Key findings
1.6 Future developments in measuring the UHC SCI (SDG 3.8.1)
1.6.1 Refresh of the UHC service coverage monitoring framework in 2025
In accordance with General Assembly Resolution 71/313 (19) the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (IAEG-SDGs) will conduct a comprehensive review of the global SDG indicator framework throughout 2024 to refine, revise, and replace indicators used to monitor progress towards the 2030 agenda (20). For SDG 3.8.1, the review will consist of a conceptual revision of the index construction and basket of indicators, followed by methodological development.
Importantly, the indicator selection and validation will consider aspects of data frequency and availability. The next country consultation on using the updated methodology will take place at the end of 2024 or beginning of 2025.
1.6.2 Effective coverage
One of the critiques of the current SCI is that it is not fully aligned with the definition of UHC as written for SDG 3.8, and therefore does not provide the full picture of progress toward the service coverage aspect of UHC as measured by SDG 3.8.1. This is, in part, due to the inclusion of indicators that measure the proportion of target populations to receive interventions, but do not indicate whether the interventions were of sufficient quality and quantity to achieve the desired health outcomes.
Different approaches to measuring effective coverage have been proposed, but are ultimately limited by data availability and the degree to which certain methodological approaches are fit for purpose in the context of Member State-consulted measurements and reporting requirements for the SDGs. Nonetheless, continued advances to measuring effective coverage are key to improving the assessment of progress towards UHC.
Conceptually, effective coverage links potential health gains with health systems inputs and processes. Proposed effective coverage cascades provide analytical frameworks to identify barriers and facilitating factors in achieving intervention coverage targets (21,22). On a practical level, the identification of service provision bottlenecks, particularly among specific subpopulations or geographic areas, is key to making progress towards UHC, especially when intervention coverage has reached a relatively high threshold at the national level. While these cascades are informative on the intervention or programme level, such as those proposed to improve quality of care for maternal, neonatal, child, and adolescent health and nutrition (MNCAHN) interventions (23), an index of effective coverage indicators to use as a proxy of UHC at the country level for all Member States requires data inputs beyond what are currently available. To ameliorate the data availability issues, and address the critiques regarding the appropriateness of service coverage indicators selected in the current UHC SCI, the inclusion of additional data not derived from country-based sources and the use of relatively complex methodological approaches were used to estimate an effective coverage index to proxy UHC (24). The degree to which a similar approach to measuring the service coverage dimension of SDG 3.8 could be operationalized in the context of SDG reporting requirements and WHO’s commitment to Member State consultation will be explored in the refresh of the monitoring framework discussed in section 1.6.1.
Monitoring Sustainable Development Goal 3.8.1: coverage of essential health services 21
1.6.3 Unmet need /forgone care
One aspect of making progress toward UHC requires that everyone receives the health services they need. To continue the expansion of service coverage, especially in contexts of relatively high levels of existing coverage, it is essential to understand who has not received the needed services as well as the reasons that they have not received them. There is no universally accepted definition or measurement framework for unmet need and forgone care, but rather a variety of definitions are used for different purposes (see Box 1.5 for examples). Individuals with unmet needs are those who have the potential to realize a health benefit from a given service, which may differ from perceived need due to a variety of social, cultural, and economic factors (25). The unrealized or unexpressed demand for services from those with unmet needs adds further complications to addressing coverage gaps. From a measurement perspective, these groups are difficult to differentiate with respect to many health interventions without extensive diagnostics and monitoring at the population level. This is important also when the reasons for forgoing care or barriers to access are evaluated, such as through household survey data, where the populations discussed are only those with perceived and expressed unmet demand for services. It should be noted that unmet need is commonly defined and measured in the same way as forgone care, i.e. as occurring when people are unable to access a service they felt they needed due to a range of health system-related factors (e.g. cost, distance, waiting time) or other factors. The lack of widely accepted definitions for these terms adds complexity to the comparability across studies and data sets. At the global level, routine reporting systems are not designed to capture unmet needs and therefore data availability would be a major limitation to its adoption as a proxy to making progress towards UHC. Despite these limitations, as with effective coverage in section 1.6.2, continued advances to measuring unmet needs and understanding the reasons populations forgo care are key to ultimately making progress towards UHC.
22 Tracking universal health coverage 2023 global monitoring report
Box 1.5. Definitions of unmet need and forgone care
Both conceptually and from a measurement perspective, unmet need is not well-defined, however, there are some working definitions used for different purposes. A collection of these follows, to demonstrate the range of content and specificity of definitions.
• “The variables on unmet needs for health care are used to assess health inequalities with respect to health care services. They refer to the proportion of persons aged 15 years or over that felt they needed health care in the previous 12 months but did not receive it for reasons of financial barriers, waiting lists and distance/transport.”
Source: Unmet health care needs statistics. Eurostat [online database] (https://ec.europa.eu/eurostat/statistics- explained/index.php?title=Unmet_health_care_needs_statistics#Unmet_needs_for_health_care, accessed 29 July 2023)(26).
• “An individual is categorized as having unmet needs if they are unable to access quality care when needed arising for various reasons, including barriers related to the availability, affordability, accessibility, and acceptability of services.”
Source: Rahman MM, Rosenberg M, Flores G, Parsell N, Akter S, Alam MA, et al. A systematic review and meta- analysis of unmet needs for healthcare and long-term care among older people. Health Econ Rev. 2022; 12(1):60 (27).
• “The Inverse Care Law states that the availability of good medical care tends to vary inversely with the need for it in the population served. The marginalized and hard-to-reach populations have poorer health and still have limited access and or utilization of health care services because of various reasons and barriers related to availability, accessibility, acceptability, quality care etc. in comparison to the affluent population. This may indicate unmet need and the operation of the Inverse Care Law.” Sources: Hart JT. The inverse care law. Lancet. 1971;297(7696):P405–
12 (28); and Watt G. The inverse care law revisited: a continuing blot on the record of the National Health Service.
Br J Gen Pract. 2018; 68(677):562–3 (29).
• “Unmet need for healthcare can be seen as covering a spectrum of healthcare needs that are not optimally met.
At one end there is “unexpressed demand” (people who have healthcare needs but who are not aware of them, or who choose not to seek healthcare). At the other end there is “expressed demand that is sub-optimally met”.
This can include people ineligible for treatment, or who have poorer quality treatment than would optimally be the case. For some individuals, their unmet need may be a combination of the two.” Source: Unmet need in healthcare.
Summary of a roundtable held at the Academy of Medical Sciences on 31 July 2017, held with support from the British Academy and NHS England. London: Academy of Medical Sciences; 2017:1–16 (30).
Forgone care is a dimension of unmet need that aims to capture the inability of an individual to fulfil their perceived health service needs. The reasons for forgone care are often assessed to describe the systematic barriers to accessing quality care of sufficient quality. However, as with unmet need, there is no consensus on the conceptual or measurement framework used to define forgone care.
• The forthcoming WHO handbook on forgone care defines it as follows: “Forgoing health services occurs when someone who realizes that she/he needs services, prior to establishing initial contact with services for a given condition or at any point along the patient pathway and continuum of care, is unable to access the services or required medicines and health products due to a range of barriers. Forgone care is different than unmet need as the latter can also occur without someone realizing that they need services (i.e. a 50-year-old woman may not realize that she needs to get screened for cervical cancer, but the fact that she does not get screened implies she has an unmet need).” Source: Handbook for conducting assessments of barriers to effective coverage with health services in support of equity-oriented reforms towards universal health coverage. Geneva: World Health Organization (in press) (31).
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