dimensions. Currently available data on coverage of specific services refers largely to maternal and child health, such as antenatal care, delivery care and immunisation. This provides a starting point, but needs to be extended to other key areas of health care, such as non-communicable diseases, so as to include the main contributors to the burden of disease in a particular country. Breadth is arguably the simplest to measure, for example by asking in household surveys whether respondents consider that they are included in some insurance scheme or equivalent (although with the caveat that those least likely to be covered are least likely to be included in surveys, such as illegal migrants). This should also take account of equity, for example by capturing differences in coverage by wealth, gender or income quintile. This should also consider other markers of marginalisation, such as having a disability or being a member of an indigenous population. Height is also relatively straightforward and can be measured as a reduction in the share of out-of-pocket payments for health care below a fixed percentage, using data from the World Bank’s living standards measurement surveys and similar household surveys. The fifth indicator is the commitment of adequate resources to deliver UHC. There is emerging evidence showing that the ability to deliver UHC is associated with the ability to raise direct taxation T h e r i g h t t o h e a l t h (paper submitted). Accordingly, we propose the achievement of a fixed percentage of gross national product on health care, and not as in the Abuja Declaration2, a percentage of government spending. We have considered, but rejected, the idea that the percentage should vary, from a low figure in the poorest countries to a higher one in the richest, as this would accentuate inequalities. The sixth indicator relates to cost-effectiveness. Policy-makers at national and sub-national levels have limited resources and must choose among many interventions that target different diseases and vulnerable populations (Chopra et al., 2012). A possible indicator could be the use of expensive branded drugs when cheaper alternatives are available or the ratio of complex to basic items of equipment. However, cost-effectiveness of mortality reduction for the entire population does not necessarily mean that it will also be ‘equitable’, as these are two separate dimensions. Deaths can be reduced in a highly cost-effective way when investments are targeting the wealthiest quintiles, just as when they are targeting the poorest. An appropriate indicator might be the number of deaths or disability-adjusted life years (DALYs) averted per cost of intervention scale-up in the poorest quintile of the population. Figure 1 Ten indicators for UHC based on the right to health Indicator Commonwealth Health Partnerships 2015 23 The existence of a legal mandate for UHC in the country The extent of coverage in terms of depth (which services are covered) The extent of coverage in terms of breadth (who is insured) with attention to equity The extent of coverage in terms of height (what proportion of costs are covered) with focus on reduction in share of out-of-pocket payments for health care The commitment of adequate resources to deliver UHC with focus on percentage of gross national product on health care Cost-effectiveness with attention to equity International assistance as a percentage of GDP Existence of an international development policy explicitly including specific provisions to promote and protect the right to health SARA on participatory decision-making SARA on prioritisation of marginalised groups Underlying legal principle Minimum core obligation/progressive realisation Minimum core obligation/progressive realisation Minimum core obligation/progressive realisation Minimum core obligation/progressive realisation Minimum core obligation/progressive realisation Cost-effectiveness/non-discrimination Shared responsibility Shared responsibility Participatory decision-making/nondiscrimination Attention to vulnerable and marginalised groups/non-discrimination Data source Global health law repository Household survey data Household survey data World Bank’s living standards measurement surveys/household survey data World Bank statistics Data on use of branded/generic drugs or high-tech/basic equipment OECD-DAC database Extended SARA Extended SARA
Commonwealth Health Partnerships 2015
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