Ways of Achieving Health Equality in All Countries

Collection Review Monitoring Intervention Coverage in the Context of Universal Health Coverage Ties Boerma1*, Carla AbouZahr2, David Evans1, Tim Evans3 1 World Health Organization, Geneva, Switzerland, 2 Independent consultant, 3 World Bank Group, Washington (D.C.), United States of America prevention, treatment, rehabilitation, and palliation, and coverage with financial protection, for everyone. The former captures the aspiration that all people obtain the health services they need, while the latter aims to ensure that they do not suffer financial hardship linked to paying for these services. For all countries, moving towards UHC is a process of progressive realization. It is about making progress on several fronts: the available range of services; the quality of the services; the proportion of the costs of those services covered; and the proportion of the population covered. For richer countries, the main challenges relate to protecting and extending past gains in the face of financial constraints, ageing populations, new health threats, continuous advances in technologies capable of extending life or improving health, and increasing expectations on the part of the public. For the poorest countries, the challenge is to initially ensure basic essential services to the whole population. The diversity in the nature of the challenge has implications for the selection of indicators for monitoring of progress towards UHC goals in countries. Overall monitoring of health progress and health system performance uses a range of indicators that measure determinants of health, health sector inputs such as finances and health workforce, outputs such as access to and quality of services, coverage of interventions, and health impact. For UHC monitoring we propose a focus on the level and distribution of coverage of health interventions and financial protection [2]. These are the most direct results of country UHC strategies and investments. This paper is part of a PLOS Collection on UHC monitoring and focuses on the measurement and monitoring of health intervention coverage in the context of UHC. Monitoring financial protection is discussed in an accompanying paper in this Collection [3]. It should be stressed, however, that UHC requires Abstract: Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Ways of Achieving Health Equality in All Countries

Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Citation: Boerma T, AbouZahr C, Evans D, Evans T (2014) Monitoring Intervention Coverage in the Context of Universal Health Coverage. PLoS Med 11(9): e1001728. doi:10.1371/journal.pmed.1001728 Published September 22, 2014 This paper is part of the PLOS Universal Health Coverage Collection. Copyright: ß 2014 Boerma et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This work was partly supported by a grant from the Rockefeller Foundation and the Ministry of Health of Japan to World Health Organization (WHO). This included a technical meeting of principal investigators in Singapore, 16–17 September 2013, organized by the WHO and Ministry of Health of Singapore, to discuss the overall framework of the review. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction Universal health coverage (UHC) has been defined as the ability of all people who need health services to receive them without incurring financial hardship [1]. UHC consists of two inter-related components: coverage with health services, including promotion, Competing Interests: The authors have declared that no competing interests exist. Ways of Achieving Health Equality in All Countries

Abbreviations: MDG, Millennium Development Goal; NCD, noncommunicable disease; UHC, universal health coverage. Collection Review articles synthesize in narrative form the best available evidence on a topic. Submission of Collection Review articles is by invitation only, and they are only published as part of a PLOS Collection as agreed in advance by the PLOS Medicine Editors. * Email: boermat@who.int Provenance: Not commissioned; part of a Collection; externally peer reviewed PLOS Medicine | www.plosmedicine.org 1 September 2014 | Volume 11 | Issue 9 | e1001728 Summary Points General Health Sector Monitoring Framework N UHC monitoring constitutes one part of a broader results framework that is commonly used for monitoring and evaluation of progress and performance of specific programmes [4–7] and the health system [8] by many countries and globally. Figure 1 presents a results framework where health sector inputs such as money and health workforce lead to outputs such as access to and quality of services, coverage of interventions, and ultimately to health impact, that is, improved levels and distribution of health and wellbeing, and improved health systems responsiveness. Results at each step are affected by health system policies and influenced by the social determinants of health. To make progress towards the goal of UHC countries will have to advance in terms of health system inputs, outputs, and coverage of good quality services in all population groups. In this paper, we propose to focus on the coverage indicators of the results framework, i.e., people receiving the services they need, as the most direct measures of UHC progress in the population. In addition, improved health status of the population is indicative of UHC progress although it is also influenced by socioeconomic, environmental, nutritional, and other factors. Input indicators, such as total health expenditure per capita or health workforce density, and output indicators, such as access to services (whether the health services that people might need are available, close to them), help to determine or explain observed levels of coverage with both health services and financial protection and are useful in identifying policy levers that might be used to improve coverage. However, they are conceptually different to the concept of UHC in that they are purely instrumental—they are not valued for their own sake but are ways of ensuring that people can receive interventions. Output indicators, such as service availability and general service utilization, can provide an indication of the degree of access to services, but are less suitable for UHC monitoring than service coverage indicators, as they do not relate to a specific need for services. Moreover, setting targets for output indicators is difficult and often of limited policy value. Ways of Achieving Health Equality in All Countries

Utilization of outpatient and inpatient services and interventions varies widely even in countries where access to services is supposedly very good. Improvements in UHC coverage should, in principle, translate into improved health status. However, using health impact indicators, such as mortality and morbidity by age, sex, and cause to monitor UHC would be less suitable because they are insufficiently specific to UHC, being strongly affected by socioeconomic, environmental, behavioural, and other determinants of health. Changes in coverage are more responsive to programme inputs and occur more rapidly than for health impact; they are, therefore, of particular value for guiding policy and programme decisions. Box 1 provides a summary of the terms of access, utilization, and coverage used in this paper [9–12]. N N N N N N N N N Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health. Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage. Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal. Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people’s expectations, the indicator sets will not be the same everywhere. Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure. A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights. Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention. Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations. The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC. It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers. simultaneous monitoring of intervention coverage and financial protection, with an equity focus. First, we present an overall results framework for monitoring health system performance that can be used to track progress towards UHC in countries and argue for the focus on intervention coverage indicators. The framework has been applied in different ways in several country case studies in this PLOS Collection. Subsequently we examine the current coverage indicators for UHC, from health promotion to palliative care, and discuss the suitability of a set of tracer indicators for multiple intervention areas, including a quality of care dimension. We identify the main measurement gaps and summarise the investments in health information systems that will be needed to address them. Ways of Achieving Health Equality in All Countries

PLOS Medicine | www.plosmedicine.org Coverage Indicators There are dozens of intervention coverage indicators that could be used to track UHC progress. Countries should select those indicators that are most relevant to their own situation. A systematic approach is needed to ensure the selection of an optimal set of indicators for the main health priorities and the identification of measurement gaps. This approach should also help avoid giving too much weight to intervention areas where many indicators are available and neglecting others that are more difficult to measure and monitor. 2 September 2014 | Volume 11 | Issue 9 | e1001728 Figure 1. Results chain framework for monitoring health sector progress and performance: focus of UHC monitoring in the red box. doi:10.1371/journal.pmed.1001728.g001 women of reproductive age), pregnancy and delivery care (e.g., antenatal care attendance), and immunization coverage (specific vaccines or full coverage), as well as coverage of interventions on behavioural risk factors. Indicators on safe water and sanitation should also be included, even though they are generally not the primary responsibility of the health sector, because improvement of health can be considered a primary purpose of these interventions. Reduction of risk factors for chronic conditions and injuries includes policy measures that apply at a population level, such as tobacco control, which eventually translate into measurable changes in personal behaviours that can be expressed in terms of coverage. The indicators should measure the positive behaviour and are therefore presented as the inverse of the prevalence of the risk behaviour, e.g., non-use of tobacco among the adult population. The denominator of the coverage indicators is relatively straightforward for most promotion and prevention indicators as the target population is usually all persons with certain age-sex characteristics, such as children under one year of age for immunization or pregnant women for antenatal care. For some indicators, such as the need for family planning satisfied, the denominator is more complicated as desire for another child, pregnancy, lactation, and exposure status will have to be taken into account [16]. The numerators of the coverage indicators are relatively straightforward for most interventions, provided there is a standardized intervention that can easily be recalled in surveys or reliably be reported through facility reporting systems. For some indicators such as immunization coverage, home-based records of child immunization are used in surveys to improve the quality of the recall data in household surveys. Indicators of anthropometric status, e.g., the proportion of children underweight or stunted, are not included as they reflect health status rather than intervention coverage. Ways of Achieving Health Equality in All Countries

UHC contributes to improvements in anthropometric status, which is affected by multiple factors, but the numerator of the indicator is not related to a specific intervention. Indicators that monitor interventions and risk factor reductions can be classified in different ways: according to the type of intervention (promotion, prevention, treatment, rehabilitation, palliation), the type of condition or intervention area they address (related to the health Millennium Development Goals [MDGs], noncommunicable diseases [NCDs], injuries), the characteristics of the target population (e.g., by stage in the life course or sex), and the level of delivery of the interventions (from non-personal or population health measures to tertiary hospital services). Table 1 presents a list of examples of indicators by intervention areas and type of intervention, divided into two major groups: promotion and prevention, and treatment services (including ambulatory and in-patient services). The coverage indicators are derived from existing listings, such as those adopted by Member States as part of World Health Assembly resolutions. Other international agreements include the coverage and risk factor indicators in the MDGs [13], the Countdown to 2015 for maternal, newborn, and child survival [14], and the action plan for monitoring NCDs [15]. The proposed UHC list is not intended to be comprehensive, but it does include the majority of the most commonly used indicators. Data availability and measurability of the indicators are highly variable. Ideally, a small set of tracer indicators is identified to assess overall progress towards UHC. The choice of indicators should, to the extent possible, be based on objective considerations, but will involve a tradeoff between the desire to keep the numbers of indicators small and manageable and, at the same time, address a breadth of health interventions to capture the essence of the goal of UHC. Box 2 summarizes the considerations for selection of indicators (Table S1 provides an application). Since UHC goals are essentially about progressive realization, tracer indicators are likely to be added or changed as the country socioeconomic and epidemiological situation changes. Promotion and Prevention Coverage Indicators Commonly used indicators in this category include coverage of family planning services (measured by need satisfied among PLOS Medicine | www.plosmedicine.org 3 September 2014 | Volume 11 | Issue 9 | e1001728 Self-Reports Box 1. Definitions of Terms Self-reported medical diagnosis is commonly applied in surveys in high-income countries, where access to services is good. For instance, the National Health Interview surveys in the USA and Taiwan asked for a diagnosis of arthritis, diabetes, hypertension, and stroke. The method is however of limited value in detecting unmet need for treatment when people do not know they have the condition or do not report correctly [17]. Indicators of the coverage of interventions for injuries (e.g., caused by road traffic accidents) are often based on self-report of the event in a survey interview, as they require data on the number of injuries that would have required emergency care. Challenges are the quality of self-reports on severity of the injury and survivor bias. Because of these problems, monitoring of deaths caused by road traffic accidents has been proposed as a summary indicator of promotion, prevention, and treatment interventions [18]. Coverage of assistive devices or products among people living with disabilities has been proposed as an indicator [19], and need can be measured through questions on specific disabilities. Disability however has many dimensions and responses in surveys are highly dependent on the interview questions [20,21]. Instruments can range from a few questions, such as the six questions to assess difficulties with seeing, hearing, mobility, cognition, self-care, and communication developed for censuses and surveys by the UN Statistical Commission Washington City working group (http://www.cdc.gov/nchs/washington_group. htm) to full questionnaires with comprehensive assessments of functioning. Considerable investment will be needed to obtain comparable data between or even within countries over time. Clinical markers, such as a vision test (see below), are a useful alternative for some disabling conditions. Service access: the opportunity or ability for people to obtain the services they need without financial ruin. Access has three dimensions: physical accessibility, financial affordability, and socio-cultural acceptabili .. Ways of Achieving Health Equality in All Countries