Chapter 1. Universal health coverage and country dashboards
This chapter uses Universal Health Coverage as the basis to analyse a core set of indicators on health, health systems and inequalities in the Latin American and Caribbean (LAC) region. Country dashboards shed light on how LAC countries compare amongst themselves and with the OECD, across five dimensions: population health, coverage and services, financial protection, quality of care, and health inequalities. This overview provides a first glimpse on the overall situation of LAC countries and establishes linkages and dependencies between the indicators that the full report contains.
The aim of this chapter is to present a set of key indicators related to population health and Universal Health Coverage (UHC) that informs the organisation of the report and establish linkages and dependencies between the indicators it contains. Table 1.1 shows a summary of these selected indicators.
For each dimension, a set of indicators is presented in the form of country dashboards. The indicators are selected based on their policy relevance, but also on data availability and interpretability. Indicators where coverage is highest are therefore prioritised.
Country dashboards
In order to allow for cross-country comparisons of performance, the central tendency measures presented for all indicators are medians. The classification of countries being close to, better or worse than the LAC countries average is based on an indicator’s standard deviation (a common statistical measure of dispersion). This method is preferred to using a fixed percentage or fixed number of countries per category, since it reflects the degree of variation, i.e. how far a country is from the LAC countries average. Countries are classified as “close to the LAC average” (blue) whenever the value for an indicator is within half of a standard deviation from the LAC average for the latest year. For a typical indicator, and assuming a standard normal distribution of the data, about 38.2% of the countries (12-13 countries) will be close to the OECD average, with the remaining 61.8% performing significantly better (green) or worse (red).
This classification applies to all indicators, with a caveat for the dashboard on coverage and services: given the nature of the indicators presented, high levels cannot be classified as being clearly better or worse performance, the symbols simply imply that the values are significantly higher or lower than the median. When the number of countries that are close to the LAC average is higher (or lower), it means that cross-country variation is relatively low (or high) for that indicator.
Universal health coverage (UHC) is achieved when all people, communities and social groups have access to health services they need, that these services have a high degree of quality, and that users are not vulnerable to financial hardship through the use of health services (WHO and World Bank, 2017[1]).
Despite recent progress, in 2019, at least half of the world’s population still did not have full coverage of essential health services. Lack of financial protection pushes about 100 million people into poverty worldwide as a result of health care related payments, and nearly a billion spend more than 10% of the household’s budgets in health-related expenses. UN member states have agreed to achieve UHC by 2030, as part of the Sustainable Development Goals (SDGs) (WHO and World Bank, 2017[1]).
The definition of UHC includes three related dimensions:
Access to health services – all people in need of health services should be able to receive care, independent of socio-economic characteristics, location, wealth or any other vulnerability.
Financial protection – all people should be safe from financial risk when incurring health care expenses, therefore service affordability and mechanisms that facilitate access to care should be prioritised.
The quality of health services should be at a standard where it is effective in providing care and improving outcomes, while it is also cost effective and sustainable. Access without quality can be considered an empty universal health coverage promise (OECD/WHO/World Bank Group, 2018[2]).
This chapter also considers an important factor that must be included in every discussion on UHC: inequalities. There are gaps in population health in all three of these UHC dimensions across different socio-economic groups.
The 200+ indicators included in this publication offer the reader a comprehensive sense of LAC health systems, and how countries compare.
UHC has as its ultimate goal the improvement of health status and the reduction of risk factors across all population groups. Ensuring access to services, quality and financial protection are key contributors to better population health, but several other societal factors determine final health status. The following two dashboards offer an overview of health status and risk factors for health using a partial list of the indicators discussed in Chapter 3 (Health Status) and Chapter 4 (Determinants of Health).
Health Status
The five indicators presented in this dashboard offer a general view of health status based on mortality indicators. This includes life expectancy at birth for females and males (2017), survival to age 65 for females and males (2017) and under age 5 mortality rate (2017). They provide an overview of where countries stand in terms of lowering mortality (see Table 1.2).
Determinants of Health
Health status depends not only on the provision of health care, but also on the behaviour of people and the environment in which they live. The five indicators presented in this dashboard offer an overview of the prevalence of risk factors or behaviours (smoking among persons aged 15 and above – 2016, alcohol consumption in litres per capita among persons aged 15 and above – 2016, and prevalence of overweight among adults – 2016) and of environmental factors that affect health (access to basic drinking water – 2017 and access to basic sanitation – 2017) (see Table 1.3).
Access to health care depends firstly on whether there are enough resources available to provide the necessary care. The dashboard illustrating progress in the coverage and services dimension uses one indicator of medical infrastructure availability (number of hospital beds per 1 000 population – latest year available), three indicators of human resources availability (doctors per 1 000 population – latest year available, nurses per 1 000 population – latest year available and psychiatrists per 100 000 population – latest year available) and one indicator of coverage for maternal and child health services (mothers receiving at least four antenatal visits during pregnancy – latest year available) (see Table 1.4).
Access to health also depends on whether people can afford care. The indicators included here provide an overview of the expenditure level of the countries of the region (shown as overall health spending per capita – 2016 and the proportion of total health spending which is out of pocket payments – 2016) and the prevalence of financial vulnerability that exists in countries (shown as the proportion of population that are overspending in health – latest year available and the proportion of population being pushed by health expenditures into the poverty line, defined as the higher of the USD 1.90 (USD PPP 2011) poverty line and a 50% of the median consumption poverty line – latest year available) (see Table 1.5).
Health care which is of low quality can harm patients and waste resources. The quality of care dashboard includes two vaccination coverage indicators (diphtheria tetanus toxoid and pertussis – 2017 and measles – 2017) and three five-year cancer net survival indicators (breast – 2010-14, cervical – 2010-14 and colon – 2010-14). Gaps in data availability for these and other quality indicators remain substantial in the region (see Table 1.6).
Finally, this dashboard illustrates another important consideration necessary to measure a country’s progress towards UHC: the level of inequality experienced by population groups in their health status and health determinants, as well as their access to, affordability of, and coverage of health services. This dashboard displays the average difference between the poorest and the wealthiest income quintile for each indicator in each LAC country and compares them with the regional average. If the difference is larger than the average, a red icon is displayed, while a green one is shown when the difference is smaller than the average. The available international comparable data for this dashboard was taken from the Health Equity and Financial Protection Indicators database (World Bank, 2019[3]).
References
[2] OECD/WHO/World Bank Group (2018), Delivering Quality Health Services: A Global Imperative, World Health Organization, Geneva 27, https://dx.doi.org/10.1787/9789264300309-en.
[1] WHO and World Bank (2017), Tracking universal health coverage: 2017 global monitoring report: executive summary, World Health Organization and International Bank for Reconstruction and Development / The World Bank, https://apps.who.int/iris/bitstream/handle/10665/260522/WHO-HIS-HGF-17.2-eng.pdf.
[3] World Bank (2019), Health Equity and Financial Protection Indicators (HEFPI), http://datatopics.worldbank.org/health-equity-and-financial-protection/ (accessed on 19 November 2019).