The expert group in charge of developing the indicators for the Sustainable Development Goals has agreed to reconsider an indicator for universal health coverage.
On Friday, members of the Inter-Agency and Expert Group on the SDGs accepted the World Health Organization and World Bank’s proposed indicator on financial protection for SDG target 3.8, which aims to achieve UHC. The decision came months after intense lobbying and campaigning by civil society organizations and other global health actors, who strongly opposed any indicator that measures people’s access to health care services based on insurance coverage alone.
The WHO and World Bank originally put forward an indicator that looks at the “fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure” as a means to measure financial protection. In February 2016 the IAEG changed the indicator to “number of people covered by health insurance or public health system per 1,000 population.”
CSOs and other actors argued the IAEG indicator did not fully measure how many people suffer from financial hardships and therefore struggle if not unable to pay for health services. They said access to a health insurance does not guarantee financial protection.
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In February over 300 CSOs, dismayed over the IAEG’s sudden decision to change the indicator to health insurance, wrote to the expert group, including the United Nations Statistics Division, urging them to scrap it and revert back to the original or refined version given by WHO and the World Bank.
The IAEG finally accepted last week — much to the relief of all those involved in the yearlong campaign.
“It took hundreds of passionate, persistent partners campaigning for more than a year to ensure that this measurement framework captured both essential elements of universal health coverage — access to quality health services and financial protection,” said Michael Myers, managing director at The Rockefeller Foundation. “Now, millions of people who suffer financial hardship seeking health care have a chance to be seen, and we have a tool to hold countries accountable.”
We've called on world leaders to measure what matters, and now they will. #UHC means services AND financial protection #HealthForAll
Keeping the momentum in ensuring the IAEG uses the WHO-World Bank proposed indicator was a huge effort that required civil society’s perseverance as well as strategic thinking in terms of communication and tapping the right people at the right moments, said Anna Marriott, health policy adviser for Oxfam GB.
“The challenge is maintaining that momentum and picking your moments strategically to make sure you get those big numbers again and again,” Marriott, who leads Oxfam’s health policy work internationally and who was involved in the campaign from the start, told Devex.
CSOs lobbied the World Health Assembly in May to come up with a resolution that would give WHO a clear mandate in supporting the IAEG on the indicators. CSOs also lobbied different U.N. missions and forums, made sure there was huge response to the public consultations IAEG issued in September for a list of indicators including the one on financial protection for health, and helped coordinate and mobilize the academic and research community in supporting their cause.
On Tuesday, 351 members from the academia and research community endorsed the WHO and World Bank indicator in an open letter to the IAEG published in The Lancet.
“We felt that was a critical piece of work: a clear message from health academics and researchers whom we would hope the IAEG members would see as their peers working on health statistics [and] health economics,” Marriott said. “We felt that would be a message that would be even better received than from NGOs.”
Mobilizing these different alliances was not easy to pull off, but Marriott said it helped that there was huge consensus across the global health community to “defend what we’d won.”
“We all worked so hard to get UHC up in the global agenda and agreed in the SDGs target, and then before our eyes we saw a huge risk that this is all going to be undermined and taken away from us by a group of statisticians that have nothing to do with that long-term campaign that we’ve all been involved in,” she said.
CSOs such as Oxfam also gave members of the IAEG real-life stories of impoverished people from India to Malawi who couldn’t afford to pay for their family’s health care needs. The idea, according to Marriott, was for the statisticians to understand the impact their decisions will have on the lives of these people.
The next challenge
Consensus on the indicators is a key step in the process, but things are still fragile. Anything can happen between the global health community’s win on Friday and ECOSOC’s meeting in July, when member states are expected to sign off on the whole indicator framework.
“I don’t think anything’s in the bag to be honest, and that’s why we have to watch this very, very closely,” Marriott said.
Given the overwhelming response the IAEG received on the indicator, it would be difficult for them to apply changes to it, although “it’s not impossible,” warned the Oxfam policy adviser.
At present, the accepted indicator is still in the third tier, meaning there are still questions about its methodology and how the data will be generated, said Marriott. CSOs are hoping the WHO and the World Bank would be able to satisfy the U.N. Statistical Council’s questions on how the data will be generated for this indicator — and the methodology on how to measure it — for the indicator to move to the first tier in March.
If all goes well, they can start focusing ahead to implementation, which Marriott said they would have preferred to focus their energies on for the past 12 months instead of the “long ongoing drudgery of following the process.”
“But this [indicator] change feels like we’ve had to fight hard to stand still on UHC, which is tricky,” she said.
Despite this, Marriott admitted the process helped CSOs build a huge coalition of activists and academics who will be valuable allies as their focus shifts to implementation. This network will help them in monitoring and keeping governments accountable to their commitments under the SDGs.
These actions, Rockefeller’s Myers said, will continue to require active CSO participation and engagement.
“Now that countries will be asked to track coverage of quality services and the financial impact of health costs on households, it’s up to all of us to ensure that they are actually collecting and acting on this information to ensure everyone has access to quality health services without suffering financial hardship,” he said.
Jenny Lei Ravelo is a Devex senior reporter based in Manila. Since 2011, she has covered a wide range of development and humanitarian aid issues, from leadership and policy changes at DfID to the logistical and security impediments faced by international and local aid responders in disaster-prone and conflict-affected countries in Africa and Asia. Her interests include global health and the analysis of aid challenges and trends in sub-Saharan Africa.
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