In this course, learners will become familiar with principles and theories of global health problems, and major challenges and controversies in improving global population health as well as practical applications of quantitative methods to analyze and interpret issues and challenges for policy. Topics will include health and foreign policy, health governance, acute disease surveillance, non-communicable diseases, burden of disease, universal health coverage, health systems strengthening, health financing, and human resources for health and ageing.
Health Service Coverage
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Do curso por The University of Tokyo
Global Health Policy
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Universal Health Coverage in the Context of Aging
In Module 3, we will introduce the basic concept of universal health coverage (UHC), some technical aspects of health financing, and methods for measuring and improving UHC systems. We will also discuss the challenges to UHC posed by aging and development, including for developing countries. Finally, we will explore policy solutions to aging, and look at new policies being used around the world to improve and strengthen UHC systems.
Conheça os instrutores
Hiroshi Nishiura(Former Affiliation) Associate Professor, Graduate School of Medicine, The University of Tokyo
(Current Affiliation) Professor, Graduate School of Medicine, Hokkaido University
Stuart GilmourAssociate Professor
Department of Global Health Policy, Graduate School of Medicine
Kenji ShibuyaProfessor and Chair
Department of Global Health Policy, Graduate School of Medicine
In the previous lectures, we saw some basic methods for
defining health coverage, financial protection, and impoverishment.
Before we go on to talking about measures of equity, we need to discuss how to
measure the quality of health service coverage and its effectiveness.
So in order to measure the quality of health coverage,
we first need to identify indicators of what health coverage is.
So a good indicator of health coverage needs to be relevant,
it needs to measure quality, it needs to be available, and
it needs to be able to measure equity if possible.
That means, for relevance, it needs to address something that is actually
a health priority and it needs to measure or give an indication of the quality of
a cost effective intervention not just any intervention.
It also needs to measure quality, that is, it needs to measure not just who
has access to the intervention in question, but how effective it is.
It needs to use available standard methods.
So the indicator that you choose to measure Universal Health Coverage
progress, needs to be based on a standard method that can be measured on a regular
basis.
And is comparable between groups and countries.
And finally,
we need to be able to desegregate the indicator into different groups.
For example, different poverty or wealth groups, different genders, or rural and
urban areas so that we can measure equity.
So we'll look at some of these indicators today.
So first of all, we need to distinguish between coverage and effective coverage.
So, the coverage of an intervention is the share of a population that is receiving
that intervention.
Whereas, the effective coverage is the proportion of the population
that actually achieves the health outcomes the intervention aims to achieve.
So we can measure the process of delivering health service, or
we can measure the actual effected outcome of delivering it.
Which is the more important population that we'll measure.
As an example, with hypertension, we aim to reduce systolic blood pressure.
And so rather than assessing whether or not people received treatment for
systolic blood pressure, we might choose to measure
the ratio of their actual systolic blood pressure reduction from the treatment
to the potential blood pressure reduction that we wish to achieve for those people.
So if our goal with systolic blood pressure is to reduce it to, for example,
70, and we actually only reduce people to 80, then the ratio would be 8 on 7,
and we would use that as our indicator of effective coverage.
So in all cases, we need to consider not just the process, but
the health outcome that the intervention aims for.
There are many kinds of indicator that can be used to assess the coverage and
quality of universal health coverage systems.
And this slide shows examples of many of them.
They can be divided into promotion and prevention indicators.
That is, measures of how well their health system is working to protect health.
And treatment indicators,
which are measures of how well it handles conditions.
In the promotion and prevention column of this table, you can see improved water and
adequate sanitation which protect against basic diarrheal diseases which
are major killers in developing nations.
A range of vaccinations such as DPT and
Polio, which are necessary early childhood interventions.
Having at least four more antenatal care visits from a skilled birth provider for
pregnant women.
Seeking care for acute respiratory infections and diarrhea,
in order to prevent the spread of these preventable diseases.
And two important behavioral measures,
which are reducing the use of solid fuels and reducing the use of tobacco,
both of which are major causes of chronic obstructive pulmonary disease and
lower respiratory infections in developing settings.
In treatment, we have access to treatment for
acute respiratory infections and diarrhea.
We have access to skilled birth attendants,
so actually being able to get a skilled birth attendant when you deliver.
Delivery in an institution rather than at the home for pregnant women.
And for non-communicable diseases, we have diabetes control and hypertension control,
which are two important ways of preventing death and
injury due to these non-communicable diseases.
So we can measure any or all of these indicators when we try to
assess the progress of universal health coverage systems.
As examples, we have for promotion and prevention the proportion
of households that have access to improved water sources.
This may vary significantly between countries and also between rural and
urban areas.
As a treatment example, we might measure the proportion of deliveries
assisted by a skilled birth attendant.
And in this case, we're not measuring the proportion of
households that might be within, say, five kilometers of a skilled birth attendant.
We're assessing the actual attendance of a skilled birth attendant at the delivery so
that we measure the health outcome.
We can measure these using simple measures such as the simple mean or
the unweighted mean, or we can use more complex measures such as regression.
Which, essentially, are for
weighted estimates of the proportions, and adjust for covariates and confounders.
But in either case,
this is how we're essentially measuring the coverage of the system.
This is an example from four countries which shows the different levels
of coverage, of prevention and treatment interventions in these countries.
So the blue,
the light blue column is prevention and the light pink column is treatment.
And each of those symbols indicates a particular intervention within
that category.
The blue column and the pink column stop at the point
of the average level of coverage of all of the interventions in that category.
So, for example, in Chile, we have about 85% coverage of prevention, and
about 50% coverage of treatment.
You can see, for example,
that TB case detection can be quite low in some countries.
And that more than four antenatal visits, which is the purplish square in
the prevention column, declines rapidly from Chile,
where it's nearly 100%, to Bangladesh, where it's around about 30%.
So different countries has different qualities of coverage
in different aspects of prevention and treatment.
And this gives us an overall measurement of the effectiveness of service coverage
in that particular health system.
This is another example of how we show the inequity and
the distribution of coverage within regions.
It's similar to the slide that we saw in the previous lecture for
financial protection.
Here we mention coverage of treatment and coverage of prevention services for
the poorest to the richest 20% of the region, divided by regions.
So you can see in South Asia, which in the previous slide we saw had very
high levels of inequity in financial protection.
But there's also quite high inequity in coverage of prevention services,
with the poorest 20% of the population having much lower
coverage of prevention services than the richest.
So this gives us a measure of the distribution of coverage, and
it allows us to desegregate that coverage between countries.
So in summary, we have different criteria for
selecting indicators that measure the progress of the universal health coverage.
An indicator has to be relevant, it has to measure quality rather than just process
of the indicator, it has to be capable of measuring access, and
it has to be capable of being desegregated into different groups or
wealth quintiles so that we can measure equity.
We have two intervention categories that we primarily measure,
prevention and treatment.
And we usually find that coverage of prevention interventions is
higher than treatments.
And we can see that there's a large variation in coverage between rich and
poor across the globe.
And many different systems have different levels of quality of coverage, and
different levels of coverage of prevention and treatment.
In the next slide, in the next lecture, we'll talk about the measures of equity,
and how we can define and improve equity in universal health coverage systems.
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