25 July 2016

A call for change

SDG indicator 3.8.2

Sustainable Development Goal 3 is to ensure healthy lives and promote well-being for all. Within this broad Goal 3, there are 13 targets to meet and the eighth target is about achieving universal health coverage (UHC). This is of particular relevance to IHP+, which is part way through a transformation process to become the International Health Partnership for UHC 2030.  

Target 3.8 of SDG 3 is to achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. 

A question of concern is how can we measure how far countries are making progress towards this target and ultimately reaching it?  The target is about the multi-dimensional nature of universal health coverage, and indicators are needed to effectively monitor each dimension. For example, indicator 3.8.1 concerns the coverage of essential health services and indicator 3.8.2 concerns the proportion of the population not financially protected. The 69th World Health Assembly resolution 69.11 ‘Health in the 2030 Agenda for Sustainable Development’ considers WHO’s work to further develop and finalise the indicators with the Inter-Agency and Expert Group on SDGs (IAEG-SDGs). 

The current formulation of indicator 3.8.2 proposed by IAEG-SDG is the ‘number of people covered by health insurance or a public health system per 1000 population’. 

However, many consider that the current formulation is not a valid measure for financial protection. H.E. Ms Mary Robinson, speaking at the IHP+ side event of the High Level Political Forum on UHC spoke about the need for the right indicators to measure progress, “including one that focuses on cutting the number of people suffering financial hardship.”

Simon Wright from Save the Children, UK echoed this. “The problem of financial hardship is due to the impact of high levels out of pocket expenditure. We are so concerned about the currently proposed SDG indicator 3.8.2 because it does not reflect this and needs to be changed as the current formulation is both dangerous and meaningless,” he said. 

The concern about the current formulation of this indicator is that it is not a valid measure for financial protection. A valid metric should monitor the impact of household health expenditures on its living standards. Affiliation to a health insurance scheme or coverage by a public health system does not measure this.  

The existing indicator would neither provide meaningful international comparisons as it is not possible to distinguish across countries for coverage by a public health system nor is the interpretation of what constitutes ‘health insurance’ the same across countries.  

Beyond these measurement issues, there are also concerns that the indicator is not neutral in respect of specific policy instruments to implement progress towards the target. The existing formulation risks implicitly encouraging countries to introduce or expand any form of health insurance.

The finalization of the SDG indicators is still in process. The IAEG has met three times since 2015 and its 4th meeting is scheduled in Addis Ababa on 18-21 October 2016. The indicator refinement process including 3.8.2 indicator will happen by the 48th UN Statistical Commission in March 2017. Health experts and UHC supporters are encouraged to discuss this issue with statisticians and IAEG-SDG members to contribute the forthcoming indicator refinement process. 

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