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Will the SDG indicator group make Universal Health Coverage indicator fit-for-purpose? by Anna Marriott, Public Services Policy Manager, Oxfam


In March this year we posted a blog on global health check about a dangerous and surprising last minute change to the indicator measuring financial risk protection for Universal Health Coverage (UHC), being developed by the Inter-Agency Expert Group on the Sustainable Development Goals (IAEG-SDGs). The IAEG is meeting in Geneva this week and aims to conclude discussions on this indicator (3.8.2), along with some of the other contentious indicators they have identified within the SDGs global indicator framework.

Since we reported on the danger of the nonsensical indicator undermining the highly valued SDG target on achieving UHC (that gives everyone access to quality health services, without causing impoverishment), the global health community has mobilized in large numbers to call for the reinstatement of the original indicator or a revised version of it, as proposed by the World Health Organisation (WHO) and World Bank (WB). Here are a few highlights of the actions from a range of constituent communities with a stake in this issue over the past few months:

  • As an immediate reaction to the changed indicator, over 300 NGOs wrote to the IAEG-SDGs last February calling for the new indicator 3.8.2 to be immediately revoked and replaced
  • Executive Director of Oxfam International Winnie Byanyima made this statement also in support of the WHO/WB proposed indicator
  • In the IAEG’s own open consultation in September 2016 on the possible refinement of global indicators, significantly more responses [144] were received on indicator 3.8.2 than the next most popular indicator [92] and 70% of respondents favoured the WHO/WB proposed indicator. Importantly, 62% of these respondents were explicit that the WHO/WB indicator should replace and not be in addition to the current flawed indicator.
  • In the run up to this week’s IAEG-SDGs meeting, another CSO letter signed by 98 organisations called for the current immediate replacement of 3.8.2 with the WHO/WB proposed indicator
  • This week 351 health academics and researchers from 62 countries have written directly to the members of the IAEG-SDGs expressing their concerns with the current indicator and calling for its replacement with the WHO/WB supported indicator. This letter is published in the Lancet.

The motivation for all this is to warn against keeping the current indicator whether on its own or in combination with the WHO/WB refined indicator. The current – flawed – indicator to measure financial risk protection for UHC reads:

    ‘coverage by health insurance or a public health system per 1,000      population.

The reasons this is not fit for purpose are manifold:

  • -Coverage by health insurance or a public health system does not equate to financial protection
  • -There is no universal meaning or definition of health insurance.
  • -Numerous schemes have actually widened inequalities e.g. voluntary insurance for only those who can pay
  • -It risks promoting voluntary insurance schemes against a large body of significant and robust evidence that such schemes do not advance UHC. This is not the job of the IAEG-SDGs
  • -Every citizen is theoretically covered by a public health system rendering the data meaningless

As an illustration of these flaws see the stories of Ranu and Esther.


Thankfully the IAEG is considering the alternative WHO/WB proposed indicator – one that is based on a global consensus following extensive consultation over a 3 year period. This alternative reads:

“Proportion of the population with large household expenditures on health, as a total share of household expenditure or consumption.”

This is relevant to the UHC target, as it directly measures the financial impact on households of the costs of health services. It is methodologically sound and grounded in an internationally agreed standard definition which is scientifically robust and policy neutral. Information and data is readily available from routine household surveys conducted by national statistical offices (e.g. Budget Surveys, Income and Expenditure Surveys, Living Standards Measurement Surveys) to support calculations. Furthermore, it is amenable to disaggregation on income, gender and geographical location.

A risk remains that in an attempt to reach agreement the IAEG members will include the WHO/WB proposed indicator as an addition rather than replacement to the flawed indicator. This is unacceptable for all the reasons above but also because countries are already straining with the weight of the SDG measurement framework and it would be a waste of their precious resources. Any data issued by governments using this indicator as a measure will be useless and thus easily ignored by health and statistical experts such as the 351 signatories who signed the health academics letter, the 100s of NGOs who’ve signed letters on this, and the 22 statistical authorities who submitted to the online submission. It would work to counter the hard won global consensus and huge momentum on UHC. And the losers would be all those currently left behind by their own national health systems – those like Raju and Esther who face the stark consequences of paying out of pocket for their health care.

To avoid this danger, the current indicator must be taken off the table completely. Instead of keeping this wasteful indicator, let’s measure what really matters: the impact of health spending on households.



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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni