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
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.
“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
shock-financial shock duality and these characters make health amenable to financing from prepaid/pooled sources.
More Than a 100 Countries Globally Have
Attained or Have Committed to Attaining UHC
Bangladesh
2032
Vietnam
2020
Indonesia
2019
Lao PDR
2025
Myanmar
2030
India
2022
Philippines
2016
Thailand
2002
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
Conceptualizing UHC
1.
Population Coverage
(“BREADTH”)
2.
Service Coverage
(“SCOPE”)
3.
Financial Coverage
(“DEPTH”)
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:
ARV coverage
Hypertension treatment
TB treatment coverage
Diabetes treatment coverage
Financial Protection:
OOP spending as share of household consumption
Catastrophic and Impoverishing OOP Health
Expenditures
Catastrophic payments:
Percentage of households whose OOP health expenditure exceeds 25% of total consumption
Impoverishing expenditure:
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
Cumulative % of households Poverty
line
Consumption (C) = Medical (M) + Non-Medical (NM)
NM C
M>0.25(C)
M<0.25(C)
Non-catastrophic OOP
Catastrophic OOP
Impoverishing OOP
Source: 2015 WHO-WB Global Monitoring Report
Not Only are Levels Improving, but Inequalities
are Narrowing
EQUALITY
PRO-RICH INEQUALITIES
Source: WHO-WBG Global Monitoring Report Data: 2013
Currently 400 million people
lack at least one of these seven essential services
Hypertensive adults disaggregated by diagnosis and treatment status
… and for NCDs.
Coverage of selected interventions in selected LICs and LMICS, by wealth quintile
Share of hypertensive adults on medication in selected LICs and LMICs, by wealth quintile
And Substantial Inequalities Persist …
Regional coverage in 2000 (baseline) and 2013 (endline)
WHO-WB UHC Monitoring Framework Results
UHC Preventive/Promotive Indicators
Source: World Development Indicators
Country planningFamily ANC Skilledbirth
attendance DPT3
Tobacco
non-use Water Sanitation
Brazil 80% 96% 99% 93% 83% 98% 81%
Cambodia 51% 89% 71% 97% 76% 71% 37%
China 85% 95% 100% 99% 75% 92% 65%
India 55% 75% 67% 83% 87% 93% 36%
Indonesia 62% 96% 83% 78% 62% 85% 59%
Lao PDR 50% 53% 40% 88% 65% 72% 65%
Malaysia 49% 97% 99% 97% 77% 100% 96%
Philippines 49% 95% 73% 79% 73% 92% 74%
Russia 68% 100% 100% 97% 59% 97% 70%
South Africa 60% 97% 94% 70% 80% 95% 74%
Sri Lanka 68% 99% 99% 99% 85% 94% 92%
Thailand 79% 98% 100% 99% 78% 96% 93%
Vietnam 78% 96% 94% 95% 76% 95% 75%
East Asia & Pacific 48% 90% 83% 86% 71% 87% 67%
UHC Treatment Indicators UHC Financial Protection
Country ARV TB
Brazil 46% 72%
Cambodia 71% 94%
China 52% 95%
India 36% 88%
Indonesia 8% 86%
Lao PDR 30% 90%
Malaysia 21% 78%
Philippines 24% 88%
Russia 29% 69%
South Africa 45% 77%
Sri Lanka 19% 86%
Thailand 61% 81%
Vietnam 37% 91%
East Asia & Pacific 38% 88%
Lower middle income 29% 82%
Country
Prepaid/pooled share of total
health expenditure OOP<25 % consum ption Neither pushed nor further pushed into poverty
Brazil 70% 97% 97%
Cambodia 40% 97% 83%
China 66% 87% 90%
India 42% 99% 72%
Indonesia 54% 99% 82%
Lao PDR 60% 100% 93%
Malaysia 64% 100% 99%
Philippines 43% 100% 78%
Russia 52% 100% 100%
South Africa 93% 100% 93%
Sri Lanka 53% 100% 99%
Thailand 89% 100% 100%
Vietnam 51% 95% 75%
East Asia & Pacific 76% 98% 87%
Lower middle-income 60% 97% 84%
Financial Protection in Indonesia
Although OOP health spending is generally regressive, this is not the case for Indonesia; Most of
the impoverishing effects of health spending occur right above the poverty line among the near
poor.
“Pen's Parade” for catastrophic and impoverishing OOP OOP spending on health by economic decile
Decile share of total OOP health spending
OOP health spending share of total consumption
0 10 20 30 40 50 P er ce nt ag e (% )
Poorest 3rd 5th 7th Highest Economic deciles
Source: SUSENAS (2015)
Poverty line
Consumption post OOP health spending
10 00 25 00 50 00 10 00 0 25 00 0 H ou se ho ld c on su m pt io n pe r ca pi ta
Note: Poverty line based on Statistcs Indonesia (BPS-March 2015 period)
670,000 households (1%) face catastrophic health expenditures 1 million households (2%) impoverished
UHC Attainment Index
India CambodiaSolomon Islands
Vietnam Rusia China Sri Lanka Thailand Lao PDR Brazil Malaysia Philippines Indonesia LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE
INCOME HIGH INCOME
20 40 60 80 10 0 U H C a tt ai nm en t in de x
250 500 1000 2500 10000 35000 100000 GNI per capita, US$
Source : WDI
Key Take-Away Messages
UHC has three dimensions:
(i) number of people
covered; (ii) services
covered; and (iii) financial
protection
Progress towards UHC
should not be measured by
number of JKN cards
distributed
Globally, much progress on
coverage for ex-MDG
interventions; however,
inequalities remain
Progress on effective
coverage for NCDs remains
relatively weak globally
Indonesia needs to make
more progress on family
planning, sanitation,
tobacco, immunization,
NCDs, and reduce OOP
spending for health
UHC is about ensuring both
effective coverage and
SDGs Population Health Outcomes in Indonesia
Maternal mortality ratio
Under-five mortality rate
Neonatal mortality rate
5
1
2
2
5
7
0
2
50
7
50
1990 1995 2000 2005 2010 2015 2030 Year
Source: WDI
Note: maternal mortality per 100,000; under-five/neonatal mortality per 1,000 live births
THANK YOU
Ajay Tandon
