A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.

The goal of universal health coverage (UHC) requires that everyone receive needed health services, and that families who get needed services do not suffer undue financial hardship. Tracking progress towards UHC requires measurement of both these dimensions, and a way of trading them off against one another. We measured service coverage by a weighted geometric average of four prevention indicators (antenatal care, full immunisation, and screening for breast and cervical cancers) and four treatment indicators (skilled birth attendance, inpatient admission, and treatment for acute respiratory infection and diarrhoea), financial protection by the incidence of catastrophic health expenditures (those exceeding 10% of household consumption or income), and a country's UHC performance as a geometric average of the service coverage index and the complement of the incidence of catastrophic expenditures. Where possible, we adjusted service coverage for inequality, penalising countries with a high level of inequality. The bulk of data used in this study were from the World Bank's Health Equity and Financial Protection Indicators database (2019 version), comprising data from household surveys. Gaps in the data were supplemented with other survey data and (where necessary) non-survey data from other sources (administrative, modelled, and imputed data). A low incidence of catastrophic expenses sometimes reflects low service coverage (often in low-income countries) but sometimes occurs despite high service coverage (often in high-income countries). At a given level of service coverage, financial protection also varies. UHC index scores are generally higher in higher-income countries, but there are variations within income groups. Adjusting the UHC index for inequality in service coverage makes little difference in some countries, but reduces it by more than 10% in others. Seven of the 12 countries for which we were able to produce trend data have increased their UHC index over time (with the greatest average yearly increases seen in Ghana [1·43%], Indonesia [1·85%], and Vietnam [2·26%]), mostly by improving both financial protection and service coverage. Some increased their UHC index, despite reductions in financial protection, by substantially increasing their service coverage. The UHC index decreased in five of 12 countries with trend data, mostly because financial protection worsened with stagnant or declining service coverage. Our UHC indicators (except inpatient admissions) are significantly and positively associated with GDP per capita, and most are correlated with the share of health spending channelled through social health insurance and government schemes. However, associations of our UHC indicators with the share of GDP spent on health and the shares of health spending channelled through non-profit and private insurance are ambiguous. Progress towards UHC can be tracked using an index that captures both service coverage and financial protection. Although per-capita income is a good predictor of a country's UHC index score, some countries perform better than others in the same income group or even in the income group above their own. Strong UHC performance is correlated with the share of a country's health budget that is channelled through government and social health insurance schemes. None.

Wagstaff A ，Neelsen S 《Lancet Global Health》

Progress on catastrophic health spending in 133 countries: a retrospective observational study.

The goal of universal health coverage (UHC) requires inter alia that families who get needed health care do not suffer undue financial hardship as a result. This can be measured by the percentage of people in households whose out-of-pocket health expenditures are large relative to their income or consumption. We aimed to estimate the global incidence of catastrophic health spending, trends between 2000 and 2010, and associations between catastrophic health spending and macroeconomic and health system variables at the country level. We did a retrospective observational study of health spending using data obtained from household surveys. Of 1566 potentially suitable household surveys, 553 passed quality checks, covering 133 countries between 1984 and 2015. We defined health spending as catastrophic when it exceeded 10% or 25% of household consumption. We estimated global incidence by aggregating up from every country, using a survey for the year in question when available, and interpolation and model-based estimates otherwise. We used multiple regression to explore the relation between a country's incidence of catastrophic spending and gross domestic product (GDP) per person, the Gini coefficient for income inequality, and the share of total health expenditure spent by social security funds, other government agencies, private insurance schemes, and non-profit institutions. The global incidence of catastrophic spending at the 10% threshold was estimated as 9·7% in 2000, 11·4% in 2005, and 11·7% in 2010. Globally, 808 million people in 2010 incurred catastrophic health spending. Across 94 countries with two or more survey datapoints, the population-weighted median annual rate of change of catastrophic payment incidence was positive whatever catastrophic payment incidence measure was used. Incidence of catastrophic payments was correlated positively with GDP per person and the share of GDP spent on health, and incidence correlated negatively with the share of total health spending channelled through social security funds and other government agencies. The proportion of the population that is supposed to be covered by health insurance schemes or by national or subnational health services is a poor indicator of financial protection. Increasing the share of GDP spent on health is not sufficient to reduce catastrophic payment incidence; rather, what is required is increasing the share of total health expenditure that is prepaid, particularly through taxes and mandatory contributions. Rockefeller Foundation, Ministry of Health of Japan, UK Department for International Development (DFID).

Wagstaff A ，Flores G ，Hsu J ，Smitz MF ，Chepynoga K ，Buisman LR ，van Wilgenburg K ，Eozenou P ... -  《Lancet Global Health》

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.

Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0-100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target-1 billion more people benefiting from UHC by 2023-we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2-47·5) in 1990 to 60·3 (58·7-61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9-3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010-2019 relative to 1990-2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6-421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0-3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5-1040·3]) residing in south Asia. The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people-the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close-or how far-all populations are in benefiting from UHC. Bill & Melinda Gates Foundation.

GBD 2019 Universal Health Coverage Collaborators 《-》

Financial risk protection of Thailand's universal health coverage: results from series of national household surveys between 1996 and 2015.

Tangcharoensathien V ，Tisayaticom K ，Suphanchaimat R ，Vongmongkol V ，Viriyathorn S ，Limwattananon S ... -  《International Journal for Equity in Health》

Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016-40.

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040. We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios. In the reference scenario, global health spending was projected to increase from US$10 trillion (95% uncertainty interval 10 trillion to 10 trillion) in 2015 to $20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4-5·1) per year, followed by lower-middle-income countries (4·0%, 3·6-4·5) and low-income countries (2·2%, 1·7-2·8). Despite global growth, per capita health spending was projected to range from only $40 (24-65) to $413 (263-668) in 2040 in low-income countries, and from $140 (90-200) to $1699 (711-3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3-38·6) in Nigeria to 97·9% (96·4-98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030. We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC. The Bill & Melinda Gates Foundation.

Global Burden of Disease Health Financing Collaborator Network 《-》