Urgent call to revoke weak and harmful indicator 3.8.2 to measure Universal Health Coverage (UHC)

Courtesy of:

United Nations Statistical Division,
UN Department of Economic and Social Affairs,
United Nations Headquarters,
New York 10017,
United States


23rd February 2016

Dear Chair and members of the UN statistical commission and the Inter-Agency and Expert Group on SDG Indicators,

Re: Urgent call to revoke weak and harmful indicator 3.8.2 to measure Universal Health Coverage (UHC)

We acknowledge the publication of the Report of the Inter-Agency and Expert Group (IAEG) on Sustainable Development Goal Indicators E/CN.3/2016/2/Rev.1. We are aware of the amount of work the IAEG achieved by listing the indicators for the 169 targets on so many different issues.

We write to express our grave concern regarding the recent amendment to the indicator 3.8.2 for UHC. The proposed new indicator – “Number of people covered by health insurance or a public health system per 1000 population” – not only fails to meaningfully measure progress towards UHC but could dangerously label growing inequity and less financial protection for health as progress.

We have highlighted in previous letters to Members of the IAEG in July 2015 and in 2nd February 2016 (signed by over 600 organisations), the strong consensus that target 3.8 must be tracked through two indicators: coverage and financial protection together. Progress towards universal financial protection must be measured through decreased catastrophic payment and decreased impoverishment when people access health services. This is critical to ensuring none are left behind.

The original UHC indicator for 3.8.2 developed following 3 years of technical consultation by the WHO and the World Bank achieves this aim. The proposed new indicator to measure ‘coverage by health insurance or a public health system’ does not achieve this aim of measuring progress towards decreasing financial burden and thus achieving universal financial protection for the following reasons:

  • Health insurance has no universal meaning or definition and therefore doesn’t work for cross-country comparisons
  • Insurance is not a measure or guarantee of financial risk protection – in a number of countries the introduction of insurance schemes has not reduced out of pocket payments or provided protection against catastrophic health expenditure
  • There are numerous examples where insurance can widen inequalities (e.g. voluntary insurance that excludes people with pre-existing conditions or those unable to pay or social health insurance when only for the formal sector, thereby excluding the majority of people in low and middle income countries who work in the informal sector).
  • Dangerously the proposed indicator risks promoting voluntary insurance schemes against a large body of significant and robust academic evidence that such schemes do not advance UHC.

Above all, the proposed new indicator is not responding to the central pledge of the SDGs framework- to see the targets met for all nations and peoples, for all segments of society and the promise to leave no one behind (paragraph 4 of 2030 Agenda for Sustainable Development). For the health sector, a failure to measure out of pocket payments that lead to impoverishment or catastrophic expenses is a failure to understand the goal and principles of UHC and a failure to ensure the poorest and most vulnerable, and especially women, are not left behind.

The WHO and World Bank technical note explains the rationale behind indicator 3.8.2, the data collection and method of estimation, and strongly suggests these indeed meet the criteria established for green indicators. We fully support their analysis and explanation to ensure UHC targets will be implemented and adequately monitored.

For these reasons we urgently request you to revoke the new proposed weak and dangerous indicator and return to the original more robust indicator of catastrophic and impoverishing expenditure[i] submitted by the WHO and World Bank which enjoy wide consensus across the health community.


Yours Sincerely,

Signed by the following organisations:

ACT – Alliance for the Control of Tobacco Use and Health Promotion
Action for Global Health
ACTION Global Health Advocacy Partnership
Action Medeor E.V.
ADD International
Adivasi Adhikar Samiti, India
ADRA Germany
Advance Family Planning, Johns Hopkins Bloomberg School of Public Health
Advocacy, Research, Training and Services (ARTS) Foundation
African Agency for Integrated Development (AAID)
AFRIHEALTH Optonet Association (CSOs Network)
Aga Khan University
Age International
AIDOS Italian Association for Women in Development
ALEJO Community Support Project
Alliance for Surgery and Anesthesia Presence
Alliance of Young Nurse Leaders and Advocates International, Inc.
Allied World Healthcare
Alternative SantÉ  Cameroun
Alzheimer’s Disease International
American Cancer Society
American Heart Association
American Leprosy Missions
Aravind Eye Care System
AS – Center for the Empowerment Youth of people who are living with HIV and AIDS, Serbia
Asia Arsenic Network
Asociación Mexicana de Vacunología
Association d’Entraide Médico-Sociale  AEMS-ASBL
Association for Academic Surgery
Association of Anaesthetists of Great Britain & Ireland
Association Tunisienne de Prévention Positive
ASTRA Network
AUCI (Associazione Universitaria per la Cooperazione Internazionale)
Austrian Leprosy Relief Association
Awaka Go Forward International
Balance Promoción para el Desarrollo y Juventud A.C.
Better Place International
Blood Patients’ Protection Council(BPPC), Kerala, India
Brien Holden Vision Institute
British Foundation for International Reconstructive Surgical Training
Catholics for AIDS Prevention and Support (CAPS)
CBM Germany
CBR Asia Pacific Network & ASHA Pakistan
CCM Comitato Collaborazione Medica
Center for Advocacy and Research (CFAR)
Centre for Global Surgery
Centre for Health Policy, School of Public Health, University of the Witwatersrand, South Africa
Centre for Sustainable Development and Education in Africa
Centre of Excellence for Universal Health Coverage, James P Grant School of Public Health, BRAC University, Bangladeshh.
Christian Aid
Civil Society Organisations Forum on HIV and AIDS (FOCDHA), Serbia
Coalition des OSC du Bénin pour la Couverture Universelle en Santé
Coalition 15%
Coalition for Health Promotion and Social Development (HEPS Uganda)
Columbia University
Commonwealth Medical Trust (Commat)
Community and Family Foundation Ghana
Comprehensive Health and Education Forum (CHEF) International
Comprehensive Health and Education Forum (CHEF), International, Islamabad
Construsion Ensemble Le Monde
Concern  Health Education  Project -Ghana
Corporación Kimirina
Curatio International Foundation
Development Policy Solutions
Diamedica UK Ltd
Disability Partnership Finland
Double Positive Foundation
Drug Action Forum – Karnataka
DSW (Deutsche Stiftung Weltbevoelkerung)
Elizabeth Glaser Pediatric AIDS Foundation
Episcopal Church of South Sudan & Sudan Department of Education and Training
Equilibres & Populations
Espolea A.C.
European Network on Independent Living
Eyes of the World Foundation ( Ulls del món)
Faculty of Medicine, Suez Canal University, Ismailia, EGYPT
Fast Rural Development Program
Federacion Planificacion Familiar Estatal
Federal Medical Center Yenagoa, Bayelsa State, Nigeria
Fondation Joseph The Worker/ Structure Lazarienne
For Impacts in Social Health (FIS)
Freshwater Action Network Mexico
Friends in Health: DPRK
Fundacion Arcoiris. Mexico
Fundación Mexicana para la Salud
G4 Alliance
GASOC ( global anaesthetic surgery and obstetric collaboration)
GCAP Italy
General Trade Union of Workers in Health Services and Pharmaceutical Industries in Jordan
Global Campaign for Education
Global Health Advocates France
Global Health International Advisors GHIA
Global Network of People Living with HIV
Global Paediatric Surgery Network
Global Pediatric Surgical Technology and Education Project
Global Social Observatory
Green Cameroon
Harvard University Program in Global Surgery and Social Change
HEAL Africa
Health Access and Integrated Development Initiative
Health Economics Unit, University of Cape Town
Health For All Coalition Sierra Leone
Health Partners International
Health Poverty Action
Health Volunteers Overseas
HealthNet TPO
Healthwatch Forum UP
Helen Keller International
HelpAge International
HePDO (Health Promotion and Development Organisation)
HHRD Pakistan
HIV i-Base
HIV Justice Network
Housing Works, Inc.
Howard University College of Medicine
Hwlp Me See
Hwupenyu Health and Wellbeing project
Icahn School of Medicine at Mount Sinai
Incentives for Global Health
India HIV/AIDS Alliance
Indus Hospital
Initiative for Community Development
Initiative for Health and Equity in Society
Initiative for Rural Empowerment (IRE)
International Agency for Prevention of Blindness
International Anesthesia Education Forum
International Children’s Palliative Care Network
International Community of Women
International Council of Ophthalmology
International Diabetes Federation
International Disability Alliance
International Eye Foundation
International Federation of Surgical Colleges
International HIV/AIDS Alliance
International Planned Parenthood Federation
IntraHealth International
Irish Family Planning Association (IFPA)
IWC Barbados
Jamaica Community of Positive Women
Jan Swasthya Abhiyan – Mumbai
Jan Swasthya Abhiyan ( Peoples Health Movement-India)
Japanese Organization for International Cooperation in Family Planning (JOICFP)
Jharkhand Science Forum
Johns Hopkins University
JONGO Farmers Nigeria
Karnataka Janaarogya Chaluvali
Kenya AIDS NGOs Consortium – KANCO
Kenya Legal & Ethical Issues Network on HIV/AIDS (KELIN)
Korean American Medical Association
Light for the World International
Liliane Foundation
Liverpool School of Tropical Medicine
Malaria Consortium
Management Sciences for Health
May Dugan Center
Medical College of Georgia/University of Georgia Medical Partnership
MEDICI Centre, Western University
Medico Friend Circle
Medicos del mundo España
Medicus Mundi España
Medicus Mundi International – Network Health for All
Mending Kids
Mercy Ships
Multiple Foundation Trust
Muslim Family Counselling Services
NCD Alliance
Network of ‘Southern Africa Parliamentarians on HIV/AIDS, & Community Engagement on Prevention of Communicable Diseases, and Health Rights Advocacy (SA-PACEDIST)
Nigeria Network of NGOs
Nigerian Society of Anaesthetists
Norwegian Association of Disabled
Norwegian association of the blind and partially sighted
Operación Sonrisa Nicaragua
Operation Eyesight
Operation Smile, Inc.
Orbis International
ORES Tanzania
Organisation pour la Prévention de la Cécité (OPC)
Osservatorio Italiano sull’Azione Globale contro l’AIDS
Oxfam International
Pan African Positive Women’s Coalition-Zimbabwe
Pan-African Academy of Christian Surgeons
Pathfinder  Outreach  Ministries-Ghana
Patients’ Rights Organization in Kosovo – PRAK
People’s Health Movement
Peoples Training And research Centre
Plan UK
Plate Forme des Organisations de la Societe Civile pour le soutien à la Santé/vaccination
PLENITUD Foundation
Porridge and Rice
Positive Women
Positive Women Inc. New Zealand
Preah Kossamak Hospital
Primary Trauma Care Foundation
Princess of Africa Foundation
Program in Global Surgery and Social Change – Harvard Medical School
Public Health Foundation of Bangladesh
Public Health Foundation of India
Research and Development Division, Ghana Health Service
Restless Development
RESULTS Australia
ReSurge International
Royal College of Surgeons in Ireland
RTI International
Sahkar Social Welfare Association
Salamander Trust
Save the Children
Save the Children Italy
Schistosomiasis Control Initiative Imperial College London
Secours aux Lépreux – Leprosy Relief Canada
Sécretariat Permanent  des Organisations Non Gouvernementales (SPONG)
SEM (Sudan Evangelical Mission)
Sensoa (Belgium)
Seres (con) viver com o VIH
Seva Foundation
Smile Train
Sociedad Dominicana de Pediatria
Society for Community Health Awareness, Research and Action (SOCHARA)
Sophia Forum
SOS Children’s Villages
South African Disability Alliance
STEP Organization Pakistan
Surgical Society of Zambia
Surgicon Foundation
Sustainable Development Solutions Network (SDSN)
Tanzania Diabetes Association
Terre des Hommes
The Fred Hollows Foundation
The G4 Alliance
The Global Surgical Consortium
The Graça Machel Trust
The Hunger Project
The International Coalition for Trachoma Control
The International Community of Women Living with HIV
The Leprosy Mission International
The Rockefeller Foundation
The Well Project
THET (The Tropical Health & Education Trust)
Tororo forum for people living with HIV networks
Traditional Healers and Traditional Medicine Foundation (Thetramed Foundation)
Training and Research Support Centre
Treasureland Health Builders Initiative
Uganda Network of Young People Living with HIV&AIDS (UNYPA)
Union des ONG du Togo(UONGTO)
University of Melbourne, Melbourne School of Population and Global Health
University of Michgan
University of Sheffield
University of the Witwatersrand
University of Utah, Center for Global Surgery
University of Vermont College of Medicine
Vasavya Mahila Mandali
Vision 2020 Australia
VSO International
Wada Na Todo Abhiyan
WaterAid America
WaterAid Australia
WaterAid India
WaterAid UK
WECARe plus
Women Deliver
Women’s Hope Association
World Heart Federation
World Vision
Worldwide Hospice Palliative Care Alliance
Wote YouthDevelopment Projects
Youth Joint Online Broadcasting Kenyta
Youth Stop AIDS
Zambia Asthma Association
Zambia Heart and Stroke Foundation



[i] Catastrophic out-of-pocket health expenditures are defined as occurring when direct payments made to health care providers at the time of service use that are equal to or exceed 25% of household total consumption expenditure.

Impoverishing out-of-pocket health expenditures are defined as occurring when such payments push a household below a poverty line.

The poverty line should be defined according to national standards and also an international poverty line, consistent with SDG targets 1.1.1 and 1.2.1.

The fraction of the population experiencing catastrophic (impoverishing) out-of-pocket health expenditures is then estimated as the number experiencing catastrophic (impoverishing) payments over the total population.

Data sources: Financial protection indicators are based on information collected from nationally representative household expenditure surveys or household multipurpose surveys implemented by or in close collaboration with national statistical offices. The three most common surveys are Household Budget Surveys, Household Income and Expenditure Surveys and Living Standards Measurement Surveys. The World Bank Group and the WHO have already identified approximately 500 relevant surveys.

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