OA: Open letter on the SDGs: a robust measure for universal health coverage is essential

The Lancet

 Dear members of the Inter-Agency Expert Group on the Sustainable Development Goals (IAEG-SDGs),

We write as members of the health, academic, and, research community to urge you to agree on a refinement of SDG Indicator 3.8.2, which is on financial risk protection for universal health coverage (UHC), when you meet this week at the IAEG-SDGs meeting in Geneva.

UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. Worldwide, every year 1 billion people are denied medical care because they cannot afford to pay, while 100 million are pushed into poverty by health-care costs.¹ The need for UHC couldn't be more urgent, and the inclusion of a target to achieve UHC in the SDGs is a triumph of global decision making.

UHC means that everyone can access the quality health services they need without being pushed, or pushed further, into poverty. There are two clear indicators required to measure UHC: one for coverage (indicator 3.8.1), and one that can measure effective financial risk protection (indicator 3.8.2). We are pleased to see both aspects of UHC reflected in the framework and we congratulate you on agreeing on a robust indicator for health coverage (3.8.1).

We are, however, very concerned that indicator 3.8.2 for financial risk protection as it stands—coverage by health insurance or a public health system per 1000 population—will fail to measure the impoverishing effect of health spending meaningfully, and could undermine real progress towards UHC. Having a public health system or an insurance mechanism is, in itself, not a measure or guarantee of financial risk protection. Moreover, this indicator will not produce data that can be disaggregated by income or gender.

We endorse the WHO and World Bank supported refinement to indicator 3.8.2: the proportion of the population with large household expenditures on health, as a total share of household expenditure or consumption. Data on household expenditure on health can be collected from existing household surveys, and this indicator allows for disaggregation, including by measures such as income and gender.

As members of the academic and research community, we want to see an indicator of financial risk protection that is scientifically robust and neutral with regard to alternative health financing mechanisms. A methodologically sound measure of the financial burden of health-care costs on household budgets will help academics, researchers, and health policy makers to better understand the effectiveness of different policy instruments, and can best support evidence-based policy making.

We are grateful for the opportunity to convey this message to you, and we hope that, on consideration, you will agree on an indicator for financial risk protection that supports our global ambition for quality, affordable, and equitable health-care coverage that leaves no-one behind.

We declare no competing interests.

Supplementary Material (international signatories)

Title	Description	Type	Size
Supplementary appendix		pdf	.27 MB

Reference

1. Xu, K, Evans, D, Carrin, G, Aguilar-Rivera, AM, Musgrove, P, and Evans, T. Protecting households from catastrophic health spending. Health Affairs. 2007; 26: 972–983
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