Today we can celebrate that we are now talking about how to achieve Universal Health Coverage and not whether or not this is a worthy Sustainable Development Goal (SDG).
Oxfam, like many others across the global health community, supports an indicator that measures whether the number of people paying excessive and punishing out of pocket payments for health is going up or down.
The World Health Organization (WHO) and World Bank have proposed an indicator that in our view, and many in the global healthy community, does this: “Proportion of the population with large household expenditures on health, as a total share of household expenditure or consumption”.
The indicator currently being proposed by the IAEG-SDGs however, measures the:
“Number of people covered by health insurance or a public health system per 1,000 population”.
This current proposed indicator in our view is not a suitable measure: it fails to measure whether people are actually protected from obstructive and punishing costs associated with seeking needed health care. It would be like trying to measure someone’s health outcomes by counting the numbers of hospital beds.
Coverage by “health insurance” or a “public health system” does not eliminate the risk of high impoverishing payments for health care.
Health insurance does not always equal financial protection. In Vietnam for example 60% of people have health insurance but still face high out of pocket payments. The current indicator risks implying that all health insurance is welcome but many health insurance schemes have been shown to exacerbate inequalities.
And of course, ‘coverage by a public health system’ means nothing if that public health system charges you fees that you cannot afford.
As Dr. Gro Brundtland said at an event hosted by the Governments of Thailand, South Africa, Japan and Chile, The Rockefeller Foundation, and the International Health Partnership (IHP) 2030 in New York on 22nd September 2016:
‘The Elders share the opinion of the WHO and the World Bank, and many experts and campaigners, that the indicator to be adopted by the UN Inter- Agency and Expert Group for Target 3.8 must address the issue of financial protection coverage, rather than looking at the number of people covered by health insurance. Insurance is not a measure or guarantee of financial risk protection. We are concerned that this kind of indicator for UHC could undermine measuring real progress.’
At Oxfam we share this view. One billion human beings are being denied medical care each year because they cannot afford to pay. 100 million people are pushed into poverty each year paying for needed health care. To see how health costs impact on real lives, read Esther’s and Nhut’s stories, which illustrate how prohibitive health care costs lead to greater hardship for the whole family – or even death. We cannot let the millions of stories like Esther’s and Nhut’s remain invisible and uncounted.
Oxfam welcomes the IAEG-SDG’s decision to consider refinement of the indicator for financial protection for UHC (3.8.2). We also welcome the open consultation for refinement of this and other indicators.
Oxfam strongly supports the indicator proposed by the WHO and World Bank as a refinement – not as an addition but to act as a replacement – to the current indicator 3.8.2.
The refined indicator is a meaningful measure of financial protection– and allows for disaggregation, including by income and gender, as is required. This refinement is the indicator proposed by the WHO and World Bank after a 3 year open and transparent consultation process with the global health community. Data for household expenditure on health can be collected for this indicator from existing nationally representative household surveys.
This alternative indicator, in our view, necessarily enables us to hold governments to account – and is a fundamental means to ensure we leave no one behind.
Oxfam International Executive Director