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CBA Analysis
Measurement Indicators for Universal Health Coverage – CBA Analysis
Vanessa Mpengo
School of Professional and Extended Studies, American University
SPEX 670: Project Cost-Benefit Analysis – Section 002 – Summer II 2021
Professor Kari Strobel
August 9th, 2021
Measurement Indicators Universal Health Coverage
Executive Summary
The purpose of this report is to advance UHC measurement dialogue through a pragmatic, bottom-up approach, documenting existing UHC metrics in the literature, evaluating chances to produce these metrics using already-available data sources, and reflecting on their strengths and weaknesses (World Health Organization, 2017). Cost-benefit analyses are conducted in the report, and significant concerns about the feasibility and application of widely suggested UHC measures are raised to assist prioritize sections for additional study and advancement, more so as financiers and legislators demand reliable metrics to evaluate progress toward UHC.
From the three-dimensional framework for UHC presented in the 2010 World Health Report, I will perform a review of research that tackled one or more of the three UHC elements. All persons should have access to health care, and the financial coverage component should help ease the burdens associated with paying for these treatments when they are needed. Another important aspect of coverage is its amount and distribution across key demographic groupings, highlighting the crucial need for coverage equity across income or wealth groups, sexes and ages, places of residence and ethnic origin.
I will select indicators based on the research’s evaluation. As a result, the vast majority of financial risk protections criteria are engrossed toward calculating catastrophic payments and the amount to which out-of-pocket expenses force people into poverty. Indicators of service coverage that are most easily understood are those that measure priority service utilization. MCH and reproductive health (RH) indicators are included (RH).
Introduction and Problem Statement
Without financial difficulty, the United Health Care program guarantees that all people and society have access to critical health care services (Haas et al., n.d.). In addition to health promotion, it also includes prevention, treatment, rehabilitation, and palliative care. At the facility, outreach and community levels, it is important to have a sufficient number of competent health and care workers with an acceptable skill mix who are fairly distributed and adequately supported and like their work to effectively deliver these services. Services should be of adequate quality to improve health of individuals receiving them, according to UHC standards.
As a result of protecting individuals from the financial implications of paying for health care out of pocket, fewer people are at danger of slipping into poverty. One of the goals that countries set when they approved the SDGs in 2015 was achieving universal health coverage. At the 2019 UN General Assembly’s High-Level Meeting on Universal Health Coverage, countries reaffirmed their commitment (Haas et al., n.d.). Health-oriented countries make progress toward other health-related goals. Healthier environments allow for the education of children and the earning of income by adults, which allows people to escape poverty and build the foundation for long-term economic progress.
Achieving Universal Health Coverage (UHC) requires governments to proclaim their commitment and establish policies and procedures to achieve this goal. Standards and indicators are needed to measure and monitor progress toward this goal. According to the World Health Report 2010, UHC should focus on three major elements (World Health Organization 2017). UHC’s advantages and costs must also be understood. It is the main objective of this investigation to find out.
Service range, which are delivered (service coverage);
The percentage of total expenses that are covered by insurance or other risk pooling methods (financial coverage);
The percentage of the population that is covered (population coverage).
On one hand, everyone should have access to health care, while the other aims to ease the burdens connected with paying for these services when they are needed. As the third dimension, it shows the degree and distribution of coverage across various demographic groupings, highlighting the vital requirement of equality in coverage across sex, wealth, age and place of residence as well as migrant status and ethnicity (Rizvi et al., 2020).
In spite of its wide acceptance and effectiveness, the framework still requires additional development in order to operationalize relevant criteria for assessing a country’s coverage level. UHC may serve as a persuasive “umbrella” indicator for health activities post-2015 as the global community continues to define its post-Millennium Development Goals (MDG) agenda (Ghebreyesus, 2017).
Through a cost-benefit analysis, this study aims to further the discourse on UHC evaluation. In order to achieve this goal, a pragmatistic, bottom-up strategy will be employed. An explicit list of UHC indicators is provided in the article, as well as a discussion on the program’s advantages and disadvantages based on an evaluation of the practicalities of producing such indicators using already-existing data sources in different nations.
Methodology
I conducted a literature evaluation of studies that addressed one or more of the three aspects of UHC, starting with the World Health Report’s three-dimensional framework for UHC. After analyzing more than 25 sources (publications such as books and technical papers), I produced a list of indications that were found to be similar among them.
The primary data sources were the Demographic Health Surveys (DHS) and the Living Standards Measurement Study (LSMS) models. For my secondary data analysis, I intentionally chose five nations to investigate the selected variables. The criteria used for nation selection were as below:
Not less than two current DHS surveys
Not less than two current LSMS-type surveys
National Health Accounts estimation carried out
Representation of Asia, America, and Africa.
DHS datasets and reports were acquired through Measure DHS’ website. The calculations were based on accessible data from the five nations and the dimensions recommended in the 2017 World Health Report (WHO, 2017). Stata was used to analyze the survey’s expenditure data. In addition, the findings were categorized according to location, rural/urban residency, wealth quintile, and consumption quintile, among other factors. To show the distribution of chosen indicators, graphs and tables were created.
I validated the estimations for various financial protection indicators using the free “ADePT” program. Family planning (FP), maternity and neonatal care, vaccination, and treatment of ill children are included in the indicators. Based on my replication of the technique, I sought to include additional service coverage areas to the composite index (TB, HIV/AIDS, and Malaria). Most of this study’s efforts will be devoted to measuring the first two elements of universal health coverage (UHC. I established quintile ratings based on consumption or asset-based wealth levels, depending on the data source.
To this end, the literature’s significant indications of UHC are described, both in terms of their strengths and their weaknesses. Further study and investment in conceptual and practical efforts to enhance UHC assessment are included as recommendations. Instead of evaluating the country’s performance, the indicators were used as important aspects to aid in conducting the cost-benefit analysis.
Analysis
Pros and cons list
Advantages
Disadvantages
People have access to health insurance and medical services and no one goes bankrupt due to healthcare fees
In some nations with UHC, patients undergo long wait times
UHC minimizes health costs for the national economy as the government has control over medication and service prices
UHC is expensive – in case a government struggles with its budget, it may find that heath care takes money away from other crucial programs.
UHC equalizes prices – doctors and health facilities can no longer target and attend to wealthier patients
When one has UHC, it can result in a healthier life, and minimize societal inequality
The Stakeholder MindMap
A stakeholder MindMap is a visualization that lays out all the stakeholders involved in a project or process, and an idea. Through it, people get a visual representation of all stakeholders that influences an idea or process and their connection. The following stakeholder MindMap can be used for the UHC program:
Assessment of Bias
Understanding personal bias and preconceptions gives unique insight into how people see others. It’s hard to make excellent and relevant judgments if someone’s judgment is affected by bias, even if they’re aware of bias and preconceptions. As a result, my own prejudices and stereotypes, as well as those of individual stakeholders, have an influence on my work on the WHO’s Universal Health Coverage (UHC) project by preventing me from making accurate judgements.
Biases are a person’s or a group’s predisposition towards or away from them. Personal prejudices, on the other hand, are a natural part of being human. Our own views, experiences, education, values, peers, and families all create and affect our personal biases. Defined as an innate emotion, my unconscious prejudices influence my situation in a big way. This is because everyone under the WHO’s universal health care program has access to services that address the underlying causes of death and disease, but the service quality is insufficient to improve people’s health.
Bias and viewpoint can influence my CBA analysis project decisions. Unintentional or purposeful misinterpretation of the analytical outcome. Thus, due to cognitive biases, analytical results might be misinterpreted as fact. Also, the analysis might be skewed by the persons doing the CBA. This also impacts my aim because a biased sample does not accurately represent the full CBA project study. Toa void biasness, my data included countries from Africa, Asia, and America. This will help me to gain a wide view and implementation of the UHC program
Risk Assessment
The UHC program is very important to the world. However, there are many people that oppose the implementation of the universal health privilege. This makes it difficult to be implemented in specific nations. For instance, critics in the United States argue that its implementations would not be as feasible as other developed countries due to the large geographical area and many ethnic groups (Reich et al., 2016). The realization of this program would require a significant upfront cost. It is therefore improbable to fully realize the implementation of the UHC program globally due to its costs. Similarly, there are risks associated with the potential for general system inefficiency where patients will be forced to wait for long and impacts on medical invocation and entrepreneurship.
Data
As stated previously, I used DHS statistics and nation reports to create chosen service coverage metrics. To measure financial protection, two main data sources were used (household expenditures surveys (LSMS, and National Health Accounts (NHA). As the gold standard for household surveys in developing nations, the DHS is extensively used. To follow changes in national health patterns, most nations seek to perform the core DHS every three to five years. The MEASURE DHS website offers free DHS datasets and reports. As a result, they are one of the most readily available sources of home survey information. To compare geographic locations and wealth levels, for example, data from the DHS can be disaggregated by sample sub-groups.
The typical DHS does not routinely collect data on NCDs, TB, or injuries. Special HIV and malaria surveys have been undertaken. The study used UNSTATS MDGs data for TB and HIV indicators. These data are sourced from country statistics supplied to the UN Statistics Division.
Table 1: service coverage Indicator
Table 2: financial, maternal, and reproductive health
Analysis
Indicators of Financial Coverage
This indicator measures the population’s self-reported insurance coverage and encompasses people’ perceptions of coverage. A self-reported measure, its effectiveness depends on respondents having accurate information at the time of the survey regarding their own and their family’s health insurance coverage. At times, affiliation perceptions may not reflect the benefits that are really provided during care. The relationship between the proportion of OOP health care expenditures and financial risk protection cannot be assumed (World Health Organization, 2017). As a result, self-reported insurance coverage only reflects a person’s protection from financial ruin while seeking care. The map below shows the proportion of people who have health insurance by location.
The US, and Switzerland has the highest UHC index (83) for essential index, while Afghanistan has the lowest index (34). When it comes to essential services; financials, and maternal, and reproductive health, Peru has reported the highest percentage (70%). However the coat of UHC could be higher for nations struggling with their budgets, realizing the provisions by WHO about UHC can save a nation a great deal of healthcare costs in the future. A healthy nation will be able to work and pay taxes, which the government will use to fund other sectors. When the nation is sick, funds that could be directed to other departments will all be diverted to health sector, thus sowing the development of a particular nation (Reich et al., 2016).
Figure 1: proportion of population that reported to have health insurance by location.
The most common financial coverage indicators as indicated in UHC are shown in the table below:
Indicator
Description
Source
Insurance Coverage
Self-reported insurance cover
Percentage of the population covered by some kind of health insurance
From expenditure surveys, and some DHS
Catastrophic payments
OOP payment-related catastrophic health expenditures
Proportion of people with health expenditures exceeding 10 percent of entire expenditures
Estimated using household expenditure surveys
Prevalence of OOP-induced poverty
Proportion of people with health expenditures force them below poverty level
Estimated using household expenditure surveys
Anomaly payments mean positive overrun
Mean amount through which OOP expenditures surpass threshold
Estimated using household expenditure surveys
Poverty gaps originating from OOP payments
Mean amount through which expenditures fall below poverty line
Estimated using household expenditure surveys
Out-of-Pocket spending
OOP health spending as a percent of overall health spending
NHA reports and WHO databases
Service Coverage Indicators
The indicators, which emerged as the commonly referred measures of the service coverage of UHC are listed in the table below.
Indicator
Description
Source
Indicators relates to service utilization
Births from healthy centers
Proportion of live births delivered in a healthy hospital in the last five years
DHS
Assistance from skilled provider during birth
Women getting any antenatal care from care providers
Proportion of live births attended by a trained health practitioner in the last five years
DHS, WHO database
Women getting any antenatal care from care providers
ANC received at least once by women aged 15-49 who gave birth in the previous five years
DHS
Married women in reproductive cycle using modern family planning approaches
Percentage of married or in union women aged 15–49 who use (or whose spouse uses) a contemporary contraceptive method
DHS
Family planning requirements satisfied
Current married women who indicate they don’t want any more children or wish to wait 2 or more years before having another kid, and who are using contraception
WHO database, DHS
Reception of all primacy vaccines
BCG, measles, DPT, and three doses of polio vaccination received by children aged 12–23 months, except those who were born without the polio vaccine.
DHS, WHO database
Measles vaccine reception
Vaccination rate for children aged 12–23 months
DHS, WHO database
Reception of 3 doses of DPT vaccine
Vaccination rate for children aged 12 to 23 months who got three doses of the DPT vaccination.
DHS
Reception of BCG vaccine
Current BCG vaccination rate among children aged 12–23 months
WHO database, DHS
The aforementioned service coverage metrics show how services are used generally and by subpopulations. But they don’t specify why care has not been received. For example, almost 80 percent of women in the lowest quintile say “having to take transportation” is a major hinderance to care, as around 40 percent of women in the wealthiest quintile say the same (Stigler et al., 2016).
Figure 2: Proportion of women reporting they have challenges accessing healthcare services
Some of the identified obstacles may be similar between regions or years within a nation, but variations in the overall number of questions answered invalidate cross-country comparisons of the “Any of these” summary indicator. It is conceivable that respondents named more significant issues than if they had been asked to mention them without prodding. A substantial number of issues might have been overlooked and women were not given the opportunity to voice their concerns. Qualitative inquiries might provide insight into why groups or subpopulations may not receive critical treatment.
Conclusion
A literature research was conducted to develop a list of UHC indicators that are often used or proposed. I used indicators from household surveys, such as the LSMS or DHS, and published values for them based on the data from different countries. Researchers found it challenging to translate a three-dimensional conceptual framework for UHC from the World Health Organization into observable and practical indicators as a result of this study. A consensus-based method should be used to establish the UHC indicators. Looking at the costs and benefits of the discussed program (UHC), benefits surpass the involved costs. The costs needed to realize the program is high and can drain a developing economy, however, with its implementation, a nation can do its finances a great deal. Citizens will be able to work – since they will be healthy – and pay taxes, which can be directed to other sectors, whose budget was cut to fund the UHC program.
Spend more on data collection and documentation, speedy data gathering and sharing, simplified data access, and enhanced ways for tracking out-of-pocket costs.
Define effective financial risk prevention strategies that address “undercounting” among the underprivileged. Developing composite financial protection mechanisms that represent different financial load sources.
In addition, a global dialogue is needed on themes such as necessary vs. comprehensive UHC care packages, and a criterion for selecting indicators.
The service coverage operations research should be funded. Creation of a theoretically based and robust service coverage indexes that embrace a larger variety of conditions, as well as creating realistic, aggregate quality indicators that go beyond structural quality to include process and outcome quality evaluations.
References
Ghebreyesus, T. A. (2017). All roads lead to universal health coverage. The Lancet Global Health, 5(9), e839-e840.
Haas, S., Hatt, L., Leegwater, A., El-Khoury, M., & Wong, W. Indicators for measuring universal health coverage: a five-country analysis (draft). Bethesda, MD: Health Systems, 20, 20.
Reich, M. R., Harris, J., Ikegami, N., Maeda, A., Cashin, C., Araujo, E. C., & Evans, T. G. (2016). Moving towards universal health coverage: lessons from 11 country studies. The Lancet, 387(10020), 811-816.
Rizvi, S. S., Douglas, R., Williams, O. D., & Hill, P. S. (2020). The political economy of universal health coverage: a systematic narrative review. Health policy and planning, 35(3), 364-372.
Stigler, F. L., Macinko, J., Pettigrew, L. M., Kumar, R., & Van Weel, C. (2016). No universal health coverage without primary health care. The Lancet, 387(10030), 1811.
World Health Organization. (2017). Tracking universal health coverage: 2017 global monitoring report.
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