goals and Indicators Matter: The Experience of Sexual and Reproductive Health and Rights in the Millennium Development Goals,” Journal of Human Development and Capabilities 15 (2014): 218-231.
2. Transforming our World: The 2030 Agenda for Sustainable Development, Resolution adopted by the UN General Assembly on 25 September 2015, A/RES/70/1.
3. Claire E. Brolan, Peter S. Hill, and Gorik Ooms, “’Everywhere but not specifically somewhere’: s qualitative study on why the right to health is not explicit in the post-2015 negotiations,” BMC International Health & Human Rights, 2015: 15-22. DOI10.1186/212914-015-0061-z.
4. World Health Organization, Towards a monitoring framework with targets and indicators for the health goals of the post-2015 Sustainable Development Goals, http://www.who.int/…/indicators/hsi_indicators_sdg…, p.1.
5. Statistical Commission, Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators, 19 February 2016, E/CN.3/2016/2/Rev.1, p. 18.
6. Ibid., p. 7.
7. Jenny Lei  Ravelo, “How should we measure access to health care?” March 2016, Devex World 2016, https://www.devex.com/news/how-should-we-measure-access-to-healt…
8. Simon Wright, “Insurance is no assurance: why the SDG indicators need rescuing,” 23 February 2016, http://blogs.savethechildren.org.uk/2016/02/insurance-is-noassurance/
9. Anna Marriott and Mohga Kamal-Yanni, “Last minute change to the UHC indicator for the SDGs is raising alarm bells!” 7 March 2016, Global Health Check, http://www.globalhealthcheck.org/?p=1854.