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Urgent call from 260 organisations to amend harmful UHC indicator 3.8.2

2 Mar 2016
Urgent call from 260 organisations to amend harmful UHC indicator 3.8.2
Courtesy of:
United Nations Statistical Division,

UN Department of Economic and Social Affairs,

United Nations Headquarters,
New York 10017,

United States

26th February 2016

Dear Mr. Nabil Benshams

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 9th February 2016 (with 631 signatories), 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 the original 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 expenditure1         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.  

2        Impoverishing out-of-pocket health expenditures are defined as occurring when such payments push a household below a poverty line.  
3        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.  
4        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.
5        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. submitted by the WHO and World Bankwhich enjoy wide consensus across the health community.

Yours Sincerely,

Signed by the following 260 organisations (Please also refer to the letter sent 9th February 2016 with 631 individual signatories endorsing the original 3.8.1 and 3.8.2 indicators).  


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

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

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

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 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 15%

Coalition for Health Promotion and Social Development (HEPS Uganda)

Commonwealth Medical Trust (Commat)

Comprehensive Health and Education Forum (CHEF) International
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

Freshwater Action Network Mexico

Friends in Health: DPRK

Fundacion Arcoiris. Mexico

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 Economics Unit, University of Cape Town

Health For All Coalition Sierra Leone

Health Partners International
Health Poverty Action

Health Poverty Action

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

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 Eye Foundation

International Federation of Surgical Colleges

International HIV/AIDS Alliance

International Planned Parenthood Federation

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


Korean American Medical Association

Light for the World International

Liliane Foundation

Malaria Consortium

Management Sciences for Health


MEDICI Centre, Western University

Medico Friend Circle

Medicos del mundo España

Medicus Mundi España

Medicus Mundi International - Network Health for All


Mercy Ships


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)

Norwegian Association of Disabled

Norwegian association of the blind and partially sighted

Operación Sonrisa Nicaragua

Operation Eyesight

Operation Smile, Inc.
ORES Tanzania

Organisation pour la Prévention de la Cécité (OPC)

Osservatorio Italiano sull'Azione Globale contro l'AIDS

Oxfam International

Pathfinder  Outreach  Ministries-Ghana

Patients' Rights Organization in Kosovo - PRAK

People's Health Movement

Peoples Training And research Centre
Plan UK
Porridge and Rice

Positive Women

Positive Women Inc. New Zealand



Preah Kossamak Hospital

Princess of Africa Foundation

Program in Global Surgery and Social Change - Harvard Medical School


Public Health Foundation of Bangladesh

Public Health Foundation of India
Public Health Practitioner

Restless Development

RESULTS Australia


ReSurge International


Royal College of Surgeons in Ireland


Sahkar Social Welfare Association

Salamander Trust

Save the Children

Save the Children Italy
Schistosomiasis Control Initiative Imperial College London

Sécretariat Permanent  des Organisations Non Gouvernementales (SPONG)

SEM (Sudan Evangelical Mission)

Sensoa (Belgium)

Seres (con) viver com o VIH

Seva Foundation


Smile Train

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

Sustainable Development Solutions Network (SDSN)

Tanzania Diabetes Association

Terre des Hommes

The Fred Hollows Foundation

The G4 Alliance

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

Training and Research Support Centre

Treasureland Health Builders Initiative

Uganda Network of Young People Living with HIV&AIDS (UNYPA)

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

World Heart Federation

World Vision Germany

Worldwide Hospice Palliative Care Alliance

Wote YouthDevelopment Projects

Youth Joint Online Broadcasting Kenyta

Youth Stop AIDS

Zambia Asthma Association
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