Abstract paper were paraphrased and summarized to


Monitoring and evaluation has key role for the successful implementation of
Universal Health Coverage (UHC). UHC has been adapted by more than 90 countries
though in different time. Countries were advised to develop health systems that
avoid significant direct payments at the point of care (1). The goal of UHC
includes ensuring that all individuals who need health services receive
prevention, promotion, treatment, rehabilitation and palliative care without
exposing financial difficulty. Considering the role that monitoring and
evaluation plays to ensure that these countries achieve the goal of UHC, the
purpose of this paper is to review the role of UHC, key definition and
objective of UHC, characteristics applied at country and global level as well
as three countries experience in implementing UHC.

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This paper was done to fulfill the requirement of the course “Introduction to
Monitoring and evaluation” and reviewed and edited by members of group two
students mentioned above. The secondary sources of information were used to
write this paper. Data on Universal Health Coverage and about the role that
monitoring and evaluation had were collected from previous studies by reviewing
literatures. The sections reviewed and discussed in this paper were paraphrased
and summarized to fit the purpose and scope of this paper.


summary from this review shows that Universal Health had a framework of
monitoring and evaluation with indicators which is responsible for ensuring
that all countries are contributing their part. It shows that each countries
has specific criteria that fits their context while also having common goals
and indicators in achieving equity health service to their population without
suffering by financial constraint. The review also helped to observe that implementation of monitoring and evaluation plan towards
UHC is very critical to see the health system progress and effective service


The review found that countries follow the progress of health coverage through
indicators. The monitoring system of UHC has recommended framework and
characteristic which has common features to all countries or the specific
indicators identified for countries would contribute to the global goal.

1.     Historical

is far from having overall and total universal health coverage. The world
health assembly articulates “everyone should be able to access health and not
be subjected to financial hardship in doing so”; hence health financing has a
significant part of broader endeavor to guarantee social protection in health(1).

authorities in global health tried to have the idea of UHC in their grip for
the last several years.(2) Even though, various countries advanced with regards
to Universal Health Coverage at different period of times; Germany is credited
for starting the first system through its social insurance plan, instituted in
1883(3).Scholars believe Bismarck’s Social-insurance policies in 1883 made a
distinct feature to complete the role of the European social welfare.(3)Subsequently,
other countries like: United Kingdom in 1948 through Tax Financed National
Service with Entitlement to service, Japan in 1961 through Nationwide Universal
Coverage.(4)Moreover, Between 6th and 12th September
1978, at an International Conference on Primary Health Care, in  Alma 
Ata,  Kazakhstan,  USSR, 
134  countries approved  the “health for  all” program in the course of the Alma Ata
Declaration. The program was to be motivated by the Primary Health Care (PHC)
system (5).

2012, the United Nations General assembly accepted a declaration that allowed
the aim of Universal health coverage and gave it high place on development
agenda. It was adapted by more than 90 countries and it urged the member states
to develop health systems that avoid significant direct payments at the point
of care (1).

health care and financing reform implementation in Ethiopia has passed through
six phases to reach to its current status. These are Conceptualization and interest
Generation(1998-2001),Development of Legislative Framework for first Generation
Reforms (FGR)( 2002-2003),Endorsement and Pilot testing of FGR(2003-2005),Consolidation
and expansion of FGR and Intensive External resource mobilization and
innovations( 2005-2008),Conceptualization of Second generation Reforms and
development of preferred aid modality(2008-2009) and Maturing FGRs and piloting
part of second GR(2010-2014) (6).


1.     Definition,
Goal and Objective of Universal Health Coverage

Definition of Universal Health Coverage (UHC)

Universal Health Coverage (UHC) is one
of a critical component of sustainable development and poverty reduction, which
has a goal to ensure that all individuals who need health services receive
prevention, promotion, treatment, rehabilitation and palliative care without
exposing financial difficulty. UHC has a direct impact on a population’s health
and it exists where all people get quality health services they demand (7). World
Health Organization defined UHC as “What people need to get, be and stay
healthy” and explained the relation and integration between its elements (8).

Universal health coverage is also
defined as an effort with a goal intended to improve the chances of every
person attaining the highest level of health and well-being and contributing to
socioeconomic and sustainable development. A framework has been defined for UHC
as part of the SDGs and target date to achieve UHC is set for 2030(9).

UHC has a goal of healthy policy
development has acquired large acceptance at nation and world level; since it
communicate  to the world .Universal
coverage is the assurance of a government’s commitment to improve the wellbeing
of all its citizens.
Universal coverage is firmly based on the WHO constitution of 1948 declaring
health a fundamental human right and on the Health for All agenda set by the
Alma-Ata declaration in 1978 (10).

UHC as a condition in which all peoples
who need health services receive without incurring financial hardship that
affect daily livelihood.  One of post
2015 development agenda was UHC and also currently believed as critical
component of SDG: means for achieving appropriate and stable health benefits (11).

UHC also means the financial survival
and lack of thereof and it combines two interdependent components first related
to people’s health service need and the other is economic burden of doing so.
UHC is exactly stated as life or death concept, communities without health
coverage faces the impact of untreated sickness and premature death for
themselves and their children (12).

The former definition consist only
health service for all ,where as  the
second incorporates  two interdependent
components consisted in UHC; health service coverage which is effective
and  access to financial negative outcome
protection for all ,so progress monitoring focus on the level and distribution
of effective coverage of intervention and universal risk protection (13).

and Objective of Universal Health coverage

2.2.1 The
Goal of UHC


Universal Health
Coverage (UHC) has been defined as a situation in which all people will have
access to any demand of health service and do not suffer financial hardship to
pay for those services.(14)Cognizant on this definition UHC would become a goal
and noticeable step to be considered by each country in the way to achieve the
2030 agenda of sustainable development. In the agenda for sustainable
development, SDG3:8, UHC has been stated as one of the target to achieve SDG3
stated as ‘Achieve   universal   health  
coverage,   including   financial  
risk   protection,   access  
to   quality essential   healthcare  
services   and   access  
to   safe,   effective,  
quality   and   affordable  
essential medicines   and   vaccines  
for   all (15). Thus, UHC is a
goal that demanded to be achieved by every country in the globe. However, it is
not an end by itself; rather it is a tool countries can use on the road to
achieving the highest possible standards of health and well-being for all their
people (16).


Even though countries
will have a broad and shared goal of UHC, each country will have to set its own
contextual goal to achieve the bigger goal of UHC. Because the context and the
challenges in one country may required to set a unique contextual goal and in
others country it may need different goal. Moreover, countries have their own
health financing system. Hence, each country’s government will have primary
responsibility to make sure that all the citizens who he represent have access
to all health services needs without being suffer from financial constraints.
Furthermore, the UHC aimed to get quality health services as human right issue
and promote inter-country support in view of the UHC.






Objectives of UHC


of the objectives of UHC are to:

Equalize human kind to get access for
quality health services

Create social cohesion and stability

Provide financial protection for all

physical   and   mental  
health   and   well-being

Extend life
expectancy for all (17).


2.     Role
of Monitoring and Evaluation in Universal Health Coverage

Based on the
countries interest for help on the implementation of the UHC initiatives, WHO
and World Bank prepare a UHC monitoring framework. In the development of the
framework; country representatives, technical expertise and global health and
development partners participated and discussed on the countries study reports,
technical reviews and consultation findings (17).The
UHC framework integrates key elements from other global and national health
monitoring frameworks, including the framework for health systems performance (WHO 2011),
quality (OECD 2006), and social determinants of health (18).


framework is built on three major objectives of the UHC: equity, essential
health service for the population and financial protection of the population. So
monitoring and evaluation system/plan to achieve objective UHC for every
countries play important role on focusing the input-output and the
outcome-impact of the UHC (18). From many points addressed in the framework,
UHC framework proposes that countries need to have
a set of essential and traceable indicators suitable with regional global UHC
monitoring. When there is a common and comparable set of indicators that
measure effectiveness of coverage (even if it need multiple components,
estimates of need, use, quality and outcome of intervention) of a country,
global progress can be measured and synthesized. So as world countries need to
have monitoring and evaluation program for tracking and assessing the
achievement of UHC (17).


As indicated in
the first global report of WHO on monitoring report- tracking of UHC at 2015,
by using their monitoring and evaluation processes countries
by this time producing a credible, comparable data on both health service and
financial protection coverage, although data blind advertisements on vital
public health concerns such as non-communicable diseases (NCDs) and health
service quality. As shown in the report different countries monitor and
evaluate their regional UHC chime and report it in different ways. So this
report that is done by WHO (even if the report include from different
countries) is clearly indicates the high implementation of monitoring and
evaluation plan towards UHC in most of the world countries. It is also shows
that by evaluating the coverage of health services and financial protection together
we can reach appropriate conclusions on how effectively the health system is
providing expected coverage (18).


system strengthening is the main means by which countries can progress towards
UHC so that is why UHC monitoring needs to be integrated into broader health
systems performance assessment. The other UHC focus are health services and
financial protection coverage so again it is essential that UHC monitoring of
both aspects.


of UHC, and in general any health program meant to improve access, health
status and financial protection is difficult to evaluate. Representing a
counterfactual situation to rule out other factors that may affect the outcome
in similar way as of the intervention is important point; in other word a
question like what would happen in the absence of this intervention? , need to
be answered to determine the cause and effect of the intervention. While the
counterfactual is difficult to detect in reality, it is commonly estimated by
using comparison groups (19).


An impact
evaluation will typically analyze a group composed of those who are affected by
the intervention being evaluated called the intervention group and at least one
comparison group called the control group. So an impact evaluation faces many
challenges in showing whether the intervention was randomized or not. Some of
the key challenges in evaluating the impact of UHC schemes are discussed below,
since they were an important consideration when reviewing the robustness of the
available evidence (19).


Because of the monitoring of UHC indicators needs to be embedded within
health systems performance assessment frameworks, monitoring of UHC is the most
direct result of the implementation of those policies. In other word it doesn’t
tell why or what policy levers can be used to get better results. So country
UHC monitoring needs to be integrated into broader health systems performance
assessment if it is to realize its full potential as actionable intelligence (20).Monitoring
of UHC indicators will link changes include structural elements such as the
availability and quality of infrastructure; health professionals, medicines,
blood and medical devices, and process elements such as health system reforms
(e.g. changes in provider payment mechanisms) that seek to improve service
quality or health service utilization. Assessing the distribution of health
needs and services is critical (20).

Determine the causes of change in health coverage measures is
important to while understanding a country’s health system reforms and to
assess changes in non-health system social determinants of health educational
skill and poverty which are directly influence coverage and outcomes. As
indicated by WHO and World Bank first report, some countries are practicing and
using UHC tracking practice for their national health performance assessment.
The report put Thailand as a good example by using indicators from UHC to
monitor health sector performance. Including monitoring and evaluation on the
effects of various reform efforts will it be possible to understand why
progress towards UHC is hesitating or not, which in spin will permit for any
essential changes in strategy (20).


3.1.   Key Characteristics in Monitoring
Universal Health Coverage Framework

has a framework which has key characteristics that countries should follow at
all level or to some extent. Countries shall consider these frame work and the
key characteristics while monitoring the UHC. These characteristics include
following monitoring system which is part of the regular system; measuring coverage
of the population with essential health service and financial protection
separately; the measurement of indicators shall be disaggregated by
socioeconomic and demographic characteristic; the service coverage measurement
shall consider all components including promotion, prevention, treatment and
rehabilitation and palliation; the priority or new initiatives which were not
planned and had financial difficulties shall be measured with standard
indicators that fits into the country and global measurement; and finally
countries shall develop indicators and targets considering their level of
socioeconomic development, epidemiological situation, state of the health
system and people’s expectations, and this to some extent shall be relevant to
all countries (22).



of Country experience in Monitoring and evaluation of UHC

and Evaluation Experience in South Africa

In the first stage of UHC
implementation, the country focuses on evaluating the current status of its
health system to the goals of UHC is by compare country data with wide
benchmarks. Currently the country cascade short
of UHC goals in many respects, including its system inputs, outputs, outcomes
and impact even if there is relatively good financial risk protection (21). Substantial
social, economic and health inequities are the key trait of South Africa, so
for this case some literatures recommend that Monitoring of reductions in
injustice within the health system and health status need to be prioritized
.And Monitoring and evaluation system is required to assess the Implementation
and achievement of the country over the UHC indicators. (21)





4.1.2    Monitoring and Evaluation Experience in

UHC monitoring and evaluation uses an elaborate system of periodic health
sector reviews at district, regional, and national levels to assess progress on
its sector-wide indicators outlined in its National Health Strategy, in
concordance with the objectives of the four-year Health Sector Medium-Term
Development Plan. This annual process, led by the ministry of health, organizes
a comprehensive review system using a variety of tools such as the Holistic
Assessment Tool, feeding into the Interagency Performance Review, and
culminating in the National Health Summit. Since 2003, the Government of Ghana
has been implementing the National Health Insurance Scheme (NHIS) as the main
strategy to progressively bridge financial access barriers and provide a social
risk protection system (23).

child mortality trends alone are not a good indicator of universal health
coverage (UHC) as many factors contribute to intervention coverage, mortality
trends nonetheless offer a general measure to assess progress in reducing the
gaps. Ghana’s in-country monitoring mechanisms and relevant evaluation tools
are inadequate. There are significant gaps in quantifying equity and financial
risk protection among different wealth quintiles, and in addressing the spread
and control of non-communicable diseases and other chronic conditions (23). The
national monitoring and evaluation frameworks need to incorporate relevant
global-level indicators that define and track country effective coverage for
meaningful comparisons among countries of similar socio-economic and
demographic characteristics (23).

4.1.3    Monitoring and Evaluation Experience in

monitoring and evaluation experience mainly deals with indicators concerning
with reproductive, maternal, and child health and key infectious disease
services while non-communicable and chronic disease is usually unattended. Sources
show that most of the monitoring and evaluation indicators are gathered in the
form of survey and Health Information Management System (HMIS).Concerning with
the financial coverage it is measured indirectly in National Accounts
assessment, but direct procedures with regards to poverty caused by health care
expenditure  has not yet been developed (21).


Germany demonstrated the conception through social insurance plan Universal
Health Coverage developed and evolved through time across humankind where it is
comprised of two inter mutually supporting components health service coverage
which is effective and access to financial negative outcome protection for all.
The concept aims to offer steady and quality health services to all; hence this
can be achieved through broad and shared goal where each country’s government
will have primary responsibility to make sure that all the citizens who it
represents have access to all health services needs without being suffer from
financial limitations.

for Universal Health Coverage to be successful a WHO and World Bank arranged a
framework of monitoring and evaluation with indicators which is responsible for
ensuring each countries are contributing their part. To estimate the growth or
coverage of UHC it is essential that we have common indicators for input-output
and the outcome-impact of the UHC. Incontrovertibly, when
there is a common, relevant and comparable set of global-level indicators that
measure effectiveness of coverage among countries, global progress can be
calculated and synthesized. As the WHO UHC reports clearly shows by prominent
implementation of monitoring and evaluation plan towards UHC around world we
can reach appropriate conclusions on how effectively the health system is
providing expected coverage.

experience from different countries clearly shows the contribution of
monitoring and evaluation activities in UHC is inevitable, because it has a
necessity to check and give improving feedbacks that will help the achievement
overall goal of Universal Health Coverage.


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