Universal Health Coverage, Non-communicable Diseases, and Indicators
Eric A. Friedman | Leave a Comment
The large and growing burden of non-communicable diseases in lower-income countries is now a common storyline in global health. So too is the global movement towards universal health coverage. Might the former help in measuring progress towards the latter? Might progress on addressing non-communicable diseases (NCDs) – in particular, treatment for breast cancer, or perhaps another cancer that wholly or primarily affects women and responds well to treatment – be an important indicator of universal health coverage?
The question of how to measure universal health coverage is not easily resolved. For present purposes, I consider only coverage of health services. Measurements of financial protection, including ending the impoverishing effect of health spending — presently pushing 100 million people into poverty every year (World Health Report 2010, p. 5) — will also be needed, such as the proportion of health spending by the lowest wealth quintile or lowest several wealth quintiles that is out-of-pocket.
In terms of coverage, two main approaches are discussed. One is a composite indicator, or index, that combines coverage levels of a diverse set of health services into a single number. For an example of a composite indicator measurement and possible health services to incorporate, see this Health Systems 20/20 report (p. 25-29). For a detailed discussion on measuring universal health coverage from the World Health Organization, see this report from September 2012. (A summary of a more recent discussion on measuring universal health coverage, organized by WHO and others, is here.)
A more pragmatic, easily understandable approach might be to use “tracer indicators” (see, e.g., World Health Report 2013, p. 131), a set of indicators for specific health services that, collectively, will provide a good sense of the reach of a country’s health coverage. One challenge with this approach is that it could incentivize countries to focus on these health services — what is measured gets done, as it is said — at the expense of other health services.
While no specific measure are likely to be free of this risk, one of the favored measures for health system functioning — and so perhaps to be favored for measuring universal health coverage as well — is maternal mortality. While many factors outside the health system affect maternal mortality levels (e.g., respect for women’s rights including girls’ and women’s level of education, not being forced into early marriage, not needing permission to travel to a health center), central to reducing maternal mortality is ensuring all women access to emergency obstetrics care. This requires effective health systems, including sufficient numbers of skilled health workers, the ability for people to get to the health center, and functioning health facilities. Importantly, maternal mortality measures also say much about whether a country provides quality and non-discriminatory, respectful care — poor treatment defers women from visiting health facilities.
Furthermore, maternal health indicators are quite powerful in measuring inequities, demonstrating the massive gaps between richer and poorer parts of population, between those with more or less education, between those who live in urban compared to rural areas. The World Health Organization’s annual World Health Statistics publication (table 8) now includes such equity measures in such areas as births attended by skilled health personnel and child morality.
Yet a country could very well make significant progress on reducing maternal mortality without attending to health threats of growing importance, such as NCDs, including cancer (much less cancer treatment). In the present era, with the large and growing proportion of the burden of disease caused by NCDs occurring in developing countries, a system of health coverage that neglects or gives short thrift to NCDs could hardly be properly deemed universal health coverage.
A recent article in the New York Times on treatment of breast cancer in Uganda got me thinking about the potential for breast cancer treatment, or something similar, to be a key trace indicator for universal health coverage. At least on its face, it would share many of the advantages of a maternal mortality indicator, such as a focus on women, the need for well-trained health workers, and functioning infrastructure – including laboratory capacity, an adequate stock of medicines, and radiation equipment.
A measure of or related to breast cancer survival does have shortcomings, though, as an overall measure of health systems and universal health coverage, perhaps especially the possibility of having specialized cancer facilities that could be well-functioning, operating as a vertical health program with its own set of systems, regardless of the state of the rest of the health system. Yet cancer survival is greatly facilitated by early detection — a major problem in many lower income countries — and early detection will require the broader health system.
Perhaps, though, breast cancer survival (or survival of another cancer that solely or primarily affects women?) would be a significant supplementary measurement of universal health coverage, in conjunction with maternal mortality. From physical infrastructure to skilled health workers, reducing maternal mortality will require functioning health systems, a pre-requisite for effective and comprehensive universal health coverage. Adding on breast cancer survival would indicate the degree both to which non-communicable diseases are being incorporated into health systems and universal coverage broadly – given the importance of early detection – and whether countries are taking measures to extend the services assured through universal health coverage to include non-communicable diseases. And perhaps there is a progression and unity in how countries respond to NCDs — that as child and maternal mortality fall and countries effectively tackle infectious diseases, they would and do scale up responses to all the major NCDs affecting their populations (including, I would hope, the oft-marginalized mental health needs of the population), and not only one form, in this case cancer. Thus, breast cancer survival might serve as a measurement of how countries are covering NCD prevention, care, and treatment more broadly.
Issues such as the unity of NCD coverage scale-up may well require further investigation. Whether or not breast cancer survival should take a central place in measuring universal health coverage, what does seem clear is that while maternal mortality remains a tremendously important measure, raising the profile of indicators involving non-communicable diseases – including mental health – is necessary too to help ensure that universal health coverage is comprehensive, with quality health services for the full spectrum of health needs of a country’s population available to all, regardless of ability to pay.