Under JPG Teaching Fellowship

Permission from JPGSPH

CoE-UHC

Universal Health Coverage

Indicators and Measurements

Jahangir A. M. Khan, PhD

Head, Health Economics and Financing Research Group

Centre for Equity and Health Systems, icddr,b

Associate Professor, JPGSPH

Defining Universal Health Coverage

WHO, 2005 says:

Universal health coverage means that everyone in the population has access to appropriate promotive, preventive, curative and rehabilitative health care when they need it and at an affordable price.

Three dimensions of UHC

Population coverage

Service coverage

Financial risk protection

Three dimensions of UHC

All people in the country have access to adequate healthcare

Population segments

Sex

Age

Population coverage

Male

Female

Transsexual

Children (0-17 years)

Adults (18-64 years)

Elderly (65 years and above)

Pre reproductive age

Reproductive age

Post reproductive age

Geographic location

Urban: Slum

Non-slum

Rural: Reachable

Hard-to-reach

Low

Lower middle

Middle

Upper-middle

High

Income groups

Socioeconomic groups

Asset index based quintile

Poorest

2nd quintile

3rd quintile

4th quintile

Richest

Economic & labor market segments

People below poverty line

People in informal sector

People in formal sector

Country SHI

status

Pop

(in thousand)

Age dependency

ratio

Urban pop

Bangladesh N.A. 160,000 0.49 0.06 26%

Kenya Designing 38,765 0.78 0.05 21%

Ghana Initiation 23,351 0.67 0.06 48%

Philippines Expansion 90,348 0.54 0.07 63%

Colombia Matured 45,012 0.45 0.08 74%

Thailand Achieved 67,386 0.30 0.11 32%

Service coverage

WHO says:

Promotive, preventive, curative and rehabilitative

care

How health system is structured:

Public Health Service Arrangement in Bangladesh

Types of care Care providing agents

Primary care: Community clinics

Union Health Centers

Secondary care: Sub-district (Upazila) Health Complex

District hospitals

Tertiary care: Regional hospitals

Providers Services Promotive Preventive Curative Rehabilitative

Public

?

Community clinic, Union health

centers, vertical programs (EPI,

MNCH, TB)

Sub-district, District, Regional hospitals

?

Private for profit Urban areas (high concentration in

metropolitan cities and district towns & some

in sub-districts)

Some urban areas (mostly metropolitan

cities)

Private not for profit Yes Yes To a small scale To a small scale

Informal providers To some extent To some extent

Supply-side: Service and provider map

Assuring supply does not necessarily mean need-based utilization

Under-utilization is observed

Many sub-district hospitals are partially empty

Over-utilization is observed too

Visiting specialists when not required, Drugs, diagnostic tests

Do you agree?

Equipping the supply of services is

a prerequisite for coverage, not the

final goal.

Now, where should we try to observe the success in

achieving coverage?

Jointly,

Population in total and across population segments

Service utilization

Indicators of “population and service” coverage

Health system

agents

Indicators: Service/care available Distributional dimensions

Levels

Su

pp

ly-s

ide

Number of doctors per 1,000 people

Urb

an

: S

lum

s a

nd

no

n-s

lum

s A

ND

ru

ral

rea

cha

ble

an

d

ha

rd-t

o-r

each

are

as

Acr

oss

so

cio

eco

no

mic

gro

ups

Number of nurses per 1,000 people

Number of midwives per 1,000 people

Number of dentists per 1,000 people

Number of physiotherapists per 1,000 people

Number of community health workers per 1,000 people

Number of public health workers per 1,000 people

Number of nutritionists per 1,000 people

Number of hospital beds per 1,000 people for secondary care

Number of hospital beds per 1,000 people for tertiary care

EPI coverage

Dem

an

d-s

ide

Number of visits per 1,000 pop in community clinics

Number of visits per 1,000 pop in union health centers

Number of visits per 1,000 pop in sub-district health complex

Number of visits per 1,000 pop in district hospitals

Number of visits per 1,000 pop in regional/referral hospitals

Bed occupency ratio in district hospitals

Bed occupency ratio in regional/referrral hospitals

Number of children vaccinated through EPI system

Financial risk protection

No one should die and suffer because they cannot afford

health care, and no one should be made poorer because they

get sick.

Affordability for purchasing or availing healthcare

varies across income or socioeconomic groups.

Distribution of out-of-pocket payments across income

groups shows the ability.

Health Financing and Financial Protection

Three principal objectives of Indian UHC report (2012):

Objective 1: ensure adequacy of financial resources for the

provision of essential health care to all

Objective 2: provide financial protection and health security against

impoverishment for the entire population of the country

Objective 3: put in place financing mechanisms which are

consistent in the long-run with both the improved well-being of the

population as well as containment of health care cost inflation

Financing mechanisms

Taxation Private health insurance Out of pocket payments Medical savings accounts Social health insurance Community-based health insurance Loan, grants and donations

Risk/fund pooling

Pre-payment system verses post-payment (out-of-pocket)

Which mechanisms protect your financial risk

Health expenditure by Financing Agents and Mechanisms

In Bangladesh, 2007

Agents Mechanisms Expenditure

(in MBDT)

Percentage of

THE

Public sector Tax, donation 41,318 26%

Households Out-of-pocket 103,459 64%

Private Firms Pay-roll tax type 1,325 1%

Private Insurance Health insurance 314 0%

NGO Donation 2,092 1%

Rest of the World Donation, grant 12,391 8%

Total 160,899 100%

Source: National Health Accounts, 2007

Health expenditure per capita = 16 US$

Health expenditure as a percentage of GDP = 3.4%

Indicators: Financial risk protection

Levels (National) Distributional

dimensions

Health expenditure per capita

Urb

an:

Slu

ms

and

non-s

lum

s

AN

D r

ura

l re

ach

ab

le a

nd

hard

-to-r

each

are

as

Acr

oss

so

cio

econo

mic

gro

up

s

Health expenditure as % of GDP

Share of health spending in total government expenditure

Public spending in health (per capita & as % of THE)

Private spending in health (per capita & as % of THE)

OOPP for health (per capita & as % of THE)

OOPP in health total household consumption expenditure

Social HI contribution (per capita & as % of THE)

CBHI contribution (per capita & as % of THE)

Private HI contribution (per capita & as % of THE)

Indicators showing distributional aspects

Descriptive statistics

How indicators showing “level” are distributed across

groups of population

Composite measurements

Concentration index

Gini-coefficient

Kakwani index

Dominance test

Po

pu

lati

on

seg

men

t

Service

Public

primary

Public

district

hospital

Public

Regional

& referral

hospitals

Total

public

NGO

health

centre

NGO

hospitals

Total

private

not for

profit

Private

for profit

facilities

Pharmacy Total

private for

profit

All

types

Poorest X X X X X X X X X X X

2nd

X X X X X X X X X X X

3rd

X X X X X X X X X X X

4th

X X X X X X X X X X X

Richest X X X X X X X X X X X

CI

KI

Benefit Incidence Analysis

(BIA)

BIA aims at presenting how “benefits” either in terms of quality of good and services or its

monetary values are distributed across groups of people (like, socioeconomic groups).

Po

pu

lati

on

seg

men

t

Types of funding mechanism

Direct tax Indirect tax User fee Social

security

contri

CBHI

contri

Pvt

Ins contri

OOPP Total

payment

Poorest X X X X X X X X

2nd

X X X X X X X X

3rd

X X X X X X X X

4th

X X X X X X X X

Richest X X X X X X X X

CI

KI

Financing Incidence Analysis

(FIA)

FIA aims at presenting how “payments to a system” (like, healthcare) are distributed across

groups of people (like, socioeconomic groups).

Concentration index (CI)

What does CI mean: Concentration curve plots cumulative proportion population (ranked from the poorest to the richest socioeconomic condition) in x-axel against cumulatove poportion health in y-axel.

Cumulative proportion population (ranked from poorest to richest)

Cu

mu

lati

ve p

rop

ort

ion

OO

PP

20%

40%

60%

80%

100%

20% 40% 60% 80% 100%

O

B´

B

C

Construction of concentration index

CI = 2 * (Area under

diagonal – area under

lorenz curve)

CI ranges between

-1 and +1

Why CI is a good measurement, especially for addressing UHC:

1. It reflects the experiences of the entire population.

2. It reflects the socioeconomic dimension of benefits/payments etc.

3. It is sensitive to changes in the distribution of the population across the

socioeconomic groups.

Construction of Gini-coeffcient

G = 2 * (Area under

diagonal – area under

lorenz curve)

G ranges between

0 and +1

Cumulative proportion population (ranked from lowest to highest income)

Cu

mu

lati

ve p

rop

ort

ion

in

com

e

20%

40%

60%

80%

100%

20% 40% 60% 80% 100%

O

B´

B

C

Kakwani Index (KI)

KI measures “Progressivity of health care payments”

KI = CI of payments – G of household consumption expenditure

KI value ranges between -2 to +1.

Progressivity of health care financing and

incidence of service benefits in Ghana

James Akazili, Bertha Garshong, Moses Aikins, John Gyapong, Di McIntyre4

Health Policy and Planning 2012;27:i13–i22

Estimating socioeconomic status

Household consumption expenditure (per equivalent adult)

Quintile distribution of households

Assessing proportionality of health care financing

Progressive

If payments are made more than proportional increase in income

Proportional

If payments are made as same proportion as income increase

Regressive

If payments are made in a lower proportion than increase in income

Estimating benefits of health service used

Benefit incidence is calculated by multiplying the utilization rate of each

type of service for each socio-economic group by the unit cost of that

service.

Assessing need for healthcare

Self-assessed health: ‘How would you rate your health in general?’

Very good’

Good’

Average’

Poor’.

Need was then measured as the percentage of individuals who rated

themselves as having poor health by socio-economic group.

Data used

Ghana Living Standard Survey (GLSS)

Distribution of healthcare financing incidence

Financing Incidence Analysis

Distribution of total benefit from health

service use by socioeconomic status

Benefit Incidence Analysis

Benefits and need of health services

Can we do BIA and FIA in Bangladesh?

Existing data

Household Income and Expenditure Survey, 2010

SUMMARY

Population classification

Benefit incidence

Financing incidence

Empirical study