U n i v e r s a l h e a l t h c o v e r a g e a n d h e a l t h y a g e i n g The next two indicators relate to financial and non-financial dimensions of shared responsibility. The first is international assistance as a percentage of GDP, using the widely accepted target of 0.7 per cent of GDP. The second is the existence of an international development policy explicitly including specific provisions to promote and protect the right to health. We have finally considered the challenging issue of developing indicators for participatory decision-making, non-discrimination and prioritisation of marginalised groups. Rifkin, for example, notes that trying to capture these dimensions by indicators approved at the UN level may be meaningless or even counterproductive (Draper et al., 2010). Her main argument is that as soon as indicators are accepted, we are likely to see some tokenistic application of principles, which is likely to distract from the real issue, which is political willingness. The most feasible proposal is by O’Neill et al. (2013): to conduct ‘service availability and readiness’ assessments (SARA) as a baseline for UHC and to be updated regularly as a way of monitoring progress. These underpin the ninth indicator, on participatory decision-making, and the tenth, on non-discrimination and the prioritisation of marginalised groups, adapted to the reality of each country. Challenges in indicator development Three major challenges face any exercise to set indicators post- 2015: data availability, the universality of targets and the adaptation of global goals to local populations. Few developing countries have adequate data and there is growing recognition of the need for serious investment in data and sustainable information systems. These challenges should not be underestimated; they question the extent to which progress made towards transformative goals can be measured. Measurability will Universal health coverage 24 Commonwealth Health Partnerships 2015 inevitably influence which targets and goals can be considered, thus potentially limiting the ambitious and transformative nature of the goals. Second, universal goals may not capture the priorities of all countries. Spending time and money collecting data for indicators that are not relevant in specific contexts could lead to a neglect of problems associated with specific marginalised groups. In addition, developed countries have resisted universal goals given the political implications they have for their own domestic policies, in contrast to the MDGs, which were applied to low- and middle-income countries. Third, while some indicators might be universally relevant, such as maternal and child mortality, or life expectancy, others, such as mortality from malaria, are highly contingent. The choice of indicators may, therefore, directly affect people’s health, meaning that peoples have the right to participate in deciding what the indicators are. While this should include decisions at the UN level, as a practical and normative matter, to enable the most meaningful participation, it should also occur nationally (or even locally). Further, if the participation is to be meaningful nationally (or locally), then the results of the participation must have the possibility of having an impact, in this case, on affecting the nature of the indicator. In this article we have explicitly avoided setting specific targets to be achieved in terms of the individual indicators. Instead, we noted the principles that underpin any target-setting exercise. Targets should be specific, measurable, accurate, realistic and time bound. The process of determining targets will inevitably involve political considerations, but it is also important that it is informed by technical ones. In some cases, the process is straightforward. Thus, we note that the target for the percentage of GDP spent on health proposed by the Sustainable Development Solutions Network is five per cent3. However, we also recognise that in the poorest countries this sum will be inadequate to provide UHC and will need to be supplemented by additional funds from development assistance. Crucially, we emphasise that whatever figure is chosen should be a minimum, not a maximum. A mid-term target might reasonably be to halve the gap between the existing level of expenditure and the target. In other areas there is a need for modeling to determine feasible but challenging targets based on the starting conditions, effectiveness of policies to achieve the targets and the time lags that apply. Despite these challenges, for UHC to continue to gain momentum in the mainstream post-2015 agenda, attention must be given to the development of indicators that are universally accepted, implementable and based on an agreed legal framework. It is only through law and the right to health that individuals and populations can claim entitlements to health services, and that corresponding governmental obligations can be established and enforced (Gostin, 2014). A crucial next step is to build on the WHO/World Bank report and make UHC, as an expression of health rights, susceptible to measurement. Acknowledgements The authors thank Genevie Fernandes for her research assistance and Go4Health consortium members for their feedback on an earlier draft presented at the Antwerp workshop. On 12 December 2012 UHC received unequivocal endorsement from the UN General Assembly (including the USA) with the approval of a resolution on UHC that confirmed the ‘intrinsic role of health in achieving international sustainable development goals’.i Yet, despite UHC’s growing prominence in the post-2015 agenda, there is no single agreed definition of what it is and there is ongoing discussion about what indicators might measure progress towards it (O’Connell et al., 2013). While the 2005 World Health Assembly’s definition of its achievement as ‘access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access’ (WHO, 2005) captures key elements and the World Health Report 2010 identified the three dimensions of who, what and which proportion of the costs are covered (WHO, 2010), neither are easily operationalised for routine use. A notable exception is the 2014 WHO/World Bank report, which attempts to fill this gap by discussing possible targets and indicators from the three dimensions related to service delivery and financial protection (WHO/WB, 2014).
Commonwealth Health Partnerships 2015
To see the actual publication please follow the link above