Universal Health Coverage: Indicators, Goals, and Measurement

Universal Health Coverage (UHC) means that all individuals access needed health services without suffering financial hardship. The concept encompasses the full spectrum of essential health services, ranging from health promotion and prevention to treatment, rehabilitation, and palliative care. Sustainable Development Goal (SDG) Target 3.8 explicitly aims to achieve Universal Health Coverage by 2030, framing health as a fundamental pillar for human development and economic stability.

The Three Dimensions of Universal Health Coverage

UHC is traditionally conceptualized through a three-dimensional framework, often visualized as the “UHC Cube.” This framework tracks progress across three distinct dimensions of service delivery and financial protection.

• Population Coverage: Tracks who receives health services, aiming to extend non-discriminatory coverage to the entire population, including vulnerable and marginalized groups.
• Service Coverage: Tracks which health services are available, expanding the range of essential health interventions from basic primary care to advanced tertiary care.
• Financial Protection: Tracks what proportion of health costs are covered, ensuring that out-of-pocket payments do not drive households into poverty.

Primary Monitoring Indicators and Measurement Frameworks

Monitoring UHC progress relies on two primary indicators defined under SDG Indicator 3.8. These indicators measure service availability and financial protection independently.

Sustainable Development Goal Indicators for UHC

Service Coverage Index (SCI) Tracer Categories

The UHC Service Coverage Index aggregates 14 tracer indicators grouped into four main sub-indexes:

• Reproductive, Maternal, Newborn, and Child Health (RMNCH): Family planning demand satisfied, antenatal care coverage, full child immunization, and care-seeking for pneumonia.
• Infectious Disease Control: Tuberculosis treatment coverage, HIV antiretroviral therapy (ART) coverage, use of insecticide-treated bed nets for malaria, and adequate sanitation.
• Non-Communicable Diseases (NCDs): Prevention and control of elevated blood pressure, management of blood glucose levels, cervical cancer screening, and tobacco non-smoking rates.
• Service Capacity and Access: Hospital bed density, health worker density (physicians, nurses, and midwives), core sanitary capacity, and access to essential medicines.

Financial Protection Metrics

Financial hardship caused by healthcare costs is monitored through two primary concepts:

• Catastrophic Health Expenditure: Occurs when out-of-pocket payments exceed a fixed threshold (e.g., 10% or 25%) of total household income or consumption expenditure.
• Impoverishing Health Expenditure: Occurs when out-of-pocket payments push a household below the extreme poverty line ($2.15 per day) or a relative national poverty line.

Global Targets and Institutional Frameworks

International organizations establish specific targets to guide national policymaking and monitor health systems.

World Health Organization (WHO) Triple Billion Targets

The WHO integrated UHC into its strategic priorities through the “Triple Billion” targets.

• 1 billion more people benefiting from Universal Health Coverage.
• 1 billion more people better protected from health emergencies.
• 1 billion more people enjoying better health and well-being.

Astana Declaration (2018)

The Astana Declaration reaffirmed Primary Health Care (PHC) as the most cost-effective and inclusive foundation for achieving UHC. It shifted global strategy toward community-level health centers, preventive care, and essential diagnostic access.

Indian Context: Initiatives and Policy Frameworks

India’s strategy to achieve UHC rests on national health policies, publicly funded insurance schemes, and primary health infrastructure programs.

Key Schemes and Structural Components

• National Health Policy (NHP) 2017: Envisages increasing public health expenditure to 2.5% of GDP. It prioritizes primary healthcare delivery through preventive and promotive interventions.
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY): Provides health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization, targeting bottom socioeconomic groups based on Socio-Economic Caste Census (SECC) data.
• Ayushman Arogya Mandirs (formerly Health and Wellness Centres): Transforms primary health centers and sub-centers into facilities offering Comprehensive Primary Health Care (CPHC), expanding coverage to non-communicable diseases, mental health, and diagnostic services.
• National Health Mission (NHM): Encompasses the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) to strengthen public healthcare delivery, maternal care, and immunizations.
• Ayushman Bharat Digital Mission (ABDM): Builds digital public infrastructure for healthcare by creating unique Ayushman Bharat Health Accounts (ABHA), registering facilities, and enabling interoperable electronic health records.

Key Facts for Quick Revision

• SDG Target for UHC: SDG Target 3.8 specifically calls for achieving Universal Health Coverage by 2030.
• Dual Monitoring Indicators: SDG 3.8.1 measures Service Coverage Index (SCI); SDG 3.8.2 measures Catastrophic Health Spending.
• Service Coverage Scale: The Service Coverage Index (SCI) uses a scale of 0 to 100, calculated using 14 tracer indicators across 4 domain groups.
• Primary Health Care Foundation: The 1978 Alma-Ata Declaration and the 2018 Astana Declaration establish Primary Health Care as the central mechanism for UHC.
• Catastrophic Threshold: Expenditure on health is defined as catastrophic when it exceeds 10% or 25% of total household budget/income.
• PM-JAY Coverage: Offers ₹5 lakh per family per year for secondary and tertiary inpatient care.
• India’s Public Health Expenditure Target: The National Health Policy 2017 targets increasing government health spending to 2.5% of national Gross Domestic Product (GDP).
• ABHA Digital ID: Created under the Ayushman Bharat Digital Mission as a 14-digit unique identifier for digital health record integration.