Collection Review Monitoring Progress towards Universal Health Coverage at Country and Global Levels Ties Boerma1*, Patrick Eozenou2, David Evans1, Tim Evans2, Marie-Paule Kieny1, Adam Wagstaff2 1 World Health Organization, Geneva, Switzerland, 2 World Bank Group, Washington, D.C., United States of America essential health services according to need and protection from Abstract: Universal health coverage (UHC) has been financial hardship, including possible impoverishment due to out- defined as the desired outcome of health system of-pocket payments for health services. Both components should performance whereby all people who need health benefit the entire population. In the context of this framework, services (promotion, prevention, treatment, rehabilitation, ‘‘essential’’ is used to describe the services that a country decides and palliation) receive them, without undue financial should be available immediately to all people who need them. The hardship. UHC has two interrelated components: the full contents of the services vary by setting. spectrum of good-quality, essential health services The dimensions have commonly been depicted as a cube, according to need, and protection from financial hardship, shown in Figure 1 (adapted from [3,4]). The first axis represents including possible impoverishment, due to out-of-pocket payments for health services. Both components should the population, the people who need health services. The services benefit the entire population. This paper summarizes axis depicts the quality health services they need. The vertical axis the findings from 13 country case studies and five is the proportion of the total cost of providing services to the technical reviews, which were conducted as part of the population that is financed through ‘‘pooled financing systems’’ as development of a global framework for monitoring opposed to direct payments by patients, shown in Figure 1 as the progress towards UHC. The case studies show the box labelled ‘‘current pooled funds.’’ relevance and feasibility of focusing UHC monitoring on In this illustration, a little more than a half the population is two discrete components of health system performance: covered for about half of the possible services they need, but only levels of coverage with health services and financial half the cost of these services is met from pooled funds. There is protection, with a focus on equity. These components link thus a shortfall of service coverage among those who receive directly to the definition of UHC and measure the direct services, inequity in service coverage (a large fraction of the results of strategies and policies for UHC. The studies also population receives no services), and a lack of financial protection show how UHC monitoring can be fully embedded in (those who receive services pay a large part out-of-pocket and often existing, regular overall monitoring of health sector hence risk financial hardship). To get closer to UHC, the country progress and performance. Several methodological and would need to provide services to the people who currently need practical issues related to the monitoring of coverage of them but don’t receive any, provide more services to those who essential health services, financial protection, and equity, currently receive some but not the full range of services they need, are highlighted. Addressing the gaps in the availability and raise the fraction of health spending financed through pooled and quality of data required for monitoring progress funds to improve financial protection. At the same time, health towards UHC is critical in most countries. services need to be of sufficient quality to achieve the desired outcomes, so improving quality will be a priority in many settings. Each country progresses in filling the different dimensions of the Introduction box (Figure 1) according to its preferences and constraints, trading off what services are provided, who gets them, and how much they A movement towards universal health coverage (UHC)— are financed out of pooled funds. As such, UHC is the ultimate ensuring that everyone who needs health services is able to get objective or goal, with countries starting from different places, with them, without undue financial hardship—has been growing across the globe [1]. Close to half of the countries of the world—across all Citation: Boerma T, Eozenou P, Evans D, Evans T, Kieny M-P, et al. income levels—are currently engaged in health reforms that aim (2014) Monitoring Progress towards Universal Health Coverage at Country and to extend, deepen, or otherwise improve coverage with needed Global Levels. PLoS Med 11(9): e1001731. doi:10.1371/journal.pmed.1001731 health services and/or financial protection. These reforms have Published September 22, 2014 led to a sharp increase in the demand for expertise, evidence, and Copyright: ß 2014 Boerma et al. This is an open-access article distributed measures of progress and also a push to make UHC one of the under the terms of the Creative Commons Attribution License, which permits goals of the post-2015 development agenda [2]. unrestricted use, distribution, and reproduction in any medium, provided the UHC has been defined as the desired outcome of health system original author and source are credited. performance, whereby all people who need health services Funding: This work was partly supported by a grant from the Rockefeller (promotion, prevention, treatment, rehabilitation, and palliation) Foundation and the Ministry of Health of Japan to World Health Organization (WHO). This included a technical meeting of principal investigators in Singapore, receive them, without undue financial hardship [1]. UHC has two 16–17 September 2013, organized by the WHO and Ministry of Health of interrelated components: the full spectrum of good-quality, Singapore, to discuss the overall framework of the review. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Collection Review articles synthesize in narrative form the best available Competing Interests: The authors have declared that no competing interests evidence on a topic. Submission of Collection Review articles is by invitation only, exist. and they are only published as part of a PLOS Collection as agreed in advance by the PLOS Medicine Editors. * Email: boermat@who.int Provenance: Not commissioned; part of a Collection; externally peer reviewed PLOS Medicine | www.plosmedicine.org 1 September 2014 | Volume 11 | Issue 9 | e1001731 Summary Points This PLOS Collection focuses on the monitoring of progress towards UHC, which should be a central component of any UHC N The overall goal of universal health coverage (UHC) is strategy. Country case studies and technical reviews were that all people obtain the good-quality essential health conducted as part of the development of a global monitoring services, including promotion, prevention, treatment, framework by World Health Organization (WHO) and the World rehabilitation, and palliation, that they need without Bank Group. The country case studies [5–17] aimed to document enduring financial hardship. what indicators, measurement, and communication approaches work best to monitor progress towards UHC. The technical review N A global UHC monitoring framework, developed by papers addressed issues related to the measurement of financial WHO and the World Bank Group in interaction with the protection [18], service coverage [19], effective coverage [20], process that led to this PLOS Collection, was used in 13 equity and UHC [21], and as an example of a health program, the country case studies, underpinned by five technical implications for tuberculosis program monitoring [22]. reviews. The second version of the WHO/World Bank Group UHC monitoring framework was published in May 2014 [23]. In N The UHC monitoring framework focuses on the simul- addition to the country case studies and technical reviews, the taneous monitoring of coverage of the population with framework was based on consultations and discussions with essential health services and with financial protection country representatives, technical experts, and global health and against catastrophic out-of-pocket health payments, stratified by wealth quintile, place of residence, and sex. development partners [24]. The feedback and country case studies were synthesized and reviewed at a meeting of country and global experts in Bellagio, Italy, in March 2014 [25]. The framework was N Most countries focus on regular monitoring of a set of modified to reflect the views emerging from these consultations tracer indicators for priority health services, as well as the occurrence of financial hardship and impoverishment and lessons learned from the country case studies. due to out-of-pocket health expenses. The indicators The UHC monitoring framework aims to inform and guide generally follow international standards of measurement assessment of both aggregate and equitable coverage of essential and can be used for global comparisons. health services as well as financial protection. Monitoring progress towards these two components of UHC will be complementary N Most countries do not have an explicit framework for and critical to achieving desirable health outcome goals, such as ending preventable deaths and promoting longer healthy life UHC monitoring. The monitoring of UHC is, however, partially embedded in regular overall health sector expectancy, and also reducing poverty and protecting household progress and performance reviews which include health incomes. The main characteristics of the monitoring framework system inputs, service delivery, and health status are described in Box 1. The global goal and proposed targets and indicators. indicators are presented in Box 2. This overview of the PLOS Monitoring Universal Health N There are major gaps in the availability and quality of Coverage Collection synthesizes selected findings of the country data required for monitoring progress towards UHC. case studies and technical reviews, considering key topics such as Countries mostly rely on international survey programs the implications of the diversity of UHC policies and strategies for or national surveys to obtain disaggregated data on country monitoring frameworks, approaches to monitor health coverage and financial protection indicators, comple- service coverage, financial protection and equity, the use of targets mented by health facility data, but often the frequency and summary measures, and the required investments to improve and contents of these surveys are not sufficient to meet monitoring. The paper concludes with the way forward related to the country’s information needs. global guidance and country implementation, indicators and targets, and measurement investments. N Monitoring progress towards the two components of UHC will be complementary and critical to achieving desirable health outcome goals, such as ending pre- Country Monitoring ventable deaths and promoting healthy life expectancy, Monitoring progress towards UHC by countries should take into and also reducing poverty and protecting household account the country’s unique epidemiological and demographic incomes. profile, health system, level of economic development, and the population’s demands and expectations. These country-specific dimensions are critical for deciding what should be monitored; for very different health problems, health systems, and resources. example, emerging economies might focus on how best to expand They need to find their own paths. essential services to remote areas, whereas high-income countries UHC is a dynamic, rather than static, concept. New health might focus on modifying the range of available health services to technologies and medical products are developed continually, as are allow for a growing elderly population. While the country context new ways of improving the quality of care. The health service axis in determines the measures used, the domains to be monitored— Figure 1, therefore, expands over time. Many of the innovations coverage with essential, good-quality services and with financial come at higher costs, while population demands for new and better protection—are relevant to all countries, regardless of their level of technologies also increase, putting upward pressure on pooled income, their demographic profile or their health needs. resources and making it harder to hold constant—let alone raise— The PLOS Collection country case studies show the variation of the share of spending financed through pooled resources. That is ways in which UHC has been reflected in national policies and why the search to attain and maintain UHC concerns even the strategies. Often UHC policies build upon other policies that have richest countries, particularly at times of financial crises, when their been in existence for many years (e.g., Estonia [10], Ghana [11], ability to maintain high standards of service coverage and low and India [12]). Several countries have well-established strategies household out-of-pocket payments is put under considerable strain. to increase access, coverage, and quality of services and financial PLOS Medicine | www.plosmedicine.org 2 September 2014 | Volume 11 | Issue 9 | e1001731 Figure 1. Progressive realization of universal health coverage. doi:10.1371/journal.pmed.1001731.g001 protection among all population groups, such as Thailand [16], monitoring framework for UHC, indicators of access, quality, and Brazil [6], Singapore [13], and Chile [7]. Some countries have affordability of services are regularly tracked and reported to linked the UHC goal with broad health reforms (e.g., China [8], Parliament as part of the key performance indicators of the Estonia [10], and Ghana [11]). Other countries are in the process Ministry of Health [13]. Finally, several countries have extensive of developing overall UHC policies and focused largely on the systems of periodic health sector performance reviews at subna- Millennium Development Goals (MDGs), but are also expanding tional and national levels which provide an excellent vehicle for strategies to enhance access to services and financial protection UHC monitoring (e.g., Ghana [11] and Brazil [6]). (e.g., Ethiopia [9], Bangladesh [5], and Tanzania [15]). The paper on monitoring UHC in the context of tuberculosis No matter what policy or strategy is in effect or the stage of care and prevention provides a global example of how the disease- implementation, countries will have to embed UHC progress specific monitoring of intervention coverage and financial monitoring in overall monitoring of health system performance protection take into account the full array of indicators, from and health progress. Currently, no country has a separate input to impact, to assess programme performance [22]. monitoring framework for UHC, but for some, UHC is well integrated in the overall sector monitoring framework (e.g., Coverage of Health Services Thailand [16] and Estonia [10]). The experience from Thailand Measures for monitoring specific health interventions and [16] describes how a system that monitors progress towards UHC reductions in risk factors can be classified differently, depending can be built up over a long period, but having a solid framework on the condition, the type of intervention, the characteristics of with indicators, targets, data sources, data quality assessment and the target population, and the level of delivery of the analysis, and clear roles and responsibilities of country institutions intervention. In the UHC monitoring framework, the measures is likely to improve monitoring and enhance its efficiency. are grouped into two broad categories to cover the spectrum of The indicators used to monitor health sector performance interventions: prevention (which includes services for health generally include the main UHC progress indicators. For instance, promotion and prevention) and treatment (which includes Ethiopia already monitors three dozen service coverage and services such as treatment, rehabilitation, and palliation). There financial protection indicators on a regular basis [9]. Furthermore, are many service coverage indicators. Drawing on indicators in other countries the assessment of the current situation and agreed on by WHO for monitoring intervention coverage in the recent progress towards UHC includes a focus on coverage and context of the MDGs and noncommunicable diseases (NCDs), financial protection indicators, but also considers the full array of the framework proposes measurement of coverage for a small set health system performance indicators at the same time (e.g., Chile of prevention and treatment tracer interventions based on [7] and Estonia [10]). In Singapore, even though there is no criteria related to relevance, quality, and availability of the PLOS Medicine | www.plosmedicine.org 3 September 2014 | Volume 11 | Issue 9 | e1001731 Box 1. Framework for Monitoring Universal disease–related interventions, such as Brazil [6], Chile [7], Health Coverage: Key Characteristics [23] Singapore [13], and Thailand [16], which is largely done through specific national surveys and facility data. While the differences in Monitoring universal health coverage (UHC) in countries is epidemiology are an important contributor to those differences, a part of the regular system of health progress reviews comprehensive health information system will be needed in all and systems performance assessment of the national countries in the future to monitor progress towards UHC. health sector strategic plan, which includes tracking trends The relative paucity of good indicators of treatment coverage in and inequalities in health system inputs and outputs, the country case studies reflects the difficulty in determining needs coverage and risk factors, and health outcomes. for conditions that affect only a fraction of the population and often require facility-based care, such as cancer treatment or The UHC monitoring framework focuses on two interre- appendectomy. This lack of data on true population need is an lated but separate measures: coverage of the popu- lation with essential health services and coverage of the important concern, as illnesses that require hospitalization or long- population with financial protection against catastrophic term treatment are often associated with higher financial risks, and out-of-pocket health payments. Progress on both mea- many people may forgo these services because they cannot afford sures should be measured simultaneously and capture all them. Even in high-income countries for which there are extensive levels of the health system. Some interventions, such as data, very few treatment coverage indicators are in routine use tobacco taxes, are society-wide, while others, such as [19,26]. Nevertheless, for conditions with reliable and valid emergency obstetric care, are provided in health facilities. methods to determine population need, such as biomarkers for Similarly, financial protection measures should cover all hypertension or diabetes, household surveys can help determine levels of the health system, as costs incurred for services the size of the population in need and also the number treated. may vary widely. In circumstances where treatment coverage is difficult to measure, disaggregating general service utilization rates by equity All measures should be disaggregated by socioeconomic stratifiers offers a proxy for UHC monitoring. For example, in and demographic characteristics where relevant in order Chile [7] and Brazil [6], monitoring of secondary and tertiary care to allow assessment of the equitable distribution of service intervention rates by wealth quintiles showed that the poorest and financial protection coverage. In all health systems, quintile had much lower intervention rates compared with the there is significant stratification of risks for ill-health and wealthiest quintile. Such data are useful for monitoring UHC, but access to and payments for services according to often need additional analyses to account for the differences in household income, place of residence, sex and other factors. Measures of coverage with health services and need among populations. financial protection should also benefit the entire popu- UHC coverage monitoring should not only take into account lation throughout the life-course, including all ages and the need and utilization but also the quality of the service, often both sexes. referred to as ‘‘effective coverage’’ [20]. Effective coverage indicators capture all three components of coverage. The paper Measures of service coverage comprise the full spectrum by Ng et al. [20] reviews different conceptual aspects and potential of essential health interventions—promotion, preven- methods for the measurement of need, utilization and quality of tion, treatment, rehabilitation, and palliation—and their services. Using examples from research, it is shown that the associated costs. Special attention should be given to the tracking of effective coverage for most interventions is dependent quality dimension of the interventions. on a well-developed surveillance system to allow triangulation of health information that captures both demand and data. Countries should focus on regular monitoring of a set of tracer indicators with targets for a selected set of priority health services and the occurrence of financial Coverage of Financial Protection hardship and impoverishment due to out-of-pocket health Existing measures of financial protection provide useful insights expenses. The indicators should follow common standards into the financial hardship caused by accessing needed health of measurement and include global measures. services. The paper by Saksena et al. [18] reviews four indicators of the lack of financial protection to show average levels and While countries develop indicators and targets in line with inequalities on the path to UHC. their level of socioeconomic development, epidemiologi- Two commonly used indicators to track the level of financial cal situation, state of the health system and people’s protection in health are the incidence of ‘‘catastrophic’’ health expectations, there should also be a small set of global expenditures and the incidence of impoverishment because of out- measures and targets that is relevant to all countries, of-pocket health payments [18]. The former indicates the number irrespective of their national income (see Box 2 for of households of all income levels that incur health payments that proposed indicators). are higher than their resources, while the latter captures the degree to which health spending causes extreme hardship by pushing families below the poverty line. The two financial protection indicators [19]. This core set of interventions can be built upon measures actually measure lack of financial protection in health, over time as and when comparable, reliable measures of and both can be re-scaled so that 100% coverage represents full coverage for other intervention areas, such as rehabilitation financial protection [18]. and palliation, become available. Two other indicators that are sometimes used, although they are The country case studies clearly show that in several countries, less understandable and accessible to policy-makers, are ‘‘depth of such as Bangladesh [5], Ethiopia [9], Ghana [11], and Tanzania poverty,’’ the extent to which out-of-pocket health payments worsen [15], monitoring progress is focused on the MDG-related a household’s pre-existing level of poverty, and the ‘‘mean indicators, mostly with data from internationally comparable catastrophic positive overshoot,’’ the average amount by which household survey programmes such as Demographic and Health households affected by catastrophic expenditures pay more than the Surveys. Other countries focus much more on noncommunicable threshold used to define catastrophic health spending. PLOS Medicine | www.plosmedicine.org 4 September 2014 | Volume 11 | Issue 9 | e1001731 Box 2. Proposed Goal, Targets, and Illustrative of non-poor families impoverished by health spending to the Indicators for UHC in the Global Framework number of already poor families who incur out-of-pocket [23] payments. The total is simply the number of households that are pushed into poverty, or deeper into poverty, because of health Goal spending. N Achieve UHC. All people obtain the good-quality Most country case studies in this PLOS Collection also provide data on coverage of the existing insurance schemes in the general essential health services that they need without enduring financial hardship. or target population(s) (e.g., Estonia [10], China [8], and Singapore [13]). Insurance coverage, however, is not used as a proxy for the above indicators of financial protection. For instance, Targets the India case study shows how the multiple subsidized health N By 2030, all populations, independent of household insurance schemes for poor families fail to access the main sources income, expenditure or wealth, place of residence, or of the out-of-pocket payments, which are to obtain ambulatory sex, have at a minimum 80% essential health services care and medicines. coverage. The paper by Lo ¨ nnroth et al. [22] argues that monitoring N By 2030, everyone has 100% financial protection from financial protection because of out-of-pocket health care expen- out-of-pocket payments for health services. ditures is essential but will not guarantee effective and equitable tuberculosis (TB) care and prevention. Additional financial risks associated with tuberculosis include income losses from lost work Indicators and non-medical expenditures such as transport and food. The authors also explore ways to mitigate these losses. Health services coverage N Prevention: coverage with a set of tracer interventions for Equity in Coverage prevention services (see [19] for examples). At the heart of UHC is a commitment to equity. Yet, in # Equity: a measure of prevention service coverage as countries on the path to UHC, there is a risk that poorer, less described above, stratified by wealth quintile, place of advantaged segments of the population could be left behind [27]. residence, and sex. The global framework proposes three primary elements for disaggregation that can be measured comparably in all settings: N Treatment household income, expenditure or wealth (coverage of the poorest segment of the population compared with richer segments), place # Aggregate: coverage with a set of tracer interventions for of residence (rural or urban), and sex. The paper by Hosseinpoor treatment services (see [19] for examples). et al. [21] provides a set of recommendations on global monitoring # Equity: a measure of treatment service coverage as of health inequalities in the context of UHC, including the use of described above, stratified by wealth quintile, place of at least two complementary measures (such as wealth quintile, residence, and sex. urban or rural residence, and sex where relevant), use of a gap or gradient analytical approach, and use of absolute or relative Financial protection coverage inequality as a measure of size of inequality gaps. Household surveys are often the prime instrument to collect data on equity N Impoverishing expenditure [21], but facility data also contribute, particularly data on # Aggregate: fraction of the population protected against subnational differences [19]. For country monitoring of equity in impoverishment by out-of-pocket health expenditures, coverage, the choice of stratifiers should be informed by an comprising two types of household: families already below assessment of both those that are salient and those that are the poverty line on the basis of their consumption and measureable, given the data available. who incur out-of-pocket health expenditures that push The PLOS Collection country case studies provide many them deeper into poverty; and families for whom out-of- examples of disaggregated monitoring of key coverage indicators. pocket spending pushes them below the poverty line. All countries use multiple stratifiers. In several countries, however, the subnational differences are of prime interest, because these are # Equity: fraction of households protected against impov- explicit in the national policy documents and are directly linked to erishment or further impoverishment by out-of-pocket budgetary decisions. For instance, Tunisia [17] and Ethiopia [9] health expenditures, stratified by wealth quintile, place focus on regional inequalities. of residence, and sex. N Catastrophic expenditure Targets for Assessing Country Progress towards UHC Setting specific, time-bound targets will be critical for progress # Aggregate: fraction of households protected from towards UHC. Target setting will involve identifying from the incurring catastrophic out-of-pocket health expenditure. available data sufficiently ambitious, yet achievable, improvements # Equity: fraction of households protected from incurring in equitable coverage of essential health services and financial catastrophic out-of-pocket health expenditure stratified protection. by wealth quintile, place of residence, and sex. The ultimate goal of UHC with respect to service coverage is that everyone can obtain the essential health services they need; that is, 100% coverage. The paper on service coverage argues, partly based on projections of trends in MDG service coverage The impoverishment indicator does not capture families that indicators using different assumptions, that a minimum of 80% are pushed even further into poverty by out-of-pocket health coverage, regardless of the level of wealth, place of residence or spending; a simple way to capture this value is to add the number sex, is an ambitious, but nonetheless achievable, goal for most PLOS Medicine | www.plosmedicine.org 5 September 2014 | Volume 11 | Issue 9 | e1001731 indicators and countries [19]. For some preventive services, such The PLOS Collection shows how comparable data from four as vaccination coverage for specific antigens, higher targets are countries on 12 service coverage indicators can be used to feasible based on current levels and past trends. But for most compare the situations in a way that includes both the values of services, including full child immunization coverage, a minimum the individual interventions as well as an overall mean for the target short of the ideal may correspond better to the ‘‘sufficiently prevention and treatment domains [19]. For prevention services, ambitious but nonetheless achievable’’ criterion. Targets must also six coverage indicators are identified: fulfilment of family include consideration of measurement issues. For some services, planning requirements, at least four antenatal care visits, full such as treatment of hypertension, effective coverage can reach immunization in children, improved water source and adequate 100% only if the treatment is 100% effective in achieving the sanitation, and non-use of tobacco. For treatment services, desired health gain, which is rarely the case. Likewise, treatment another six coverage indicators are used: skilled birth attendance, indicators (such as for HIV infection) are often based on estimated antiretroviral therapy, tuberculosis case detection and treatment need, which is rarely sufficiently accurate to set a target of 100%. success (combined into a single measure), hypertension treatment, Further analyses of time trends in coverage with prevention and and diabetes treatment. treatment interventions and estimates of 2015 baseline and coverage improvement rates through to 2030 are required to Investments in Data Collection further specify treatment coverage targets. Regular monitoring of progress towards UHC requires reliable For financial protection, the available evidence suggests that a data on the selected indicators. Such data is obtained from target that is both ambitious and achievable is 100% protection household surveys and health facility data for service coverage from both catastrophic and impoverishing health payments for the indicators [19] and requires a well-functioning system of health population as a whole as well as for the proposed equity strata of accounts for the financial protection indicators [18]. Equity data the population [18]. are primarily obtained from regular household surveys, but facility The rates of improvement necessary to achieve these targets in and administrative data can be used to highlight trends and coverage over the next 15 years (to 2030) can be determined from differences between geographic areas [21]. the levels of coverage in 2015, with intermediate targets set for The PLOS Collection country case studies provide examples of 2020 and 2025. The South Africa country case study in the PLOS the required investments and data gaps. Several papers point to Collection makes a case for setting UHC-related benchmarks for the major data gaps for coverage of interventions and risk factors reduction of inequalities in service coverage and financial for NCDs and injuries (e.g., Tunisia [17] and Bangladesh [5]), protection indicators as well as overall levels [14]. Such even though these conditions are increasingly important in all benchmarks could be country-specific but should also allow countries. comparative analyses. Most country case studies relied heavily on household surveys, partly because these are the most objective source of population- Summary Measures based coverage and financial protection, but also because facility It is critical to communicate data on progress towards UHC in data–based systems often produce unreliable statistics. But there ways that are meaningful to the general public and that capture are also important gaps in the household survey implementation the attention of policy makers. One strategy is to focus on a small and contents. The reliance on internationally funded household set of tracer indicators. Another is to use a summary measure of health surveys often implies a focus on MDG-related indicators, UHC progress. A third strategy is to use both tracer indicators and while the country is facing a rapidly increasing burden of NCDs a summary measure. and injuries at the same time (e.g. Tunisia [17]). Many countries Even though a summary measure will raise debate about have some kind of household expenditure survey but do not have regular surveys to collect data on health-related household weights for the different components, it may nonetheless be a expenses. The value of a regular household survey that provides useful way to communicate progress towards UHC. Summary comprehensive and disaggregated information on service coverage measures, as simple and transparent as possible, should only be and financial protection is shown in some countries, such as the used if they help analyse, interpret, and communicate the situation five-yearly national health services survey in China [8]. Also, in and progress towards the goal of UHC. India [12], regular national and district surveys are considered Aggregation of measures entails an explicit approach to the necessary to assess the financial risks associated with use of the criteria for weighting of interventions, which range from ‘‘equal’’ private sector. The country case studies also show the potential weighting (i.e., coverage with each service is given an equal value of investing in other regular data collection efforts such as weight); to ‘‘unequal’’ weighting, whereby the relative weight for surveys to assess user satisfaction, as was done in, for instance, the coverage of an intervention is affected by the size of the effect Estonia [10]. on mortality and morbidity, including both what has been achieved already and what potentially could be added if coverage was higher. Discussion The Tanzania case study in the PLOS Collection includes a The country studies and technical papers in this PLOS UHC access index that combines service coverage indicators with Collection show the usefulness and feasibility of the WHO/World supply side indicators such as facility density or drug availability Bank Group UHC monitoring framework. They illustrate how the [15]. The intervention coverage paper in the PLOS Collection framework can be used to translate the goal of UHC into measures provides an example of prevention and a treatment summary of progress that are valid and feasible, and often comparable measure based on a small number of tracer indicators that gives among countries. Together, these measures can provide a equal weight to intervention areas [19], similar to an approach snapshot of health system performance with respect to coverage used in monitoring equity in coverage of maternal, newborn, and with some essential health services and financial protection, for the child health interventions [28]. Attempts to combine health service population as a whole and for critical subpopulations, based on access and financial protection into a single summary measure are, household income, expenditure or wealth, place of residence, and to-date, largely from a theoretical perspective [29]. sex. Using the targets and indicators, countries can identify their PLOS Medicine | www.plosmedicine.org 6 September 2014 | Volume 11 | Issue 9 | e1001731 Box 3. Recommendations The reviews of country UHC monitoring and global method- ological issues show that there are a limited number of indicators N The global UHC monitoring framework recommends the of service coverage that are relevant, of reasonable quality, and use of a set of tracer indicators of intervention coverage feasible to measure with existing instruments, especially for the and financial protection, disaggregated by socioeco- coverage of treatment services. Tracking of progress in financial nomic status, place of residence, and sex where possible protection measures is also hampered by lack of data. Investments and relevant. are required to develop methods for devising a more comprehen- N The core set of indicators and targets should be based sive set of UHC indicators. Moreover, investing in data collection on country demographic and epidemiological profile, through household surveys using standardized questions and health systems, level of socioeconomic development, health facilities information systems is an important global public and people’s needs and expectations, and as a benefit and good value for the money in the pursuit of the goal of minimum, include a small set of globally recommended UHC. Only countries with a regular health examination survey on tracer indicators. the main health priorities and a well-functioning health facility N Monitoring UHC should be fully embedded in regular information system are able to generate the full set of disaggre- overall health progress and performance reviews that gated information on progress towards UHC. exist in most countries. Monitoring progress towards UHC is central to achieving the N Countries and global partners should address data gaps global goals of the World Bank Group and WHO, the MDGs, and invest in comprehensive health information systems and the emerging post-2015 global development framework. The with regular health examination surveys that address the World Bank Group has set a global goal of ending extreme full burden of disease, surveys with health expenditure poverty by 2030. UHC is critical to achieving this goal, as it will modules, and well-functioning health facility data prevent impoverishment of hundreds of millions of families reporting systems. because of out-of-pocket payments for health services. WHO N International comparisons can be used to benchmark places the highest priority on securing the right to health and country progress, keeping in mind the considerable attaining the highest levels of health for all. UHC secures diversity of UHC strategies and contents. universal entitlement to essential health services, which are important contributors to improving the health status of the population in all countries. Similarly, the World Bank Group’s global goal to promote shared prosperity for the poorest 40% of gaps in coverage and ascertain how far and fast they should the population in every low- and middle-income country is closely improve the performance of their health systems to achieve aligned with WHO’s focus on equity and the United Nations progress towards UHC. High-level Panel’s recommendation to ‘‘hardwire’’ equity into all At this point in time, however, very few countries have an explicit post-2015 measures [2]. Monitoring and Evaluation (M&E) framework for UHC at this stage. There is emerging consensus that the post-2015 agenda should Such a UHC monitoring framework should be fully integrated in the address the unfinished agenda of the health-related MDGs as well existing overall health sector performance framework. as the emerging burden of NCDs, including mental health and The global framework for monitoring UHC is designed to injuries. There is already a strong foundation of health indicators facilitate comparison of progress towards UHC among countries. to build upon, including the intervention coverage indicators [30] Each country is expected to add further measures of service of the health-related MDGs, such as vaccination and antiretroviral coverage and further equity stratifiers in order to tailor UHC therapy coverage, the recommended priority interventions related monitoring to its context. UHC monitoring is not a substitute for to NCDs [31,32] and indicators of financial protection [33]. other measures of health system performance, such as improved Further work needs to be done in consultation with countries and health status or health worker density and distribution. Rather, it partners to identify and define specific prevention and treatment should be seen as a core part of a comprehensive monitoring indicators. The importance of multisectoral influences on health framework in which inputs are linked to outputs and health should also be acknowledged, although it is not explicitly outcomes. The UHC measures of intervention coverage and addressed in this paper. Further work is also needed to firmly financial protection can thus make a valuable contribution to link monitoring of progress towards UHC with monitoring of key assessment of health systems performance and to the achievement social and environmental determinants of health and sustainable of desired health outcomes. development. Further research and investments are needed to UHC is not built around a single universal package of address these multiple information gaps, which should be a interventions: each country should define the ‘‘essential’’ services priority for research in the coming years [34]. that need to be available to all people. Therefore, the monitoring framework does not provide a single set of essential service Conclusion indicators. However, the country case studies show that there is considerable agreement between the selected indicators. These Based on this PLOS Collection it can be concluded that the indicators generally include prevention and primary care coverage global UHC monitoring framework provides an excellent basis for indicators such as those related to the MDGs, including skilled birth global and country monitoring of UHC, with appropriate attendance and antiretroviral therapy coverage, and the prevention adaptations. The focus is on country monitoring. Each country and control of risk factors for NCDs. Only a few country studies should develop a UHC monitoring framework, embedded in included indicators of more advanced secondary and tertiary care regular overall health progress and performance reviews that interventions. These differences are partly associated with variations already exist in most countries. A monitoring framework includes between countries in levels of socioeconomic development, health the selection of a set of tracer indicators and targets, based on systems, and epidemiological situations, which in turn affects the country demographic and epidemiological profile, health systems, current priorities for the country’s UHC strategy. But it is also level of socioeconomic development, and people’s needs and because of limitations of the available data for the indicators. expectations. Inequalities should be monitored across multiple PLOS Medicine | www.plosmedicine.org 7 September 2014 | Volume 11 | Issue 9 | e1001731 stratifiers, including socioeconomic status, place of residence, and Acknowledgments sex, where relevant. Monitoring the quality of services should receive special attention. International comparisons using tracer This paper builds upon a series of consultations and discussions with country representatives, technical experts, and global health and indicators can be used to benchmark country progress, keeping in development partners. A draft of the framework was posted online and mind the considerable diversity of UHC strategies and contents. circulated widely for consultation between December 2013 and February Box 3 summarizes these recommendations. 2014. We are grateful for the 68 comments that were received from diverse To achieve such monitoring systems in countries, it is necessary constituencies globally (countries, development partners, civil society, to address data gaps and invest in comprehensive health academics, and other interested stakeholders). We also wish to acknowl- information systems that include regular health examination edge the participants of a meeting of country and global experts at the surveys that address the full burden of disease, socioeconomic Rockefeller Centre, Bellagio, Italy, in March 2014, for their input. surveys with health expenditure modules, and well-functioning health facility data reporting systems. The global community can Author Contributions contribute by developing common standards for measurement of Analyzed the data: TB PE AW DE. Wrote the first draft of the manuscript: the core indicators, aligning and minimizing disease-specific TB TE DE. Contributed to the writing of the manuscript: TB PE DE TE monitoring efforts, and streamlining health data collection MPK AW. ICMJE criteria for authorship read and met: TB PE DE TE investments in support of national monitoring systems that meet MPK AW. Agree with manuscript results and conclusions: TB PE DE TE all country needs. MPK AW. References 1. World Health Organization (2010) The world health report – health systems 20. Ng M, Fullman N, Dieleman J, Flaxman AD, Murray CJL, et al. (2014) Effective financing: the path to universal coverage. Geneva: World Health Organization. coverage: a metric for monitoring universal health coverage. PLoS Med 11: Available: http://www.who.int/whr/en/index.html. Accessed 29 April 2014. e1001730. 2. United Nations (2013). A new global partnership: eradicate poverty and 21. Hosseinpoor AR, Bergen N, Koller T, Prasad A, Schlotheuber A, et al. (2014) transform economies through sustainable development. Report of the High-level Equity-oriented monitoring in the context of universal health coverage. PLoS Panel of Eminent Persons on the Post-2015. Development Agenda. New York: Med 11: e1001727. United Nations. Available: http://www.post2015hlp.org/wp-content/uploads/ 22. Lo¨ nnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, et al. (2014) Beyond 2013/05/UN-Report.pdf. Accessed 29 April 2014. UHC: monitoring health and social protection coverage in the context of 3. World Health Organization (2010) World Health Report. Health Systems tuberculosis care and prevention. PLoS Med 11: e1001693. Financing: the Path to Universal Coverage. Geneva: WHO. Adapted from Busse 23. World Health Organization and World Bank Group (2014) Monitoring progress R, Schlette S (2007) Focus on Prevention, Health and Aging, New Health towards universal health coverage at country and global levels: framework, Professions. Health Policy Developments 7/8. Gu ¨ tersloh: Bertelsmann Founda- measures and targets. Geneva: WHO. Available: http://www.who.int/ tion. healthinfo/universal_health_coverage/en/. Accessed 7 July 2014. 4. World Health Organization (2008) World Health Report. Primary Health Care 24. World Health Organization (2013) Technical meeting on measurement and - Now More Than Ever. Geneva: WHO. monitoring of universal health coverage, Singapore, 17–18 September 2013. 5. Huda TM, Khan JAM, Jamil KZAK, El Arifeen S (2014) Monitoring and Geneva: WHO. Available: http://www.who.int/healthinfo/country_ evaluating progress towards universal health coverage in Bangladesh. PLoS Med monitoring_evaluation/universal_health_coverage_meeting_sept2013/en/ 11: e1001722. index.html. Accessed 29 April 2014. 6. Barreto ML, Rasella D, Machado DB, Aquino R, Lima D, et al. (2014) 25. World Health Organization (2012) Meeting on measurement of trends and Monitoring and evaluating progress towards universal health coverage in Brazil. equity in coverage of health interventions in the context of universal health PLoS Med 11: e1001692. coverage, Rockefeller Foundation Center, Bellagio, 17–21 September 2012. 7. Aguilera X, Castillo-Laborde C, Na ´ jera-De Ferrari M, Delgado I, Iban ˜ ez C Geneva: WHO. Available: http://www.who.int/entity/healthinfo/country_ (2014) Monitoring and evaluating progress towards universal health coverage in monitoring_evaluation/UHC_Meeting_Bellagio_Sep2012_Report.pdf?ua=1. Chile. PLoS Med 11: e1001676. Accessed 29 April 2014. 8. Meng Q, Xu L (2014) Monitoring and evaluating progress towards universal 26. OECD (2012) Health at a glance: Europe 2012. Paris: Organisation for health coverage in China. PLoS Med 11: e1001694. Economic Co-operation and Development. Available: http://www.oecd.org/ els/health-systems/healthataglanceeurope.htm. Accessed 7 May 2014. 9. Alebachew A, Hatt L, Kukla M (2014) Monitoring and evaluating progress 27. Gwatkin DR, Ergo A (2011) Universal health coverage: friend or foe of health towards universal health coverage in Ethiopia. PLoS Med 11: e1001696. equity? Lancet 377: 2160–2161. 10. Lai T, Habicht T, Jesse M (2014) Monitoring and evaluating progress towards 28. Boerma JT, Bryce J, Kinfu Y, Axelson H, Victora CG (2008) Mind the gap: universal health coverage in Estonia. PLoS Med 11: e1001677. equity and trends in coverage of maternal, newborn and child health services in 11. Nyonator F, Ofosu A, Segbafah M, d’Almeida S (2014) Monitoring and 54 Countdown countries. Lancet 371: 1259–1267. evaluating progress towards universal health coverage in Ghana. PLoS Med 11: 29. Pradhan M, Prescott N (2002) Social risk management options for medical care e1001691. in Indonesia. Health Econ 11: 431–446. 12. Devadasan N, Ghosh S, Nandraj S, Sundararaman T (2014) Monitoring and 30. World Health Organization (2011) Monitoring maternal, newborn and child evaluating progress towards universal health coverage in India. PLoS Med 11: health; understanding key progress indicators. A report prepared by Countdown e1001697. for Maternal, Newborn and Child Health, Health Metrics Network and WHO. 13. Tan KB, Tan WS, Bilger M, Ho CWL (2014). Monitoring and evaluating Geneva: WHO. progress towards universal health coverage in Singapore. PLoS Med 11: 31. United Nations General Assembly (2012) Resolution A/RES/66/2. Political e1001695. declaration of the High-level Meeting of the General Assembly of the General 14. Ataguba JE, Day C, McIntyre D (2014) Monitoring and evaluating progress Assembly on the Prevention and Control of Non-communicable Diseases. New towards universal health coverage in South Africa. PLoS Med 11: e1001686. York: United Nations General Assembly. Available: http://www.un.org/en/ga/ 15. Mtei G, Makawia S, Masanja H (2014) Monitoring and evaluating progress search/view_doc.asp?symbol=A/RES/66/2. Accessed 29 April 2014. towards universal health coverage in Tanzania. PLoS Med 11: e1001698. 32. World Health Organization (2012) Resolution EB130.R7. Follow-up to the 16. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammata- High-level Meeting of the United Nations General Assembly on the Prevention charee J (2014) Monitoring and evaluating progress towards universal health and Control of Non-communicable Diseases. In: Executive Board 130th session, coverage in Thailand. PLoS Med 11: e1001726. Geneva, 16–23 January 2012. Resolutions and decisions, annexes. Geneva: 17. Chahed MK, Arfa C (2014) Monitoring and evaluating progress towards WHO. Available: http://apps.who.int/gb/ebwha/pdf_files/EB130-REC1/ universal health coverage in Tunisia. PLoS Med 11: e1001729. B130_REC1-en.pdf. Accessed 29 April 2014. 18. Saksena P, Hsu J, Evans D (2014) Financial risk protection and universal health 33. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, et al. (2007) coverage: evidence and measurement challenges. PLoS Med 11: e1001701. Protecting households from catastrophic health spending. Health Aff 26: 972–983. 19. Boerma T, AbouZahr C, Evans D, Evans T (2014) Monitoring intervention 34. World Health Organization (2013) Research for universal health coverage. coverage in the context of universal health coverage. PLoS Med 11: e1001728. World Health Report. Geneva: WHO. PLOS Medicine | www.plosmedicine.org 8 September 2014 | Volume 11 | Issue 9 | e1001731