Measuring progress towards universal health coverage: with an application to 24 developing countries

The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. We propose a 'mashup' index that captures both aspects of UHC: that everyone—irrespective of their ability-to-pay—gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care. We break service coverage into prevention and treatment, and financial protection into impoverishment and catastrophic spending; we use nationally representative household survey data to adjust population averages to capture inequalities between the poor and better off; we allow non-linear trade-offs between and within the two dimensions of the UHC index; and we express all indicators such that scores run from 0 to 100, and higher scores are better. In a sample of 24 countries for which we have detailed information on UHC-inspired reforms, we find a cluster of high-performing countries with UHC scores of between 79 and 84 (Brazil, Colombia, Costa Rica, Mexico, and South Africa) and a cluster of low-performing countries with UHC scores in the range 35-57 (Ethiopia, Guatemala, India, Indonesia, and Vietnam). We find that countries have mostly improved their UHC scores between the earliest and latest years for which we have data—by about 5 points on average. However, the improvement has come from increases in receipt of key health interventions, not from reductions in the incidence of out-of-pocket payments on welfare.